THE NIGHTMARE OF RECOVERY

A Powerful New Book On The Drug War's Trenches Argues That Treatment
Is The Answer -- But Our Current System Dooms More Addicts Than It
Helps.

Those who believe, as most sensible people do, that the current war on
drugs is a boondoggle and a disaster also usually say that we ought to
be spending our dollars on treatment, not law enforcement, if we want
to diminish the trade in illegal drugs.

As long as rampant demand -- in the form of a buzz-hungry populace
with fistfuls of ready cash -- waits inside our borders, enterprising
individuals and organizations in other countries will find a way to
supply it, no matter how many helicopters we send to Colombia or
smugglers' boats we seize off the coast of Florida. Menacing teenagers
will shoot each other on street corners and grizzled bikers will cook
up methamphetamine in backwoods sheds provided there are enough
people, in the end, willing to pay enough money for those little
packets of white powder. (Or at least as long as selling that white
powder remains against the law, but let's stay in the realm of
political possibility.)

But if "treatment" has become a buzzword for citizens tired of seeing
billions of their tax dollars wasted on hunting down South American
drug lords and warehousing nonviolent offenders in prisons, Lonny
Shavelson, a physician and journalist, argues that it's often not a
whole lot more than that. In his new book, "Hooked," which follows
five addicts through the torturous process of getting help for their
substance abuse problems in San Francisco in the late 1990s, he makes
a powerful case that America's drug treatment program is hopelessly
flawed.

Despite "a burgeoning movement in states across our nation to shuffle
drug offenders from prison to treatment," he writes, "before we shift
hundreds of thousands of addicts into rehab, we must first treat the
treatment system."

As these five stories unfold -- at times "unravel" seems the better
word for what happens -- the truth behind Shavelson's prosaic play on
words becomes agonizingly clear.

Lives are ruined and lost, hearts shattered, precious second and third
chances squandered, trusts betrayed, hopes stubbed out. And, in a few
rare cases, people do manage to miraculously pull themselves out of
the pit. Shavelson wants to see those exceptions become the rule, and
in figuring out how we can make that happen, he overturns a few of our
most cherished notions about addiction and recovery.

The five people he writes about in "Hooked" are part of the kernel of
hardcore substance abusers whose lives, according to Shavelson,
constitute the front line of the drug war: "the most resistant,
demanding, often unlikable, and arguably the least deserving of
treatment service ... precisely the type of difficult junkie that
rehab programs must succeed with if they are to make a dent in the
crime, violence, and craziness that comprise the drug problem."
Although the number of illegal-drug users in the U.S. declined from
1979 to 1998, the number of drug-related hospital visits and deaths
went up, and most people picked up by the police for criminal offenses
test positive for drugs.

The Justice Department says drug users account for "an extraordinary
proportion of crime."

Shavelson documents their blasted lives: Darrell is a lonely, homeless
alcoholic and crackhead who has flunked out of several rehab programs,
attended thousands of Alcoholics Anonymous meetings and been
hospitalized for countless injuries, including falling out a window,
while wasted.

Mike is a skilled plumber whose unendurable memories of being molested
as a child send him back to heroin again and again despite his
heartbreakingly fervent desire to redeem himself in the eyes of his
kids and girlfriend. (In the book's opening pages, Mike is described
as shooting up while driving a truck down California's Highway 101 --
steering with his knees -- getting in a wreck and then, once
ascertaining that he's uninjured, continuing to shoot up in a ditch
beside his totaled pickup.) Glenda is a tiny, sweet-natured Native
American who has been drunk and homeless since age 16 and looks 60
instead of 37, her actual age. Crystal is a cocky crackhead who boasts
of her fearsome street reputation until she trusts Shavelson enough to
confess that she was a streetwalker and a "victim." Most daunting of
all is Darlene, whose auditory hallucinations ("noises," she calls
them) could be caused by psychosis, or by the speed she injects as
often as twice a day, or by the brutal conditions of her life in
various homeless encampments, each makeshift shelter eventually
bulldozed by the authorities without warning.

