To be effective, BMDC must be implemented in the context of contemporary substance abuse treatment, which has to be integrated with a larger system that takes into account the program setting, referral sources, professional staff, program administration, and linkage to and coordination with ancillary services and with marketing, recruitment procedures, assessment, training, supervision, program administration, and quality assurance. Successful management of a population of people who abuse a different substance requires more than simply adding interventions to an existing treatment system. Ideally, the implementation of a BMDC component to a program will bring with it changes in services, such as recruitment, referrals, case management, initial client contact, therapist training, and administration.
The majority of participants in clinical trials of marijuana dependence treatment (see Supplemental Reading B) contacted the programs in response to newspaper advertising. Advertisements were placed in the news and movie sections of major and alternative newspapers. Some treatment participants said they had taken the study advertisement from the paper and carried it with them for weeks before calling. Other avenues of recruitment included bus advertisements, radio announcements, and newspaper stories about the program. Placing small announcements in places appropriate for different groups, such as beauty parlors, pharmacies, and supermarkets, also may be effective. Many people who chronically use marijuana believe their problems with its use are unique. In a study of barriers to formal treatment, Copeland (1997) found that although women in general were aware of options for specialized alcohol and drug treatments, this was not true for the women who were dependent on marijuana. These women believed that they were the only people with such a problem, which may have contributed to their reluctance to seek treatment. It also may explain the positive response to the announcements used by MTP, which were gentle and nonthreatening and ensured confidentiality. The announcements read, Ready to make a change in your marijuana use? Not sure how to go about it? Free, confidential, and nonjudgmental marijuana counseling.
This communicated that
• Potential clients were not alone.
• Experts recognize marijuana use can be a problem and take it seriously.
• A special program for marijuana use problems existed and was readily accessible.
The nonauthoritarian nature of the ad appealed to people using marijuana who were experiencing problems and were ambivalent about their use. Clients who contacted MTP for treatment often commented that the nonjudgmental stance was important in making the offer of assistance attractive to them.
The courts and employee assistance programs (EAPs) are both sources of referrals to BMDC. Many communities have drug courts that manage nonviolent drug-related cases. Programs such as BMDC provide the courts with alternatives to incarceration for nonviolent offenders. Persons convicted of possession or driving under the influence of marijuana also may be referred appropriately. EAPs may refer employees who voluntarily present themselves or are identified following a job-related accident. Preemployment screening also leads to treatment seeking when continued marijuana use is perceived as an obstacle to desired employment. Often these referrals result in traditional treatment. However, when EAP counselors are educated about a special research-based program for marijuana use, BMDC may be seen as the treatment of choice.
Court referrals are usually subject to mandatory urine testing for drug use. In Florida between 1994 and 1999, 63 percent of persons entering treatment and reporting their primary drug problem to be marijuana (with no other drug involvement) were involved with the criminal justice system. Although court referrals generally are excluded from marijuana clinical trials, there is no reason to believe that these individuals would not be appropriate for BMDC. The possibility of incarceration is a powerful motivator for change (Hser et al. 1998).
Similarly, persons who are subject to targeted urine testing because of job-related problems may want to enter treatment. Urine testing increases the likelihood that continued use will result in the loss of employment. Thus, to the extent continued employment is important, readiness to change will be greater and ambivalence less strong.
Many MTP participants identified case management needs that were nontraditional. Their needs were often related to isolation, health, and time management. Referrals to health clubs, recreational programs, and religious activities were called for. Clients in serious need of medical care, housing, or legal counseling were rarely encountered. Programs that implement BMDC should develop case management linkages to the community to provide ancillary services, such as vocational counseling, medical treatment, and psychiatric care. BMDC uses a problemsolving approach to case management. Clients may need assistance in addressing barriers to treatment participation and recovery. Case management in the BMDC model provides linkage information rather than advocacy. Cooperative agreements for referral should be in place so that the therapist knows what services are available in the community and how they can be accessed most easily.