TREATMENT EXPERTS

DR. ALAN I. LESHNER

[He is Director of the National Institute on Drug Abuse.]

What is drug treatment?

People tend to think of drug treatment as a simple unitary thing. That's
not true. Just like you don't have a single treatment for hypertension or a
single treatment for diabetes, you don't have a single drug treatment. Drug
treatment is composed of a series of elements and components. Some of it is
biological, like medication. Some of it is counseling. Some of it might be
mental health services. Some of it might be housing services.

Treatment is the constellation of the entire set of events that helps the
individual to: A, stop using drugs; B, to return to society; C, to deal
with all of the cues that surround drug use and might trigger a relapse. We
have to help the individual resist the inevitable craving to go back to
using drugs. The ultimate goal of drug treatment is not only to get an
individual to stop using drugs, but to restore them to being a functioning
individual--in their home, and in the workplace, because if they're not
functional, they'll go back to using drugs. And then the cycle starts again.

What are the major treatment problems that you encounter?

The biggest problem in drug treatment is actually keeping people through
the initial period of abstinence and detoxification--getting people to stay
in treatment long enough for it to have an effect. Many, many people enter
a treatment program, discover this isn't going to be a bundle of fun, and
take off virtually immediately. And over time, treatment needs boosters.
You need ways to keep an addict in abstinence, to prevent relapses.
Luckily, now we have techniques for that. What seems to be most difficult
is getting the patients matched up with the treatment programs.

Is there a big difference between the effectiveness of voluntary treatment
and coerced treatment?

Very few people enter treatment truly voluntarily. There's an old saying
that all people are in treatment either because they're court-mandated or
"mommy mandated"--someone in their family has insisted on it. There's a
myth out there that you have to want drug treatment in order for it to
work. That's not true.

Studies have showed that "coerced treatment," that is, mandated treatment,
leads to longer treatment retention times--people stay in treatment longer.
And the best predictor of success is the length of time that you're in
treatment. Voluntary treatment is good. But if you have someone under the
control of the criminal justice system, two things are true. One, you can
use that control to get a person into treatment, and they'll likely have a
good outcome. And the obverse is also true: it's foolish not to force an
addict into treatment while you have them under your control.

When crack addiction first appeared, did you think it was treatable?

We didn't know anything about crack. We knew about addiction, and we did
have an array of effective treatments in the clinical toolbox. But crack
showed us that there really is no single thing known as "drug treatment."
The most important clinical lesson is that even if all crack addicts look
the same, you can't treat them all the same. What we learned from the crack
addicts is that we have to match the array of services to the individual,
to the severity of his or her addiction, and then to the environment
they'll return to.

When crack cocaine came onto the scene in the 1980s, what was the treatment
situation like?

Treatment was developed on the basis of experience--the idea of "I'm a
former addict, this was my experience." Some of that treatment turned out
to be outstanding. But it wasn't rigorously and systematically developed.
When the crack epidemic hit, people basically had no idea what to do about
it. What we were missing in the 1980s was an understanding of the drug
itself, and an understanding of what the drug did to individuals. We needed
to refine the treatment approaches for that specific drug.

I wish it didn't take us so long to figure out that crack addiction is
truly a bio-behavioral disorder. We have to attend not only to the
behavioral symptoms, but also to the fact that a crack addict is in a
different brain state. If we'd known that in the 1980s, we might have had
the sense to make a far more systematic and substantial investment in
treating those people. We wouldn't ask for a simple solution to another
brain disease; we invest in long-term rehabilitation for stroke victims and
schizophrenia.

Is treatment more effective today?

The quality of drug treatment in the late 1980s was good. But now drug
treatment is very good. We've seen the advent of a much more formalized
treatment process, or set of processes. Different programs use different
approaches, but they've become much more systematic. Let me give you one
example. In the last two years, we, the National Institute on Drug Abuse,
put out four manuals, laying out step by step exactly how you do cognitive
behavioral therapy for cocaine addicts. We didn't have that ten years ago.
We didn't have a prescription, or protocols of how you go through a
treatment process. It was much more day by day, "Figure it out as you go,
use your own personal experience," as the backdrop. It worked, but not
nearly as well as our current techniques.

What was the attitude of policymakers when the treatment world was learning
how to deal with crack?

We've lived for decades under a sort of philosophical polarity. There were
people who saw drug abuse and addiction as a moral failure and a weakness,
which we needed to approach solely from a punitive approach. Deep in their
hearts, many people believe that drug addicts did it to themselves,
therefore they're bad, and the only way to deal with them is to tough it out.

