HaCKeRz Kr0nlcKLeZ 1/HaCKeRz Kr0nlcKLeZ.iso/drugs/treatment

Text File | 1996-05-06 | 31.7 KB | 597 lines

McDermott╒s Guide to Drug Treatment.

(c) Peter McDermott, 1993
(c) Lifeline Project, 1993

This guide was first published by Lifeline Project, Manchester, UK.
This electronic version may be freely distributed electronically or as
hard copy. However, be warned that you are missing out on Mike
Linnell╒s brilliant illustrations.


Introduction/why do you want to get help?

There are hundreds of different reasons why people decide they need help
with a drug problem. Here are some of the most common ones:

Your parents have sussed you out, so you want to get them off your back.

Your boss has sussed you out, and you╒ve got to pay for your drugs somehow.

Your partner says that they╒ll leave if you don╒t ╤ and it looks like they
mean it this time.

You╒ve been nicked again. Unless you can give the court something
reasonable in your plea of mitigation, you╒re going to jail. Do not pass go.
Do not collect a methadone detox on the way. The ú200 isn╒t going to be any
use where you╒re going.

You finally recognize that you don╒t have any control over your
drug use. You want to stop for a while, or at least try to cut down, but you
don╒t seem to have any control. Your willpower keeps on slipping, just long
enough to break your determination. Given that you feel incapable of
helping yourself, perhaps somebody else can help you.

So, you╒ve just robbed the last twenty out of your dad╒s wallet/wife╒s
purse/sister╒s piggy bank, you╒ve shot, smoked or snorted all the gear, you
need to do something before they find out and finally cut you off.  They╒ve
been on at you for long enough to see somebody about the problem, but
who do you see? There╒s so many different places, all offering different
types of thing. Do you need methadone? A detox? What about the black box?
Accupuncture? Does it work? Before you sign your life away, you need to
read McDermott╒s Guide to Drug Treatment ╤ the first no-bullshit Michelin
guide for smackheads, crackheads, temazzie monsters and others in need of
a temporary escape clause.

A caution

Before you decide to go to a drugs agency, there are a few things that you
should know about drug treatment in the UK.

If you go to see a doctor, a social worker or a probation officer, the person
that you see will have received some training for the job. If you go to a
drugs agency, there worker that you see is unlikely to have been trained as
a drugs worker. They may have trained in another discipline but the
amount that they actually know about drugs or drug problems varies
immensely.

This lack of knowledge will often permeate the whole of the agency. If the
boss has very little drug-specific knowledge it is unlikely that he or she
will insist on it in his staff. As a consequence, Britain has drug services
that are typified by their lack of professionalism. The unstated position that
is implicit here is, ╘they╒re only drug addicts, anybody can deal with their
problems╒, when in fact, too many drugs workers are unable to identify the
issues even when they are spelled out for them.

The expansion of drugs agencies over the last ten years or so has been
fueled by political pressures and the availability of money, rather than any
proven success at addressing a particular problem. Much of what drug
services do is about justifying their existance or building empires and
securing salaries, rather than addressing problems effectively. That said,
there are many good, committed workers out there who will do their best to
help you, and even the ones who aren╒t can be useful if you learn how to
work the system and play the game.

The key thing to remember though, when it comes to drugs services, is the
principle ╘let the customer beware╒.


Who are you doing it for?

When you begin to think about getting some kind of help for a drug
problem, you need to think about what it is exactly that you want to do and
why.  When people are asked why they first enter drug treatment of any
kind, the first bunch of reasons in the list above are much more common
than the last.  A drug problem is something that depends largely on
definition. For many people, their only problem is how to get enough
drugs, or enough money to pay for them.

Fair enough. this booklet is not trying to force anyone to stop using drugs.
Drugs are cool, exciting, and they make you feel good. We know that this is
true, or else why would you be in such a mess. The goal of most forms of
treatment is to try and convince you otherwise. I╒m sure that you╒ve all
come across them before ╤ well-meaning, social work types with their L
registration cars and their ú90,000 houses in the bohemian part of town.
Took a couple of whiffs on a joint once when they were a student and now
they talk about ╘my hell on drugs╒.