However desperate their situations, these five people entered
treatment at an opportune moment.

In 1996, the new U.S. drug czar, Gen. Barry McCaffrey, shifted a bit
of the nation's drug policy focus from law enforcement to rehab,
declaring that "effective treatment can end addiction" and that drug
policy goals "can only be accomplished with a significant expansion of
capacity to treat the nation's drug users." (Most of the money,
however, still goes to enforcement.) And San Francisco had launched a
much-ballyhooed "treatment on demand" policy that promised to get all
addicts seeking help into a treatment program within 48 hours.

You'd think that seeking rehab just at the time when officials had
recognized the importance of treatment would give these addicts a
boost -- but you'd be wrong.

According to Shavelson, the main factor causing people to abandon
their search for rehab is basic bureaucratic disorganization on the
part of treatment providers.

That's not the kind of ideological beef that makes for chest-thumping
Op-Ed columns, but it's the kind of problem that causes vast sums of
money to be sucked up into a system that offers scarce positive
results. Addicts have to make their way through a chaotic patchwork of
services and programs, each covering a small, specific need and each
looking for a reason to refer difficult clients elsewhere.

Negotiating this thicket of paperwork and conflicting agendas makes
dealing with the average HMO seem like a snap and -- guess what? --
organization and persistence are not common traits in drug addicts.

For example, the question of whether Darlene's aggressive, incoherent
behavior results from mental illness or substance abuse (speed can
induce psychotic symptoms) -- a question that, as Shavelson points
out, isn't particularly relevant to helping her -- stymies her
progress through the system. He describes her experience as "a
cyclonic quest for rehab: referred to and then immediately kicked out
of three drug treatment programs ... referred by the city's mental
health counselors to the substance abuse counselors; referred back to
mental health again in circles that have spun me dizzy just watching."

For another example, Glenda, joyfully sober for the first time in
decades after three months in a terrific Native American-run inpatient
program, steps out of it and into a treatment vacuum.

The room found for her is in a "clean and sober" Salvation Army
housing facility, but it's three blocks from the place where she used
to hang out all day drinking with her street pals, and no one
supervises her recovery beyond the Salvation Army's weekly drug tests.

Two days later, she's drunk again and kicked out of her room and onto
the street.

A year and a half after that, she's dead.

Shavelson convincingly argues that all the money spent on treatment
programs will go to waste unless each addict is assigned a case
manager, someone who can guide him or her through detox (which
"provides medical social services during those days it takes to get
sober and withdraw"), then rehab (a program that seeks to resocialize
the addict in a clean and sober environment) and finally getting the
housing and employment he or she needs to become a functional member
of society.

Instead, he observes irately, "the seeming lack of any management that
could impose order on the myriad substance abuse programs and services
that have proliferated since the mantra of rehab took hold across the
country" means that people get briefly cleaned up and then dumped back
into the nightmare from whence they came, without anyone accounting
for their need, as Mike puts it, "to learn how to live all over. Like
from the beginning."

Mike, though, ran up against more than just bureaucratic hassles and
inadequacies. After weeks of waiting to get in (during which time he
almost died of an overdose), he became a model member of the famous
San Francisco "therapeutic community" Walden House, but then relapsed
shortly after moving on to transitional housing.

Afraid of going back to Walden to plead for readmittance, he went on a
heroin binge, then tried, without much success, to stay clean on his
own. Shavelson sees this, too, as an avoidable calamity.

Walden adheres to a common rehab philosophy that Shavelson calls
"abstentionist." It imposes a long list of regulations on house
residents, and punishes even the slightest infraction with long
periods of "reflection" time on a bench in the communal hallway.

A major violation like Mike's relapse means automatic ejection from
the program -- unless the prodigal submits to a grueling group meeting
in which he must sit in a chair in the middle of the room while the
entire community pelts him with accusations and abuse.

