DRUG-HABIT DEBATE: WIRING VS. WILLPOWER

Experts Argue Over Effects Of Chemistry And Character

Every Thursday in his Newark courtroom, Essex County Superior Court Judge
Harold Fullilove weighs more than mere evidence.

Presiding over one of 10 "drug courts" in the state, Fullilove balances
lies against truths and compulsion vs. determination. He can write off a
life or try to save it.

Addiction is no joke to Fullilove, who lost a brother to a cocaine overdose.

On drug court days, when he removes himself from normal criminal trial
division matters, he is both jurist and drug abuse counselor, as part of a
five-year-old program designed to de-criminalize addiction in nonviolent
drug defendants and find them treatment.

His participation also places Fullilove and other like-minded legal
practitioners squarely in the center of a deep and developing medical debate.

On one side are people like Francis Vocci, a neuroscientist at the
federally funded National Institute on Drug Abuse, who says research over
the past 10 years proves that addiction is a brain disease that compels
users to continue. Drug courts, he believes, are "high-minded efforts."

On the other side are people like Stanton Peele, a Morristown author,
attorney and licensed psychologist, who contends people choose to become
addicts and can break their habits if they have enough willpower. Blaming
it on the brain, he says, will lead to coddling people who need it least.

People subscribing to Peele's point of view tend to like drug courts, too.

Something Missing

People become addicts, says Peele, because there is something missing in
their lives. Addiction, he says, is a symptom, not a disease. When he works
with patients, he tries to help them fill the gap that led to the aberrant
behavior in the first place.

People are addicted to far more than just substances, he said, noting that
his first book, "Love and Addiction," written in 1975, details the power
that toxic relationships have over people.

Deciding whether addicts can help themselves and how deeply society should
become involved in this treatment is not merely a matter of philosophical
debate. Hundreds of scientists, inspired by the latest brain research, are
working to develop drugs to treat heroin, cocaine, tobacco and alcohol
abuse, changing the very nature of drug treatment.

Modern neuroscience, researchers say, has come up with a new twist on the
old conflict of free choice vs. fate, long described under various guises
in literature.

Those who believe addiction is a disease generally favor a treatment plan
that includes both counseling and medications. They also maintain that
abstinence is the best approach to break an addiction to drugs or alcohol.

In contrast, opponents of the disease model point out that many people kick
a habit without any help, professional or otherwise. Some are even able to
moderate their intake, they say, without going "cold turkey."

Addiction must be behavioral, according to Sally Satel, a psychiatrist who
is a research fellow at the American Enterprise Institute in Washington,
D.C. After all, so many addicts respond to rewards and consequences, not
just to physiology, she said.

As a result of new insights into addiction, many new medications that alter
brain activity directly related to addiction will be coming on the market
over the next few years. Some physicians see this as a godsend, helping
addicts climb out of the wreckage of their lives.

Others are not so sure.

"We have overmedicalized addiction," said Satel. "I think we have too much
faith that these medications are going to change the face of addiction
treatment." She treats patients at a methadone clinic in Washington and
views the heroin treatment as a "qualified success." But at least half her
patients, she said, are still using drugs.

"So half are, half aren't -- it depends on how you look at it if you are
going to decide whether that's good or bad," she said.

Blaming The Victim

Federal researchers have long suggested that the stigma of addiction should
be removed, since the behavior is based in the brain. How, they reason, can
people be blamed for following through on a compulsion that their brain is
wired to slavishly follow?

Satel is opposed to this thinking. "You can't remove the stigma," she said.
Fear of being stigmatized and being ostracized by society is what keeps
many people from using addictive substances, she said. "They are not doing
something that is good when they use. Why can't we say that?"

The notion that addiction may be rooted in biology also throws her, she
said, because it makes it sound as if addicts didn't have a choice.
"Addiction is self-induced -- that's not inevitable," she said. "It's not
like bipolar illness or something."

Bankole Johnson, a neuroscientist at the University of Texas who has been
working to develop a medication to treat alcoholics, said the same kinds of
criticisms were raised about schizophrenia and bipolar disorder a few
decades ago. Both were viewed by many as behaviors that were not
necessarily provoked by brain processes -- until brain scans showed
otherwise. The history of medicine, Johnson said, is marked by case after
case of physicians misunderstanding the roots of a disease, then coming to
an understanding as the scientific results poured in.

"The same will happen with addiction," he said. "These criticisms will be
disproven."

Willpower

Satel understands how differences in brain structures can help explain why
some people like a drug and others don't. What she can't comprehend is how
such a theory accounts for a situation in which two people try cocaine, for
example, and both enjoy it immensely. But one will want more and the other
will ask that the drug be kept away -- it is too dangerously enjoyable.

