TREATMENT EXPERTS

DR. JEROME JAFFEE

What kind of drug treatment did you pioneer in Chicago? How was it
different to what had been done before?

What we were trying to show was that there wasn't any single best road to
recovery from addiction, but that many treatments could work well and
synergistically together. We had methadone programs, we had detoxification
programs, and therapeutic communities. We even had a residential program
for people on methadone, where they could detoxify.

What was the science of addiction and treatment at that point?

It was better than it was ten years before, and nowhere near as well
established as it is today. There was evidence that methadone treatment was
effective. There were some good controlled studies. There was only a belief
in the effectiveness of therapeutic communities. The relapse rates for
those who stayed for a reasonable period of time were low. But we didn't
expect much of detoxification, and we didn't get much from detoxification.
The real issue was whether there were some kinds of people who were better
suited to one rather than the other. Which ones worked best in the long
run? Which did people prefer? I am not certain that anybody can say with
absolute certainty, even today, who ought to go into which kind of program.

Were you seeing a relationship between treatment and criminal behavior?

Lots of the people that we began treating had histories of arrests, and had
been in jail. When we did some of the studies on what was happening after
treatment, there was a significant reduction in those kinds of behaviors.
But totally apart from what we saw statistically, I knew these people
personally. I knew their families. And you could see that their lives were
dramatically different when they went into treatment.

Was there anyone who opposed the use of methadone?

Some policemen in Chicago were kind of skeptical about methadone. Minority
communities were also more affected by heroin, and it was felt that,
"Here's another medicine to control the minority communities, given out by
the white establishment." But we tried to make it clear that this was not
just giving out a medicine. It was a program that delivered a lot of
services in addition.

What were the recommendations of your first [1970] report to President Nixon ?

One was that we needed to do more to evaluate treatment. The National
Institute on Drug Abuse did not exist, and we needed to know more about the
effectiveness of treatment. We also noted that there were a dozen different
agencies funding treatment that didn't talk to each other. There was no
coordination, and they were bumping into each other when they finally got
down to the places where treatment was being delivered. Here were lots of
interacting pieces: law enforcement, epidemics and drug use, treatment and
prevention; the government ought to think them through and see how each one
affects the other. They needed a clear-cut national strategy.

The other thing we said was that, given the extent of heroin addiction,
methadone treatment should not be considered a small research project. That
was in late 1970, when there were at least 5,000 or 6,000 people who had
been on methadone for a number of years. It was not just an experiment, and
it ought to be made more widely available. People were waiting for
treatment, and it could have a real benefit for society. At that time,
there was very, very little in the way of treatment support. The big
resources were still in the criminal justice system.

What happened when you first went to the Pentagon to talk about heroin use
amongst the troops in Vietnam?

I told the assembled generals and the colonels that they needed a program
of testing, so that people who were actively addicted to heroin would not
be just put on the airplane and sent back and discharged, but would be
treated in Vietnam. The news media was saying that maybe fifteen or twenty
percent of the servicemen in Vietnam were addicted to heroin. There were
suggestions in Congress for civilly committing all of these people. The
idea of 150 untreated heroin addicts trained in combat, coming in every
day, was not one that made people feel comfortable. Our plan was, "We'll
test people when they leave. Those people who haven't used heroin will get
on the plane, and those people who have will be our guests in Vietnam for a
little longer, while we make sure they've had at least some treatment."

To the military, this was basically mollycoddling. This was being soft on
the addicts. Under the Code of Military Justice then, if you were found
using heroin, it was a court-martial offense. So in order to institute a
program of universal testing, you had to change that. The president simply
ordered the change in the Code of Military Justice. If you tested positive,
it was no longer a court-martial offense. Later, we were able to reverse
some of the bad conduct and dishonorable discharges that people had
received simply as a result of having used drugs. This wasn't to encourage
drug use, but there was no point in destroying peoples' lives for that kind
of offense.

To get a program like that up and running within two-and-a-half weeks, in
retrospect, was quite unbelievable. The logistics were tremendous. They
built detoxification facilities in Vietnam. They built special places where
you could collect the urine, and they did it all in a couple of weeks. The
new development of urine testing made it feasible to test the roughly 1,000
people who were leaving Vietnam every day. Testing had an immediate effect.
As people learned that heroin use was no longer something that could not be
detected, the tendency to use it dropped. The word got out very quickly
that there is no way to leave this place if you're using heroin.

