Seattle, Washington; Alternatives for Girls in Detroit, Michigan; and the On the Streets Mobile
Unit-Options Program in New York City. Most of these programs use former sex workers as
outreach staff, use a risk-reduction model of care, and establish linkages with organizations in
the treatment continuum.
Homeless people
Homeless people suffer higher rates of many diseases, including HIV/AIDS and substance abuse
disorders, than the general population. No national statistics exist, but studies within maj or U.S.
cities are illustrative. In a 1990 survey of homeless adults in St. Louis, Missouri, 40 percent of
men and 23 percent of women reported substance abuse, and 62 percent of men and 17 percent
of women reported alcohol abuse. Another 1993 study of homeless adults in Mississippi revealed
that 70 percent of respondents engaged in at least one of the following high -risk behaviors:
unprotected sex with multiple partners, injection substance abuse, sex with an infected partner,
and exchanging unprotected sex for drugs or money. Of these respondents, nearly half reported
two risk factors, and 25 percent reported three or four risk factors. Homeless people--especially
women and youth--may engage in risky behaviors for survival reasons.
Developing New Substance Abuse Treatment Goals
Altering admission requirements
A "one-size-fits-all" abstinence-based approach to admission effectively serves only a small
number of clients. Insisting that clients detoxify and remain substance free prior to admission to
substance abuse treatment programs assumes a homogeneity of substance abuse and substance
abuse behavior that does not exist.
Providers should realize that some clients use substances as a way to control mood, monitor
affect, and adhere to a schedule of activity. Drug use as a life management strategy may seem
dysfunctional but is not necessarily a personal deficit. Eliminating substance abuse without
understanding the context and role it plays in the lives of clients may, in counter-intuitive
fashion, increase the chances of lapse and relapse among clients. Stopping substance abuse
without substitutes or proxies for its socially constructed meaning is fraught with risk.
Removing substances of abuse without acknowledgment of the psychological benefits perceived
by abusers is also laden with risk. Providers should appreciate (without necessarily agreeing) that
many people use substances because they like the way substances make them feel. Many
substance abusers find replacement of this feeling extremely difficult, if not impossible, to
obtain. Breaking, changing, or altering a chronic cycle of substance abuse is difficult under
optimal circumstances where clients have social, psychological, and material supports and
services. Changing chronic cycles of substance abuse without these supports and services is not
impossible but very nearly so.
Programs should include a harm-reduction treatment track that can accommodate the retention in
treatment of clients who are active substance abusers but willing to control their substance use
(i.e., agreeing not to consume substances on the premises and agreeing not to participate in
programs when under the influence). Admission requirements might be altered depending on