Satel sees these acts as an example of differing levels of willpower.
Johnson said the difference could be explained as brain-based, too.
Impulsivity and control are clearly tied to levels of brain chemicals, he
said. Some people may have genetic variations that induce them to respond
differently to certain drugs.

Satel doesn't buy this logic. "It's not politically correct in some
therapeutic circles to say this, but I'm going to ask it anyway: What about
conscience and character and harnessing one's will? Aren't these involved,
too?" she asked.

A study conducted by University of St. Louis researchers, she said, found
that 85 percent of heroin addicts returning from Vietnam were able to quit
the drug once they came home, indicating that cultural factors, the higher
price of the drug and fear of arrest helped them end their addiction.

Viewing drug addiction as an uncontrollable behavior is not only incorrect,
she said, but potentially damaging as well. "It's a fairly pessimistic
message," she said. "The message that addiction is chronic and relapse
inevitable is demoralizing to patients and gives the treatment system an
excuse if it doesn't serve them well." She advocates treatment but prefers
to call addiction a behavioral condition.

"The person, not his autonomous brain, is the instigator of his relapse and
the agent of his recovery," she maintains. In this view, treatment is
important but punitive measures also may deter drug abuse.

Drug addicts spend long periods each day when they are not using, she said.
She tells her patients that they have the power to make a lot of decisions
in one day. One of those decisions could have been to go to a drug
treatment center, she tells them.

She is not opposed to addiction research. But she views the language used
by many federal researchers to describe the biological model of addiction
they subscribe to as a poor public health message and, worse, one that is
self-serving.

"It serves a lot of purposes," Satel said. "It gives them funding. It takes
personal responsibility away from patients. And what do you have? You have
nothing. You have doctors colluding with patients in their desire to use
drugs with no consequences."

The model in the middle, halfway between biological and behavioral issues,
is drug court, she said.

Satel likes these programs because studies show that patients who have been
ordered by a court to seek treatment will generally stay longer than those
who have not been ordered there. The programs, she said, also emphasize
personal accountability and moral issues that empower addicts.

"You work with them," she said. "You shape the incentive so that people
make a choice that's in their best interest."

The Hard Way

The mission of drug courts is to stop the abuse of alcohol and other drugs
and related criminal activity. They are unique in the criminal justice
environment because they build a close relationship between law
professionals and experts in drug treatment. Within a somewhat relaxed
courtroom atmosphere, a judge heads a team of court staff, attorneys,
probation officers, substance abuse evaluators and treatment professionals
to support and monitor a participant's recovery.

Defendants generally dry out from their addiction in jail and then, through
the courts, enter a treatment program such as Integrity House in Newark or
Straight and Narrow in Passaic.

Though scientists promise they are coming, there are few medications
currently available to help addicts curb their cravings. Most of the
defendants going through drug court, as a result, dry out the hard way.

"They are basically locked up in these programs for 30 days so they can't
get access to the drugs," said Carmine Centanni, a counselor who works in
Fullilove's drug court.

The New Jersey Adult Drug Court program began in 1997 when Superior Courts
in Camden and Essex counties started accepting participants. These local
projects evolved into programs that have paved the way for additional pilot
programs. By 1999, additional programs were established in Mercer, Passaic
and Union counties. The effort has continued to expand.

As of April 2002, more than 2,000 offenders had gone through the state's
drug court pilot programs. The current roster of drug court participants
statewide is approximately 1,411.

About 72 percent of addicts in the program will stay to the end.

Most studies conclude that the longer a patient is in treatment, the better
the chances for success. At least 90 days of treatment is what people need
to get the highest rates of success, the studies show, which is why
organizations like Alcoholics Anonymous and Narcotics Anonymous stress "90
meetings in 90 days" to newcomers.

On any given day in Fullilove's courtroom, the scales of justice can tip in
either direction.

When one defendant, at her weekly check-in, reads a selection from a
Narcotics Anonymous handbook, he smiles and tells her to go and "have a
good week."

When another appears, his head low after having been found drunk over the
weekend by his probation officer, he receives the full tough-love treatment
from the normally sunny judge.

"Are you absolutely crazy?" Fullilove asks with an exasperated air. "Why
shouldn't I just throw you in jail?"

Threatening defendants with a stay in what he ordinarily calls the "Hotel
Fullilove" -- county or state jail -- usually chastens them.

Then the addiction counselor in the judge comes out. "You have to
understand that what other people do, you can't do," Fullilove said. "You
can't drink. You can't."

He gives the defendant, Willie Nieves, an unemployed mechanic, one more
chance. "Come back in a week," he said.