The first thing to say is that if you are looking for a miracle cure, look
elsewhere. Only God works miracles. The only totally effective treatment
programme I know of was in China. First time they caught you, you got
twenty years in the re-education camp. The second time, they used the
magic bullet. The one to the back of the head. And even that was only
effective because you knew that they would catch you. If people thought
they could get away with it, they╒d use, death penalty or no death penalty.

As with drugs, different things work for different people. If you are
seeking treatment because you genuinely are motivated to try to stop using,
then you stand a very strong chance of succeeding regardless of what type
of treatment you choose. However, you can probably increase your chances
even further if you pick a type of help that suits to your personality and
your circumstances.


Why do people use drugs?

People use drugs for an wide range of reasons. Some people use
intoxicating drugs for religious reasons, like the communion wine in this
culture, smoking ganga in Rastafarianism or drinking the sacred brown-
mixed among that curious North-Western tribe, the Tetleybittermen. Others
use drugs to medicate illness, like some of the the community care cases
that we all know and love.

Fact of the matter is, a great deal of drug use, legal and illegal, does not
produce any problems. However, some people and some drugs just don╒t
mix. For every one person who can use the brown on high days and
holidays, there╒s another ten who are sitting clucking in a cold flat because
they are too sick to get out on the street and sell their arse. For every one
person who likes a line of charlie before they go out trying to pick up a
lover, there╒s another who just sold their house because they couldn╒t keep
from spending the mortgage money on rock.

Treatment usually seeks to do one of two things. It either attempts to
stabilize one╒s drug use, to reduce the harm associated with it, or it seeks to
help you achieve abstinence from drugs. Which, if either, of those two aims
is yours is something that only you can know. However, it does help if you
are clear about what you want. Too often, people go along to drugs agencies
and think, ╥what is the best thing to tell them in order to get what I want?╒
Perhaps we should just tell them what we want, because you╒ll only get
whatever it is they are going to give you, regardless of what you say.

Some theories of drug addiction argue that drug users will never stop until
they reach rock-bottom. Different people reach rock-bottom at different
times. Some never do. Drug addiction is a relatively new phenomena in
Britain, but as far as we can see, some people may continue using all their
adult lives. The negative consequences of drug use are a product of the
relationship between drug, the mind-set of the individual using them, and
the social situation in which the drugs are taken. Thus, somebody who
injects large amounts of diamorphine on a daily basis to relieve the pain of
cancer is not regarded as having a drug problem, whereas somebody who
smokes a large amount of brown to relieve the pain of living is seen as
having a very serious problem indeed.

Academics have rightly pointed out that a great deal of the harm that is
seen as being caused by drug use is in fact a product of the way that society
reacts to the issue. So one of the most common problems is the illegal status
of drugs, which causes people to experience problems with the police and
the courts. This also drives the prices of drugs artificially high, and so some
people end up committing crime to pay for their habit. These harms may or
may not be the fault of society, nevertheless, they are still harms. If you
are experiencing problems as a result of your drug use, it is easier to
change your own patterns of drug use than it is to change society.

What is the nature of your problem?

Your first step on the route to resolving your problem, is to try to identify
just what the problem is. Other people may feel that they know what the
problem is ╤ you take illegal drugs. This, in itself, rarely constitutes a
problem for anybody. On the other hand, you might be experiencing so
many problems that you can╒t sort out which ones are related to the drugs
that you are using, from those that are simply a part of your day to day life.
Some people will be quite capable of identifying their problems for
themselves, whereas others may need some help with this.

For such people, a drug advice and information centre will be the first port
of call. These services used to describe themselves as ╘counselling╒ services
and were avoided like the plague. Staff tended to be either well-meaning
do-gooders who didn╒t have a clue, or they were just corrupt know-
nothings who were earning Brewsters╒ for sitting on their arses. This last
group were infinitely preferable to the first lot. If you weren╒t careful,
they╒d be trying to persuade you to do a ╘family sculpt╒ or tell your feelings
to a chair. Fortunately, these are now an endangered species, although
they can still be found in certain parts of the country.

Anyway, a good advice and information project can sit you down and try to
help you identify what your problems are, and give you advice on what the
various options are. Bad ones will identify problems that you never
recognized as problems and tell you that only they can help you get over
them. This booklet intends to play a similar role, but it cannot give specific
information about services available in your area, so ask your friends, see
if any of them can recommend a good drugs agency or worker.