And at the other end there were people who were compassionate for the drug
addicts, and worried about the reasons they got into addiction. Of course,
it's a combination of the two. Drug use is a voluntary behavior. You do
make the initial choice to use the drug. The problem is that, over time,
the drug use changes your brain in fundamental and long-lasting ways, and
you develop, in effect, another brain state. The person you're dealing with
isn't the same person who started using drugs voluntarily. They can't exert
the same level of control.

The problem historically--and I'm sorry to say it hasn't changed that
much--is that there wasn't a lot of public confidence in the ability of
drug treatment to help deal with the problem. There was a lot of disbelief
about the effectiveness of treatment. I also don't think our treatments
were as sophisticated as they are now, a decade later. Science has given us
a lot of techniques used to help in the recovery process and in the
treatment process.

Since the 1980s, have attitudes changed?

The biggest proponents for drug addiction treatment today are people in the
criminal justice system. That's a significant change from what you saw 15
years ago, when the attitude was, "Lock them up, get them out of my face,
warehouse them if you have to." Today, the criminal justice system
advocates treatment, either as an alternative to incarceration, or during
incarceration, if people have committed crimes. What we've learned now is
that you can't warehouse that many people. And if you send them out on the
street again without treatment, they'll be back--back committing crimes,
and back using drugs.

Do you see a visible success rate with treatment today?

There's no question that drug addiction treatment is effective. The success
rates for drug addiction treatment--50 or 70 percent, depending on exactly
what you count--is absolutely comparable for that of any other chronic
relapsing illness, whether it's the control of hypertension, diabetes, or
asthma. But the problem we have with drug treatment is the same problem
that we have with other chronic illnesses: people don't adhere to the
treatment regimen. If you don't take the whole course of antibiotics,
you're not going to get better. If you don't take the full course of drug
treatment, you're not going to get better.

There's a tremendous database that shows, depending on the study, that for
every dollar you invest in treatment, you get between four and seven
dollars back in savings in "societal benefit." And all of the analyses have
shown that 50 to 60 percent of those people who complete a treatment go
back to full work productivity in a relatively short period of time. If you
think about the price of a drug addict, you have to think about not only
their drug use, but also the crimes they commit, what's happened to their
family, and the healthcare costs that we incur because of it. So drug
treatment is tremendously cost-effective. There's this sort of myth out
there that drug addiction treatment doesn't work very well--but look at the
data.

Do policymakers recognize the value of treatment?

I think it's only in the last few years that we really are seeing people
both in the general public and in the treatment community who understand
addiction to be the illness that it is--a brain disease. And I think what
we've learned now is that we have to have systematic protocols that you
follow that are similar to the treatment protocols you'd use for any other
kind of illness. But there's a terrible treatment gap, and that gap has to
be filled.

I think that the misunderstanding about the nature of drug abuse and
addiction is at the core of much of the problems we've had over the past
couple of decades. If you see drug addiction only as a failure of will, as
a moral weakness, then your corrective approaches are going to be that
simplistic. And they're not going to work.

We still have about four million hardcore drug users in this country, and
only about half of whom have ever had any treatment experience at all.

How do heroin and crack addiction differ?

Crack is a very different substance from heroin. Heroin sort of mellows
people, whereas crack is a stimulating substance--addicts are hyperactive.
Crack cocaine withdrawal is very different from heroin withdrawal. People
on crack would go into these phenomenal depressions without having physical
withdrawal symptoms.

Do you think crack use has significantly declined since the 1980s?

I don't think so. Drug use has always been cyclic. There have always been
rises and falls, which I think are tied pretty much to the perception of
harm. After the late 1980s, the general population did become a bit more
sophisticated, more knowledgeable, about what crack could do--how it could
take over your life, hijack your brain and hijack your life.

But we go through these cycles where we have mass hysteria about the drug
problem, then we make a little bit of progress and we say, "Okay, now
things are terrific."

There's a mistaken relaxation of concern around crack. Too many people
think there is no longer a crack problem, because the numbers aren't going
up anymore. Well, that's wrong. Things aren't terrific. We still have
terrible drug problems in virtually every community in this country. In
fact, studies just released show that drug use amongst young people in
rural environments is actually higher than it is in urban environments. The
truth is that crack cocaine is not over. We still have millions of people
who are addicted.

There seems to be a lot of focus on whittling down the number of casual
users. Does this mean that what's left is a hard-core, perpetually addicted
population?

What most people don't realize is that the majority of long-term, hard-core
drug addicts are dying in their 40s and 50s. The latest studies show that
the life expectancy of a drug addict is 15 to 20 years after they start
being a drug addict. So what we see is a replenishment of the population, a
new crop of addicts. There are no 90-year-old heroin addicts. Most of those
we were recording 20 years ago have died. The numbers are relatively
stable, but they're constantly being replenished.

Who are the hard-core addicts?

