ABUSE IN AMERICA: THE WAR ON ADDICTION

Fresh Research And Shifting Views Of Treatment Are Opening New Fronts In A
Deadly Struggle

Maybe you've seen the movie: Dad, an Ohio judge and the nation's new drug
czar, needs a cocktail to "take the edge off." Mom has her own youthful
history with drugs and scoffs at Dad's suggestion that she was just
"experimenting." Their 16-year-old daughter, a lovely straight-A student at
a fancy private school, starts freebasing cocaine, then turns tricks to pay
for her habit.

Whatever happens next month at the Oscars, the movie "Traffic" is a
cinematic IV injection--a jolting reminder of the horrors of drugs and the
drug war. After a campaign in which both parties all but ignored the drug
issue, director Steven Soderbergh manages the nearly impossible feat of
illuminating a national debate without taking sides (both reformers and
hard-liners like the movie), beyond attaching a patina of hopelessness to
the whole issue.

Actually, the future may not be quite as bleak as the film suggests.

While policy revolutions--like legalizing narcotics or somehow eradicating
supply--are pipe dreams, change is coming to the world of addiction and
drug policy. Voters in several states are far ahead of the politicians,
approving ballot initiativesthat offer more treatment options. "Drug
courts" that allow judges to impose substance-abuse treatment in place of
jail have grown fiftyfold since the mid-1990s, part of a new understanding
that, even with frequent relapses, treatment is much less expensive for
society than prison and interdiction. All of the former drug czars as well
as the man rumored to be President Bush's choice for the job, retired Col.
James McDonough, stress treatment and demand-side reduction as their first
priority, though the funding decisions have yet to catch up to the new
rhetoric.

More broadly, this relatively peaceful interlude in the nation's drug
history (half as many regular drug users as in 1979 and the crack epidemic
ebbing) offers a rare chance to rethink old approaches not just to renewed
threats like heroin but to the mother of all abused substances--alcohol.
Science is yielding clues about the "hedonic region" of the brain, while
breakthrough medications and greater understanding of the mental-health
problems that underlie many addictions are giving therapists new tools.

INNER DEMONS

Addiction is hardly an American affliction, but it sometimes looks that
way. The master narrative of public life these days seems to be all about
abuse and recovery, with inner demons replacing outer enemies or forces of
nature as the dramatic foils of choice.

After leaving drug rehab, Jennifer Capriati stages an improbable tennis
comeback to win the Australian Open. Robert Downey Jr. relapses once again,
a haunting symbol of the limits of treatment. The departing president of
the United States appears to have been addicted to sex, while the new
president--by his own account--once had a drinking problem.

In the real America, the toll is incalculable. Consider Areina Garcia, 34,
mother of four children ages 1, 2, 4 and 7. She admits she was "selling my
ass for drugs" and getting high in front of her kids. She didn't stop until
her husband reported her to family court.

Or Brian Kelly, 31, who started drinking at 8 while tailgating with his
alcoholic parents at Notre Dame games. His crack habit landed him in a
$14,000-a-month "country club" treatment program with a pool, tennis courts
and nothing but what he calls "appeasement" of his problem.

Now both Garcia and Kelly are midway through a no-nonsense, 12- to 15-month
residential treatment program at Phoenix House, still at real risk of
relapse, but with at least a fighting chance to salvage their lives.

The aggregate consequences of addiction are staggering. Consider that the
number of inmates in American prisons more than tripled over the last 20
years to nearly 2 million, with 60 percent to 70 percent testing positive
for substance abuse on arrest.

These inmates are the parents of 2.4 million children, all of whom are
disproportionately likely to follow their parents to jail. According to the
exponential math of a Brown University study, if the prison population were
to continue growing at the current rate, by 2053 the United States would
actually have more people in prison than out.

Even greatly expanded prison capacity that consumes billions can't
accommodate this flow. So over the next few years, as sentences from the
high-crime 1980s are completed and reform of drugs laws accelerates,
hundreds of thousands of offenders will be released or sentenced more
leniently. Hard-core addicts in some jurisdictions are estimated to commit
100 petty crimes each per year. If their substance-abuse problems aren't
addressed, the country will face another crime wave soon.

DISEASE OR CRIME?

In an attempt to break the vicious cycle, drug addiction is increasingly
being viewed more as a disease than a crime. (Drug trafficking is a
different matter.) California approved Proposition 36 last fall, a landmark
referendum that offers treatment options in place of jail for nonviolent
offenders. New York is rewriting its draconian Rockefeller-era drug laws.
The outgoing drug czar, retired Gen. Barry McCaffrey, says the phrase "drug
war" should be retired in favor of "drug cancer." The straight-talking
military man has little to say about interdiction. His No. 1 recommendation
on leaving office last month was that insurance companies offer the same
level of coverage for mental-health and drug disorders as they do for any
other illness.

This is unlikely (managed care has led to lower reimbursements for
treatments). But even hard-liners are beginning to say that we can no
longer incarcerate our way out of the problem.

Of course old habits die hard. Washington still directs two thirds of the
federal drug budget (including $1.1 billion in military aid to Colombia) to
law enforcement, while state legislatures--leery of seeming to coddle
criminals--lag behind public opinion on funding treatment.

So-called harm-reduction strategies like needle exchanges (common in
Europe) have a tough time winning approval, despite many studies proving
that they save lives. The new attorney general, John Ashcroft, has opposed
not just needle exchanges, but a taxpayer-supported media campaign aimed at
teens.