Harm reduction

Many services claim that they now operate according to a ╘harm reduction╒
philosophy. This rather grand term means that some drugs workers have
finally started listening to drug users rather than pretending that they
know it all.

Before we go any further, I must point out there are some experts who feel
that the very idea of frug treatment is a nonsense. They believe addiction is
not a ╘curable disease╒, but a particular set of goals and values. Some people
like to take legal drugs like alcohol and tobacco, other like to take illegal
drugs like cocaine and heroin. Some people like to spend ú1000 a week
skiing, others like to spend ú1000 a week on crack. Because of the difficulty
in actually defining what the problem is, there are similar difficulties
coming up with forms of treatment that are effective with even a majority
of people who enroll in any particular programme. There is an old saying
in the drugs and alcohol treatment field that goes, ╥It doesn╒t matter what
you do, a third get better, a third get worse, and a third stay the same.╙ For
this reason, a wide range of treatment options are available, some very
different to others. Hopefully, this booklet will help you choose the one
that best suits you.


What services are available, and where do I get them from?

Advice/Information

The drug advice and information service should probably be your first port
of call. Unfortunately, most areas dont have a stand-alone advice and
information unit ╤ they tend to be part of a bigger project, such as a Drug
Dependency Clinic or a counselling service. Where this is the case, those
agencies might not be quite so committed to the quality of the advice and
information that they give out. Test them, ask the workers questions that
you know the answers to in order to see whether they know the answers as
well. That should give you some insight into the quality of the advice or
information that you get from them.

These agencies do what they say they do ╤ offer advice and information. If
you╒ve got a problem, they╒ll have suggestions as to what you should do
about it. They should also be able to refer you on to a more appropriate
service if necessary. Unfortunately, because many advice and information
services are also counselling agencies, and because the people who fund
counselling services want to see results (i.e., numbers), many agencies will
immediately suggest that what you need is a spot of counselling (see below)
and can you come back next week.

Therefore, you should be clear about what it is that you want. If you want to
have a chat about your drug use with some sad old dear once a week, then
that╒s fine by me. If you want to secure a supply of methadone , or you want
to come off, then there may well be other, more appropriate services.


Counselling

In the early eighties, counselling agencies dominated drug service
provision in the U.K. There are a number of historical reasons for this.
Before the eighties, there were only a few drug dependency units in the
U.K., mostly dealing with old heroin addicts from the sixties. When the new
wave of brown heroin flooded the country around about 1980, parents
began screaming ╘what are you going to do for little Johnny╒. By this time,
maintenance prescribing had fallen out of fashion, so many local
authorities funded voluntary sector drugs agencies.

Of course, they were set up by people who had little idea what to do about
the issue. So they looked around. Drug Dependency Clinics are run by
...psychiatrists. What do psychiatrists do?  They cure people by talking to
them. (In fact, they really cure people by giving them drugs or ECT, but
how were they to know that?) Anyway, psychiatrists are expensive, so
perhaps we should hire counsellors?

So what is counselling? Well, there are almost as many different types of
psychotherapeutic counselling as there are counsellors. In classical
Freudian psychotherapy, you would see a highly-trained therapist as often
as three times a week, every week for a year. At the other extreme, you are
more likely to see somebody who has been on an eight-hour, introduction-
to-counselling course. Furthermore, the quality of counsellors is also very
patchy.

The basic idea is that by talking about your problems with a non-
judgemental counsellor, you can be helped to see the obstacles thus
bringing about change. What the funders weren╒t aware of, is the fact that
at the heart of most models of counselling, is the idea that the victim (oops,
sorry) that the client sets the agenda and decides what changes they feel
they want to make. The problem being, that at any given time, a majority of
drug users actually don╒t want to stop taking drugs, and those that do rarely
find that counselling offers them any concrete help with that process.

As a consequence, drugs counsellors have tended to focus on the other
areas of the client╒s lives. If you do have a particular problem, for example,
past sexual abuse or some emotional difficulty, then you may find
counselling helpful. However, it is not a ╘cure╒ for addiction, nor is it a
magic wand that can change the way that you think and feel overnight,
and a more specialized counsellor, like a sexual abuse therapist or a
marrage guidance counsellor might be better trained and more
experienced. So before you enter into a counselling contract, get the
counsellor to justify what they think they can offer you, and why.
Remember, they are providing a service, and if you don╒t think that what
they offer is appropriate, then you need to tell them that.