And so, the soldiers would stop. The only people who would show up as
positive at the point of departure would be those people who were really
addicted, who couldn't stop. There were also people who had been so
isolated from the others, and who didn't hear about the testing, but I have
a feeling they were exceedingly few. What that demonstrated was that even
though heroin remained available and cheap, that sort of intervention could
still reduce the extent of heroin use. We found that, of those people who
were addicted in Vietnam, there was only a five-percent relapse rate over
the first year after returning home. I think, at most, there might have
been a ten-to-fifteen percent relapse over three years. This was totally
counter to everything everybody had expected, at least in the beginning.

Was your primary mission to deal with heroin?

Heroin was the serious drug problem at the time. In 1971, 1972, there was
very little cocaine use. It might have been on the distant radar screen,
but there was almost nobody seeking treatment. Marijuana was also a problem
in terms of drug use, but there was virtually nobody seeking treatment.

What was your sense of Nixon and his own feelings about drugs and drug abuse?

It's clear that he had very strong feelings about it. He felt that drug use
really eroded the fabric of society. It wasn't just that this policy was a
way to reduce crime. Nixon really thought that drugs themselves needed to
be reduced. I felt that it wasn't just for political purposes that he
wanted to do this. He was willing to make some changes in the Controlled
Substances Act, so that first-time offenders would not necessarily be
subject to imprisonment. Nixon seemed very pragmatic. I was given absolute
carte blanche in terms of recruiting. And for the first time, the federal
government was making a commitment to treatment in the community, and to
supporting it. We were able to say that we intended to make treatment
available, so that nobody could say they committed a crime because they
couldn't get treatment. That was a major commitment, and we went about
trying to make good on that promise. I think, for a brief time, we did.

What were the goals of the drug initiative you ran under Nixon?

A national strategy had to be developed, and we had to develop some
confidentiality regulations. One of the issues was that people would not
step forward to get treatment unless they believed that the records would
be protected from the police, who might see this as a convenient way of
finding people that they could arrest. That was a major effort.

And then, of course, there was this issue: if you're going to approve
methadone or something like it as a treatment, there's a whole chain of
consequences that has to be dealt with. Who should be able to prescribe it?
How much? Is there going to be take-home? In a sense, we began this issue
of defining what treatment was in various modalities, and tying the
resources to that. We had to build an infrastructure that ensured people
could basically send out the checks and make sure the treatment was
delivered. We also needed to almost immediately launch some effort to test
how effective that treatment was. We set up things like the household
survey and the DAWN [Drug Abuse Warning Network] system, and the National
Institute on Drug Abuse was put into the original legislation.

We also instituted a program in the drug courts called "treatment
alternatives to street crime," which basically linked treatment with the
court system. It was a way of trying to reduce crime by getting people who
had been arrested into treatment. But the reality was that the kinds of
programs that we were putting into place didn't happen overnight, and there
was at least a year or two before they had their maximum impact--before
people got fully trained and really delivered services. Within a year or
so, you could see the number of programs expanding, and the number of
people coming into treatment expanding. But at the same time, we were very
preoccupied with overseeing the Vietnam intervention.

We knew that what we were doing was probably the right thing to do--that
treatment helped people, so it was a good thing to make available. But we
did not have the data that we now have to show that not only is it helpful,
but it's cost effective. In terms of what society gets for every dollar
invested, it's terrific. We have that data now.

What was unique about the approach to the drug problem during that period
in history?

I had the feeling, almost from the first day, that the willingness to look
at the demand side, rather than the traditional American law enforcement
approach might be a transient phenomenon--that it might pass, and we would
go back to our old ways of more and more law enforcement. And I was right.
We have never had that proportion of federal resources devoted to
intervention on the demand side. We'd never had it before, and we've never
had it since. Up to that time, we had about 65 years of a law enforcement
approach. I wasn't certain that the general attitudes of Congress had
totally changed. It seemed as if every day was an important day in getting
things done, and putting things into place. We really had to move quickly
to institutionalize the treatment system so that it would not just decay
and fall apart when the current interest in treatment faded.

What was your relationship to the law enforcement side of things?

We had discussed that if law enforcement was successful at raising the
price, at reducing the trafficking, more and more people would seek
treatment for their addiction. We saw eye to eye on the way in which the
law enforcement could be synergistic with reduction of demand and so, at
least for a brief time, we saw that they were both needed to deal with a
problem like heroin addiction.