When we talk about hard-core addicts, we mean very, very heavy drug
users--whether it's heroin, crack cocaine, powdered cocaine, or the
methamphetamine we now see in the West and the Midwest. When we say
"hard-core addicts," we're talking about people who use large quantities of
drugs, and who are addicted to the point that their drug use interferes
with the rest of their lives. From a medical point of view, what matters in
addiction is the compulsion to use drugs in the face of tremendous negative
consequences.

Our best estimates are based on people using regularly, though this varies.
Some people who are very heavily addicted are using multiple times a day.
Heroin addicts typically inject three or more times a day. Crack cocaine
addicts, when they are bingeing, are taking another hit every 20 to 30
minutes. But the exact number and the exact definition of "hard-core
addict" is a very complicated issue, and very controversial. We don't
really know exactly how many addicts there are.

How important are the hard-core addicts to the market of drugs, and the
problems associated with them?

There's no question that the hard-core constitutes the largest percentage
of the drug market. They are using tremendous quantities of drugs in a day,
in a week. They drive much--but not all--of the market

What are the major problems with drug treatment policy today?

My own belief is that we need to get treatment going far earlier than we
do. The historic approach has been to wait until somebody is a terrible
mess. Then you've got them in jail, or their family has forced them into
treatment, and you have to work tremendously hard to get them to stop using
drugs. From a clinical point of view, I think everyone would agree that the
earlier you can intervene, the greater the probability is that you can
actually prevent the transition from occasional drug user to addict.
Because once you've gone over that point--once the switch has flipped in
your brain, and you're no longer under voluntary control--then you're a
compulsive user. You're an addict. And treatment is far more difficult than
it ever was before.

Is there an appropriate response for the casual drug user that's different
to the response for a "hard-core user?"

There are lots of things that you can do with a voluntary drug user that
you can't possibly do with someone whose drug use is frequently out of
control, who is truly compulsive. We make distinctions, both from a
prevention point of view and from a treatment point of view.

Why does public policy link crime to drug use?

The relationship between drugs and crime is not a simple one. Using,
selling, and having drugs is illegal. However, many people who are drug
addicts go out and commit other kinds of crimes in order to secure the
resources to keep their drug habit going. So as General McCaffrey says, "If
you hate crime, you'll love drug treatment." Drug treatment is the most
effective way to reduce the criminality associated with drug use.

What would you say is the main story about drugs in the 1990s?

The biggest story about drugs in the 1990s is methamphetamine.
Methamphetamine is a sad, but fascinating phenomenon. It has passed across
this country from the Southwest through the West into the Midwest like a
public health plague. It began as an isolated phenomenon in southern
California, and then the Southwest, and then it moved up the West Coast.
And now the largest methamphetamine problems are in the middle of the
country. We don't know exactly why that happened, but the task is to keep
it from spreading eastward.

Is methamphetamine the new crack?

There are people in certain parts of the country who refer to
methamphetamine as the new crack, except that it seems to be attracting a
somewhat different population. Methamphetamine users and addicts tend to be
wealthier, and they tend to be people coming out of working communities
rather than unemployed communities. So we don't know really whether it's
methamphetamine substituting for crack, or methamphetamine as an addition
to crack. But in cities like San Diego, San Francisco, and Los Angeles,
methamphetamine is equal to crack cocaine as a drug problem.

What about the new wave of "designer drugs?"

Club drugs, like Ecstasy, GHB, and ketamine are an emerging drug plague,
especially in the cities around the country. That is what all our early
alert systems are telling us. The task is to get ahead of that plague, get
in its path and prevent it from evolving. It's an emerging drug crisis--one
that is not quite here today. The question is, can we stop it?

The lesson that we learned from the crack epidemic is that when we start to
see a drug problem coming, we have to get in there immediately with a
full-bore intervention. So the National Institute on Drug Abuse has mounted
a major multimedia campaign geared towards young people and their potential
use of these club drugs. We have a special site, clubdrugs.org, and we send
out cards in bars, and record stores, telling people about the dangers of
Ecstasy. We've started this multimedia approach to try to get in the path
of the plague.

PBS Frontline Series Follow Up by Tom O'Connell, Kevin Zeese, Doug McVay,
and Eric Sterling:
http://www.drugsense.org/dsw/2000/ds00.n170.html#sec1

Campaign for the Restoration & Regulation of Hemp's HempTV website has the
full, two part, total of almost 4 hours of video of the PBS Frontline "Drug
Wars" available on the web for free video streaming using the Real Player 8.

To watch Part one of Drug Wars, go here:

http://www.crrh.org/hemptv/docs_drugwars1.html

To see part 2, go here:

http://www.crrh.org/hemptv/docs_drugwars2.html

Click this link for an index to this series:
http://www.mapinc.org/drugnews/v00.n1551.a01.html