Out-patient detox.

If you want to stop using opiate drugs like heroin and you find that you are
unable to stop, one option is to go for an out-patient methadone detox. At
one time, it was difficult to find a doctor who was prepared to prescribe
methadone. However, in recent years there has been an enormous
expansion in the use of methadone.

A few words about the pro╒s and con╒s of methadone might be in order
here. Methadone is a synthetic opiate. This means that it was chemically
synthesized, rather than comes from the opium poppy, and has very
similar effects to natural opiates. Doctors like to use it in preference to
heroin for a number of reasons. This means it stays in the body for a long
time, unlike heroin, which only lasts a few hours. It can be prescribed in
an oral mixture, which is intended to break the injection habit, and if it is
prescribed in high doses, it becomes difficult getting enough heroin to
have any impact.

On the other hand, it is regarded by many as producing an inferior buzz
and being more addictive than heroin. Withdrawals are felt to last longer
with a methadone habit than a heroin habit. Also, it does seem that those
people who go onto a methadone script are likely to stay addicted for longer
than those who don╒t, although they may also suffer fewer problems than
those who avoid methadone.

If you want to try a detox, remember that methadone isn╒t the only option.
Some doctors may be prepared to use di-hydro-codeine (DHC, DF118) or
benzodiazapines or both. You need to decide which one you think is best for
you.

Where to get an out-patient detox?

The obvious first port of call is your family doctor. In the past, many G.P.╒s
would throw you off their list if they knew that you had a drug problem.
Today, many of them are more sympathetic. If he╒s not prepared to take on
the task himself, ask him to refer you to your local Community Drug Team
(CDT) or Drug Dependency Clinic (DDC). Many drug clinics will not take you
onto their list unless you have first been referred by a G.P.

Another alternative is to go to your advice and information service. If
there is a waiting list at the DDC/CDT, they might well be able to fix you up
with a G.P. who will take you on to his or her list for a detox. Finally, if they
aren╒t any use, try approaching your Family Health Service Authority and
telling them about your needs. They should be able to put you in touch with
a doctor who is prepared to treat you.

Methadone maintenance

If you are experiencing problems as a result of opiate addiction and you
either don╒t want to come off, or you can╒t manage to do it, you might want
to think about methadone maintenance. This means that you will receive a
maintenance dose of methadone for an extended period, until you feel
ready to try to stop.

At first, this sounds like a good deal. Free, legal drugs for as long as you
want. However, there are drawbacks. Any addiction involves some
surrender of personal freedom. On methadone maintenance, you have to be
at the chemist, every day to pick up your script. You need to attend the
clinic regularly. Your life is no longer your own ╤ key decisions about
what you can or can╒t do will be made for you by a doctor or nurse.
Sometimes, you may have to have to suffer the indignity of giving a urine
sample to check whether you are using the drugs that they give you, and to
check that you are not using on top. Again, I should stress that enrolling in
methadone maintenance is likely to extend the period for which you are
addicted.

On the other hand, compared with having to find large sums of money
every day, then finding a dealer who won╒t rip you off, only to find that
the gear is lousy and hasn╒t sorted you anyway, methadone maintenance
might be a good deal. Once again, it╒s a matter of personal choice,
dependent on your particular circumstances.

Where to get methadone maintenance

If you do want methadone maintenance, it is most likely to be available at
your local Drug Dependency Clinic or Community Drug Team. Some G.P.╒s
may prescribe methadone on a maintenance basis, but they are rare and
they usually prefer it if you╒ve already been assessed by a specialist drug
service first. On the other hand, many DDC╒s or CDT╒s will only take people
who have been referred by their G.P. Your local drugs advice/information
service should be able to give you the details of your local services.

A brief word about heroin maintenance

In the golden era, before 1967, all doctors were allowed to prescribe heroin
and cocaine for the treatment of addiction. However, this facility is now
strictly limited to doctors in possession of a special license from the Home
Office, most of whom are Consultant Psychiatrists who work at Drug
Dependency Clinics.

Although there has been a great deal of debate lately about the desirability
of such prescribing, the actual number of doctors who are prepared to do it
is very small, and those who will prescribe heroin or cocaine tend to only
do it for a limited number of people. Why? Well, the reasoning seems to be
that you can attract more people than you can treat by prescribing
methadone, why bother? So all that I╒ll say about heroin maintenance is
that it is theoretically possible, but it isn╒t very likely.