What happened when the medical community discovered the growth of cocaine
use in America?

When the issue was just heroin, and it was limited to perhaps poor,
underclass, inner-city drug users, medical interest was not as great as
when the cocaine spread into the general population. At least for a few
years, the spread of cocaine resulted in an expansion of interest on the
part of medicine in general.

Within the addiction community, did the discovery of cocaine addiction make
you feel like you had to go back to the books again? Was this a significant
problem?

The short answer is, yes. It was clear that we could not assume that
cocaine addicts would respond to the same kinds of treatments as heroin
addicts. You had to go back and start again. At first, there was even a
question of whether there were hardcore cocaine addicts. When cocaine first
came on the scene, some people doubted its addictiveness.

What was the political atmosphere like when crack emerged?

Crack emerged at a time when, at least at the national level, there was a
growing belief that treatment was ineffective. That was the mid-1980s.
There was a general feeling that we had to have zero tolerance for drug use
in general. There was a law enforcement approach that applied to marijuana,
to cocaine, to all drugs. And when crack came onto the scene, the penalties
for sale or possession were escalated. It was portrayed in the media as
even more addictive than cocaine. I felt that this was going to result in a
lot of people serving a lot of time in jail. Some of that long-term cost
could perhaps have been avoided.

Where did the hype surrounding crack come from?

Where people got the idea that crack was instantly addictive is not clear
to me. But once somebody had said it, everybody seemed to repeat it in sort
of an automatic fashion. It became an accepted bit of wisdom that was not
scientifically validated, but was nevertheless a bit of information on
which legislation was made. Mostly, cocaine had been used by inhalation of
the powder, and people were truly concerned about the powerful effect of
taking the drug by inhaling the freebase. This induces an effect, which is
as powerful, in terms of its euphoric effect, as injecting it. But it
certainly didn't make it instantly addictive, nor did it mean that
treatment was impossible. There were also "crack babies." Some women who
used cocaine during pregnancy had babies who had some odd behaviors when
they were born. The fears of brain-damaged kids were perhaps exaggerated,
but still the issue is not fully resolved.

What changes did you see with cocaine use in the 1980s?

By the mid-1980s, we were beginning to see a decrease in casual use of
cocaine. I think the decrease was accelerated when the media widely
publicized the death of Len Bias. There was the case of an athlete in great
physical condition who died after what was reported to be his first
experience with cocaine. There were some other deaths also given wide
publicity at the same time. And in that sense, the media probably gets some
credit for publicizing the deaths of otherwise healthy people. I think that
brought home to the average user that cocaine was not benign; that there
were real risks to a life in using it. Fads also pass, and people move on
to other things. And so casual use dropped, but hardcore use did not.

So what we got was a kind of residuum of a large group of hardcore users
who seemed unable to break their association with cocaine. That group was a
lot smaller than the millions who had used it casually, but we believed
them to be responsible for a lot of the cocaine-associated crime. I don't
see that it was primarily law enforcement that brought about the decline in
casual use. I think it was far more an appreciation by the public on the
real dangers of this drug.

The other part of the decline is that, by the late-1980s, we started to get
some notion that treatment was effective. There was very little treatment
available for cocaine use in the mid-1980s, and certainly none that had
been carefully evaluated. A lot of people say it should have been supported
more generously, but at least something was better than nothing.

How did the moralizing of the drug issue affect treatment?

Making something illegal, declaring it to be somewhat immoral, often gets
the great majority of people often adhering to that. But it also results in
a stigmatization of those who deviate: the sinners. There's then a
reluctance to invest in the redemption of the sinners, at least in those
terms. There is a belief that people who behave that way must therefore be
immoral, and perhaps a little unworthy of treatment. It is a very difficult
balance to achieve.

How does the availability and quality of treatment today compare to
treatment in the 1970s?

When you adjust for inflation and you adjust for the number of people who
need treatment, I don't think that support for treatment, at least within
the public sector, is actually as generous as it was back in the 1970s.
Treatment that the public sector is able to deliver is just not of the same
quality that it was 25 years ago. I think the people who are involved in
treatment are more knowledgeable, and often they're better trained, but
they're overworked. I think that they try to see too many patients. And I
think they're under continuous pressure to somehow do more with less.
Inevitably, this is going to reduce the effectiveness of treatment.

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