This militaristic, "tough love" approach has disreputable roots in the
scary Synanon movement that started in the late '50s and flourished in
the '70s. Synanon, which practiced a form of "attack therapy" called
"The Game," eventually was discredited when its cultlike antics
expanded to include stockpiling weapons and placing a live rattlesnake
in the mailbox of a lawyer who'd sued the group.

Nevertheless, with some significant toning down of its more extreme
aspects, the Marines-like, zero-tolerance model persists in
therapeutic communities like Walden, which claim that the addict is
like an irresponsible child whose personality must be broken down and
rebuilt from the ground up in a highly structured, rigorously sober
environment.

While it no doubt works for some people, Walden's strategy
spectacularly failed Mike. Shavelson considers it abusive and
self-defeating and points out that Mike's underlying psychological
problems (particularly intrusive, recurring memories of being raped as
a child) never got treated at Walden. The constant demands of the
community's daily routine kept Mike distracted from his demons much as
heroin once did, and the harsh, humilation-based methods used to
reinforce the house's regimented lifestyle discouraged him from
opening up about a past he remembered with tremendous shame.

Worst of all, when he relapsed -- which most recovering addicts do --
the emotional ordeal that is the price of returning to Walden was more
than he could face.

Not surprisingly, a new treatment philosophy has emerged in recent
years, called "harm reduction." One advocate tells Shavelson that harm
reduction defines what it wants from addicts as "any positive change."
Its first commandment is "Meet the clients where they're at." Instead
of jettisoning addicts from the program if they don't stay clean, harm
reduction offers them different kinds of services, congratulates them
for using fewer drugs and does whatever it can to help them "have less
violent lives, steal from fewer people, become somewhat less crazy,
and even, possibly, a bit happier." The zero-tolerance side considers
harm reduction to be an unconscionable betrayal of the addict, who is
engaged in a life-or-death struggle in which halfway measures don't
work. (One of the drug users Shavelson interviewed, Darrell, agrees.)
McCaffrey condemned harm reduction as a plot devised by drug
legalization advocates.

Whichever approach works best, the existence of these competing
approaches has resulted in a "drug treatment world ... divided into
two armed, deeply entrenched encampments that to this day continue to
fire bullets of contempt at each other's rehab philosophies."
Shavelson clearly favors harm reduction, particularly in the case of
someone like Darlene. Remarkably eloquent despite the utter confusion
of her life, at one point she drags Shavelson into a store and shows
him the cover of a comic book:

It's a busy, medieval scene.

Dark, ominous castles are surrounded by wooden carts filled with
dozens of blood-soaked, nearly naked women's bodies.

Men in armor, holding swords, gawk at their exposed, bloodied
flesh.

I look at Darlene, puzzled. "Shrinks always want to know about the
noises in my head," she says ... "That's a picture of my noises.

It's the place I don't want to go no more."

She later explains that she's afraid to stop shooting speed because
the "noises" might not go away and she'd be proven to be crazy.

Darlene may indeed need structure in her life, but first she needs
intensive professional psychotherapy.

Yet Darlene does, eventually, make it to Walden (albeit in a special
program -- one that wisely combines full psychiatric care with drug
rehab). So does Crystal, a rehab candidate who, while free of
psychosis, is almost as unpromising as Darlene because she enters the
system without the slightest desire to get off drugs.

Shavelson, ever the pragmatist, doesn't think much of the bullying
ways of attack therapy, which addicts voluntarily endure.

But he finds himself, to his astonishment, endorsing a practice that
superficially seems even more disrespectful: coerced treatment. The
reason is simple: He has seen it work. Glenda, the most "pitiful,
disheveled, near-death, long-term street alcoholic" he had ever known,
was kidnapped and forced into rehab by concerned homeless service
workers and came out "three months later -- cleaned up, sober, and
healthy."