In-patient detox

If you find that you can╒t manage to stop taking drugs because the
temptations around you to continue using are too great, you might benefit
from an in-patient detoxification. These usually take place in a special
hospital ward called a Drug Dependency Unit, although you could also end
up on a general psychiatric ward. Some of the residential drug
rehabilitation units (rehabs) are also now beginning to do in-patient detox,
although this may be conditional on your agreeing to sign up for the full
programme when your detox is complete.

In-patient detox usually involves a relatively rapid reduction that may or
may not be supplemented with sleeping medication once the methadone
has stopped.

A recent development has been the rapid naltrexone detox. This involves
being put to sleep with large doses of sedatives, then being given opiate
antagonists to flush the opiates out of the system. Although the worst of the
turkey is done while you are asleep, your sleep patterns will still be
disrupted for up to a month afterwards. Furthermore, this type of detox is
physically traumatic, so requires a great deal of nursing attention to
monitor the sleeping patient. In drug withdrawal, as in life, there are no
short-cuts.

Besides the medication, some hospitals also provide some kind of
psychological therapy which may or may not be compulsorary. As with
counselling, the nature and the quality of the therapy of offer is very
variable. Some hospitals have well thought out programmes based on
relapse prevention models, while others just have free-form encounter-
type groups.

There are a number of advantages in going into hospital to do a detox. You
are removed from your immediate environment, which can give you a
break from the everyday pressures of your life, and remove some of the
temptation to go out and score. However, detox units are no different from
anywhere else and you can often still score on the hospital ward. You are
also going to have to face those pressures once you get out, so the situation
is an artificial one, but the achievement involved in actually getting drug-
free may well help you sustain your resolve.

The type of therapy that is on offer at these places seems to have little clear
discernable impact upon outcome rates. All detox programmes have a high
drop-out rate and a high relapse rate, so you should not go in expecting a
magical cure. The best predictor of success in drug treatment is the
motivation of the patient. If you are really determined, you can get clean.
If you find that you continue to relapse, then rather than doing detox after
detox, you might find that you need the longer and more intensive regime
of a residential rehabilitation programme.

You can get information on in-patient detoxification facilities from your
G.P., your C.D.T. or D.D.C., or from your local drug information and advice
project.


Residential rehabilitation

Residential rehabilitation is the big daddy of drug treatment options. They
usually involve a long stay, usually anywhere from six months to two years
(though programmes are getting shorter).

There are  several different types of residential rehab (also known as a
therapeutic community). They include:

Concept Houses ╤ concept houses have a particular theory of addiction and
recovery, sometimes specific to that organization, sometimes just based
upon the Minnesota Method and the twelve step programmes.

Religion-based therapeutic communities - it is rarely a condition of
acceptance that one accepts the religious principles that inform the house,
although there is usually some attempt to proselytize for a religious point
of view.

Non-ideological residential rehabilitation units - These are lacking a
single, organizing dogma like the first two types and tend to use an eclectic
mix of counselling, groupwork, relapse prevention, etc.

Rehabilitation or brainwashing? The difference between the two is simply
a matter of personal values. The aim of the residential rehabilitation unit is
to totally restructure the personality, changing you from a person who
thinks that drugs are a reasonable way of dealing with your problems, into
a person who thinks that drugs are damaging your life, perhaps even
killing you.

Residential rehabs polarize the views of ex-residents. Some people believe
that it was their stay in a rehab that saved their life. They are usually the
final option when all other methods of help have failed, and are presented
to the drug user as just that ╤ their last chance.

Other people though, feel that the rehab that they stayed at actually
damaged them. There has been little independent control or regulation of
rehabs, and in the past, they tended to make extensive use of programme
graduates, who would perpetuate abusive situations in the name of
╘therapy╒.

Some examples:

In one rehab, a female resident is told that she will not recover from her
addiction unless she participates actively in the group therap[y sessions.
She is encouraged to talk to the group about her experience of being
sexually abused by her father. However, not all of the residents are
committed to the therapeutic process. Some of the men regard this as as a
sexual fantasy. Back on the streets a few weeks later, they gossip about her
experiences.

