BOX 2.3 A Closed Door

At the request of his state drug abuse authority, one member of this committee opened a methadone clinic in a rural community. At a get-acquainted meeting with the city fathers, he was told bluntly that the community leaders did not want methadone treatment in their area. They were not interested in research data showing methadone's reduction of crime and health-care costs; they preferred that those who needed methadone treatment move to a city with a methadone clinic.

despite the double societal stigmas of their disease. The National Alliance for the Mentally Ill (NAMI) is an excellent example of effective advocacy efforts lead by family, friends, and supporters of those who suffer from mental illness. The National Alliance of Methodone Advocates (NAMA) also provides a working example of how those most affected by addiction can advocate for themselves.

Another stigmatizing factor is job status. To a greater degree than in other chronic disorders, the field of addiction has in the past had large numbers of workers who have themselves experienced the problem. This included physicians and nurses as well. Of all the health care treatment programs, drug abuse treatment may be the most frequent employer of its own graduates. Historically, and to some extent yet today, the ranks of counseling have been filled with significant numbers of former drug abusers, while the ranks of administrators have been less so (Brown, 1997). This disparity in status is often complicated by co-occurring ethnic differences.

Recovering workers have been increasingly accepted as effective counselors (Christensen and Jacobson, 1994), and there has been a growth in the development of certification programs for drug abuse counselors. Nonetheless, credentialing requirements tend to discriminate against experientially trained staff, and counselors in recovery are challenged to develop a more theoretical perspective and apply research in their clinical work.

The stigma of the field may also contribute to the lack of mainstreaming of substance abuse in the curricula of undergraduate and graduate programs in health-related fields. The recommendations of the 1995 conference on training sponsored by the Macy Foundation represent a step in the right direction as does the inclusion of this training objective, for the first time, in the National Drug Control Strategy (ONDCP, 1998).

The Macy report recommended training about drug and alcohol abuse for all primary care physicians (i.e., family-practice, internal medicine, pediatrics, and obstetrics-gynocology). Internal Medicine residency programs are now required to have this training (Josiah Macy, Jr. Foundation, 1995).

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