The early signs are that the Bush team will essentially maintain the status
quo on drug policy.

Even so, a "third way" consensus between liberals and conservatives is
emerging, especially at the local level where the real money is spent.

It combines flexible enforcement with mandatory treatment.

The drug-court idea, which comes with strong backing from most prosecutors,
is sometimes known as "coercive abstinence"--using the threat of jail to
motivate substance abusers to get help. "The real, nut-cutting issue is
motivation," says Joseph Califano, chairman of the National Center on
Addiction and Substance Abuse. The research shows that those forced into
treatment do at least as well as addicts who enroll voluntarily--often
better, because they must stay in therapy longer or risk reincarceration.
In all recovery programs, the best predictor of success is the length of
treatment.

While relapse is common, those who remain at least a year are more than
twice as likely to stay clean.

RESISTANT TO TREATMENT

So drug-treatment experts now often favor the "big foot" of law
enforcement. "The legalizers don't understand the psychodynamics of
addiction," says Dr. George De Leon, author of the National Institute on
Drug Abuse's most thorough study of treatment. "The nature of the disorder
is that the client is resistant to treatment." This suggests the need for
intensive drug treatment not only in jail, where addicts are a captive
audience, but after release, with sentences shortened in exchange for
successful enrollment. Drug-court judges use carrots (gift certificates;
the promise of fewer court dates) and sticks (return to jail) to change
behavior.

Drug-policy reformers like Ethan Nadelman of the Lindesmith Center don't
buy the approach: "Alcoholics don't have coerced treatment," Nadelman says.
"So why should drug abusers?" But those who actually provide treatment say
they have fewer empty beds when the courts are involved.

They worry that California's Proposition 36 doesn't do enough to compel
long-term treatment. Addicts will "get kind of a driver's-ed course in
drugs that isn't going to force them to take a self-inventory and change
themselves," says Dr. Mitchell Rosenthal, founder of Phoenix House, which
operates residential-treatment centers in eight states.

Rosenthal says Phoenix House has relied on the criminal-justice system for
its recent growth spurt.

As in all treatment, the vast majority drop out before completing the
program, but those who make it through the whole year have a surprisingly
good prognosis.

The research shows that about three quarters of those who graduate from
12-month residential programs are employed, drug-free and not in jail five
years later.

The results for in-prison programs and outpatient therapy are worse than
for long-term residential care, but there, too, the key variable is length
of treatment.

WHAT'S MOST COST-EFFECTIVE?

At the same time, all but the fanciest 28-day residential programs are less
expensive than prison, and outpatient care is much cheaper.

Even when you throw in the costs of the drug court, the total expense is
less than half as much as jail, and the results are far more effective.

Inmates assigned to drug courts in Los Angeles and Washington, D.C., were
30 percent less likely to be rearrested than those who went through
conventional courts--a huge savings to society.

In another survey, only about 10 percent of those under drug-court
supervision tested positive for drugs; for those in regular probation, the
"dirty urine" figures were one third.

Meanwhile, hundreds of laws remain on the books that make it hard to treat
substance abuse as a public-health matter.

Consider heroin addiction.

In nine American cities, men 20 to 54 are more likely to die of a heroin
overdose than in a car accident.

But courts won't often authorize methadone treatment, and junkies routinely
fail to report overdoses to the authorities for fear of being arrested.

In "Traffic," the kids leave their overdosed friend at the hospital and
run--a common response.

In New Mexico, where GOP Gov. Gary Johnson is an outspoken drug reformer,
the authorities are trying a new harm-reduction strategy to fight
overdoses. Last month New Mexico doctors began giving addicts syringes full
of Narcan, an easy-to-inject medication that counteracts the heroin, often
saving lives.

One test of the new public mood on drug-policy reform will be if other
states follow suit.

REASSESSING THE HARD-LINE APPROACH

New York is beginning to reassess its tough drug laws, which date from the
1970s. Last month Gov. George Pataki, once a major hard-liner, proposed
cutting the minimum sentences for serious drug felons from 15 years to
eight and giving judges more discretion. In reviewing the clemency process,
Pataki says he found "dramatically unfair sentences--people sentenced to 15
years when their involvement was minimal." But at the federal level,
so-called mandatory minimum sentencing requirements are in no danger of
being repealed any time soon.

Spending priorities right now look pound foolish.

The Center on Addiction and Substance Abuse released a study last week
showing that states spend more than 13 percent of their total budgets
showing that states spend more than 13 percent of their total budgets just
"shoveling up" the wreckage of addiction--as much as they appropriate for
higher education and 100 times what they spend on prevention and treatment.

Another study by Rand Corp. shows that every dollar spent on treatment
saves seven dollars in services.

That's because even if addicts eventually relapse, they are clean during
their time in treatment, saving millions in acute health-care costs and law
enforcement.

For all its promise, treatment remains a spit in the ocean of national
substance abuse.

Phoenix House, the nation's largest network of treatment centers, has only
about 5,000 residents--out of more than a million people arrested every
year on drug-related charges.

California's Proposition 36 will fund 10,000 new treatment slots.

But that's out of 160,000 inmates who need it. While drug courts are
multiplying fast, they still make up a tiny percentage of all criminal courts.

In other words, like treating addiction, changing national drug policy will
take patience, commitment and time. All we know for sure is that we have no
choice but to try.