In another rehab, residents are woken up in the middle of the night. All
the clocks are removed, all windows are shuttered. Staff begin a marathon
session of sensory deprivation lasting several days that is intended to assist
residents to regress to the point at which they were born. One resident
suffers a total psychotic breakdown and is transferred to a psychiatric
hospital.

The major problem with residential rehabs, is that they are often staffed by
people with very little training, but who believe that they have the
magical power of cure. Because there is no single model of how best to deal
with a drug problem, what you get is any number of competing theories. As
a result, the idea has been spawned that anybody can be a drugs worker. No
specific training is required, all you need is for somebody to give you a job
╤ you╒ll pick it up as you go along.

In this context, the ex-user is a good idea. At least they understand the
scene, and they know what worked for them. More numerous though, is the
type that has trained to be a counsellor in order to better understand their
own pathologies. Then they decide that they want to put their new found
skills to the test ╤ and drugs has recently been one of the few growth areas
for a trained counsellor. Unfortunately, some of these workers are just as
dysfunctional as any drug user ╤ but they are less likely to get into legal
difficulties as a consequence.

You can learn a great deal during your stay at a rehab. You can learn about
yourself and why you do the things that you do. You can learn work
discipline, and get experience of what it is like to take on managerial
responsibility. You can learn that it is possible to live without drugs for an
extended period. Like in-patient detox, it is something of an artificial
situation, but most rehabs make some efforts to slowly re-integrate
residents back into the outside world.

However, they tend to be rigidly heirarchical, and necessarily go in for
somewhat strict discipline which can sometimes verge on the abusive ╤ for
example, you might be forced to wear a jesters outfit for a week if you
continuously crack jokes, or you might have to walk around with a big
placard round your neck, telling the world that you are a liar and a thief or
subit to some other equally demeaning practice. The point of all this, is to
break down the old ╘addict╒ personality and replace it with a new ╘healthy╒
or ╘non-deviant╒ personality. Like all forms of treatment, far more people
relapse and return to use, but for those who are committed to attempting to
stop using drugs, it is a strategy that works for some.


Self-help groups.

A self-help group is any group of people who come together for the
purposes of supporting each other through a problem. Perhaps the largest
and best-known of these groups is Alcoholics Anonymous, but there is laso
Narcotics Anonymous (which focuses of drugs, both prescribed and illegal)
and more specialized ones like Overeaters Anonymous and Sex Addicts
Anonymous. Most of these groups are ╘twelve-step programme╒, which
means that they are based upon the twelve step model of Alcoholics
Anonymous.

Adherents of these groups claim that Twelve-step programmes are really a
spiritual rather than religious programmes. The steps combine a set of
tried and tested methods for staying drug or alcohol free, with a quasi-
religious authority that exhorts members to change the things that they
are able to change, and rely on a higher power to take care of the things
that you can╒t change for yourself.

Many people baulk at the overt religious nature of N.A., but it does have
advantages over other drug treatment programmes. Support comes, not
from paid workers, but from other people who have shared the same
situation, and therefore often have a level of insight into the type of
behaviour that addicts go in for.  This results in a much greater level of
commitment, and NA groups often provide a circle of support during that
difficult period after stopping use. NA╒s strength is that it can pass on the
stored experience of hundreds of thousands of addicts (which is how they
prefer to be described) about the things that work for them in their
struggle to stay drug free.

Although the 12 step movement is not anything like as big in the U.K. as it
is in America, there are still groups in most areas. You can find out about
your local group by ringing World Service Organization at ?, or ask at your
local advice and information or other drug service.

So finally....

As you can see from this booklet, drug treatment is an enormously varied
field with incredibly diverse standards. Some things you might find
helpful, others you won╒t. The key to success is to shop around, find out
what suits you.

You should also remember, the majority of people stop using drugs on their
own, without any help. Ultimately, the real work has to be done by you.

Drugs services can give you medication, a place to do it, advice,
information, skills and contacts. Some people find that they get useful
emotional support from a drugs worker but the vast majority don╒t. That╒s
why the user groups like NA and others exist ╤ so that people can get
support from those who have experienced these problems and discovered
solutions that work for them.

Whatever stage in your life you are at at the moment, remember, you still
have the whole of your future ahead of you. It╒s time to start making the
most of it.

Good luck.


(c) Peter McDermott, Lifeline, 1993