The system ultimately failed Glenda, but it succeeded with Crystal,
who was charged with selling crack and sent to San Francisco's drug
court instead of criminal court.

Drug courts, originally established in Florida while Janet Reno was
the state's prosecuting attorney, supervise an addict's recovery in
much the same way that Shavelson envisions case managers doing it,
from detox to rehab and on through getting a GED, getting out of debt
and finding employment. The addict is required to take regular drug
tests and report to the court every two weeks.

If the addict doesn't comply, he or she is sent back to criminal court
to face jail time. There's ample evidence that drug courts have the
highest success rate -- that is, the lowest dropout rate and
recidivism -- of any method of dealing with addicts, therapeutic or
criminal.

And this despite the fact that they fly in the face of one of the
recovery movement's core truisms: that a substance abuser has to be
truly ready and willing to quit in order to get sober.

Boasting from the start that "I can fake my way through any
program.

I'll take 'em for what they got," Crystal graduates two years later a
changed woman. Shavelson attributes this success to the fact that
despite her relapses and occasional truancies, the drug court judge
and rehab team "simply [stuck] to her like glue." More an exquisite
piece of theater than it is anything else, a drug court walks its
charges through a predictable series of rebellions and transgressions,
intensifying treatment when they start using again instead of kicking
them out, manipulating them into the kind of program they need. The
threat of being sent back to criminal court is the drug court's stick,
and lavish praise for those who clean up their acts is its carrot.

Crystal's stint in Walden is predictably "stormy" and she shrewdly
observes that "when things get deeper at Walden than 'Don't do dope,'
they don't know how to deal with it. But I talked to the judge and my
Drug Court case manager and they're insisting I have a therapist at
Walden 'cause I need some real help with this depression or I'll be
back on the crack pipe."

The great irony of drug courts, though, is that you have to be a
criminal to end up in them. Darlene, who supported herself with petty
thefts but never got caught, managed to get the care she needed only
because Shavelson went to bat for her, getting her a meeting with a
gifted psychiatrist and pleading her case when his clinic tried to
have her kicked out for threatening a worker.

Mike does eventually wind up in jail for burglarizing his
sister-in-law's house for drug money, but stands little chance of
getting into drug court because the break-in was residential, not
commercial, and prosecutors don't want to seem to be coddling
offenders who have been "terrorizing the community." Not only that,
but because he has been convicted of a couple of other minor,
nonviolent felonies in the past, he faces a three-strikes penalty of
25 years to life -- a grotesque travesty of justice, given how badly
he wants to be a responsible husband and father and how well he might
do with the right kind of help.

"Hooked," with its tales of lives horribly mangled by everything from
childhood abuse to mental illness to bad luck and, of course,
addiction, gives the lie to the boot camp mentality that prevails in
our public conversation about drug abuse.

You need only look at the "before" and then the radiant "after" photos
of Darlene and Crystal (beaming as she graduates from drug court) to
see the kind of results that playing drill sergeant will never get us.
Drug courts -- derided by some as "hug courts" -- don't coddle
addicts, but they don't abuse or abandon them either.

Shavelson has good things to say about a recent judicial mandate in
New York that would send nearly all nonviolent drug-addicted offenders
into rehab, but cautions that California's recently passed Proposition
36 doesn't insist on the kind of coordinated monitoring needed to make
its similar directive pay off.

If you believe, as I do, that the war on drugs is really just a job
creation program for people who'd otherwise be out of work now that
the Cold War is over (the spooks and soldiers go to Colombia and the
weapons-plant workers go to the prison-industrial complex), then,
alas, it's hard to see the kind of revelations found in "Hooked"
having much effect on public policy.

Despite McCaffrey's own endorsement of the drug court model, you just
have to do the math to see that things haven't changed that much. As
McCaffrey left the Office of National Drug Control Policy at the end
of 2000, the 2001 budget allocated $50 million to drug courts, $420
million to new prisons and $1.3 billion to fight the drug war in Colombia.