IN THE NATION'S BATTLE AGAINST DRUG ABUSE, SCHOLARS HAVE MORE INSIGHT THAN
INFLUENCE

To an outsider, the drug-treatment wing of Delaware's Gander Hill prison
seems part family, part regiment, and part kindergarten. The 240 or so men
here are separated from the general inmate population so that they can think
recovery all day, every day, for up to 18 months.

Overseen by a small counseling staff, the inmates assume job titles based on
seniority and merit, and they manage their daily routine themselves. Each
morning at 8, clad in white prison uniforms, they leave their dormitory for
a motivational meeting that, says one inmate, "sets the tone for the day."

After their morning chores, they trot single file back into the day room,
rhythmically clapping and yelling "Or-i-en-ta-tion!" Inspirational slogans
and murals cover every wall and pillar. Most of the residents settle into
folding chairs, chanting and cheering as a senior inmate explains the ways
of the community to the "babies," or brand-new residents. Several dozen
others split off for encounter-group sessions, where they express their
feelings or reproach and encourage their brothers.

When asked, inmates explain that the "Key" program, as it is called, demands
not only clean urine, but also a constant effort to become more reflective,
responsible, and accountable.

When they complete the program and get out of prison, they carry those
expectations with them. Graduates move on to another residential treatment
facility, called the "Crest" program, for the work-release portion of their
sentences. In the third and final stage, they will continue with self-help
therapy and other "aftercare" services.

About a fifth of them will flunk out of the Key program. Many more will
resume their dependence on alcohol or drugs after treatment ends. And some
will end up right back in prison. Yet scholars still consider Key/Crest a
standout in the field of drug-abuse treatment. Unlike many programs, it
builds on insights from decades of research, tracks its graduates long after
they leave, and has shown remarkable success at turning drug-abusing
criminals into productive citizens.

That achievement underscores the fact that, although scholars have learned a
lot about effective therapies for drug dependency, their findings often do
not influence the providers who treat drug addiction in this country, or the
policy makers who decide how to wage the battle against drug abuse.

In recent years, social scientists have scrutinized a range of psychosocial
treatments for drug abuse. Although methadone has been successful in weaning
people from heroin, similar pharmacological approaches have not been found
for other illicit drugs.

What's more, most addicts' problems are more complicated than simple drug
use. Three major national studies in the past 20 years have demonstrated the
effectiveness of therapies that reform the way drug abusers think and
behave.

"Now we have a better understanding that treatment is a process. It's not a
magic bullet. It's not one-stop shopping," says D. Dwayne Simpson, a
psychologist at Texas Christian University who directed the Drug Addiction
Treatment Outcome Study, the most recent of the national surveys. Among the
findings in the studies he reviewed:

* Detoxification is just a prelude to sustained treatment. "If they are not
in treatment for at least three months, you're not going to see evidence of
change," says Mr. Simpson.

* Recovery will be far more difficult for patients whose dependency is more
severe, who have psychiatric problems, who are unemployed, or who lack a
network of relatives or friends to see them through recovery.

* Successful programs tend to provide patients with individual counseling;
help them with medical, psychiatric, and family problems; reinforce their
good behavior; and refer them to follow-up treatment, often in self-help
groups.

Researchers have put a variety of psychosocial therapies to the test -- and
have found that many improve the odds of recovery. In various "cognitive"
approaches to therapy, for example, the presumption is that many users turn
to drugs to cope with adversity and to salve negative thoughts and beliefs.
So therapists try to reshape patients' mental habits and teach them better
ways to deal with their impulses.

Other therapies rest on a "behavioral" theory of drug use. "Drugs control
behavior by acting as reinforcers, the same way that food and sex and water
and heat can do that," says Stephen T. Higgins, a professor of psychiatry at
the University of Vermont. Drugs bring pleasure, and satisfying a craving
for them feels better than resisting it. The goal is to find incentives that
reward and reinforce a patient's decision to abstain.

A third approach, which can incorporate cognitive or behavioral techniques,
is the "therapeutic community," a residential program of up to two years'
duration in which patients' own peers help instill self-control,
responsibility, and other principles of "right living."

What's uncertain is how all that knowledge is helping clients of the
nation's 9,000 or so treatment facilities. Many of them rely on unproven
strategies, including group therapy, relaxation techniques, and drug
education. Even 12-step programs for drug abusers, such as Narcotics
Anonymous, can point to little scientific evidence of their effectiveness,
in part because their tradition of anonymity makes outcomes difficult to
evaluate. Yet 12-step therapy is widely respected, and programs like
Key/Crest, which recognize the importance of long-term treatment, typically
rely on self-help groups for continuing aftercare.

Of course, scholars themselves share the blame for providers' ignorance of
research. Psychosocial therapies "have been found to be effective in
relatively prissy treatment settings," where scholars run tidy, controlled
trials with homogeneous groups of patients, says Alan I. Leshner, director
of the National Institute on Drug Abuse, a part of the National Institutes
of Health. "If we want to improve the use of treatment-based components, we
have to find out whether they will work in real-life settings with real-life
patients."

To confront that problem, Dr. Leshner's agency has recently set up a
"clinical trial network" to pay for long-term studies of treatment programs
in 10 locations. Scholars will collaborate with staff members at community
clinics to test the multitude of therapies for different kinds of drug
dependency. For example, Kathleen M. Carroll, an associate professor of
psychiatry at Yale University, will work with clinics in New Haven, Conn.,
to improve the ways in which pharmacological approaches and psychotherapy
are used in concert.

Without such collaboration, some of the most promising ideas for treatment
could remain on the drawing boards. A good example of that problem is
vouchers. Behavioral researchers like Vermont's Mr. Higgins reason that drug
abusers can shake their dependency if they learn that abstinence is more
rewarding than drug use. So scholars propose "contingency management":
rewarding users for staying clean and sticking with their therapy sessions,
job-training classes, and other paths to recovery.

In prison, that's not difficult. The clients are supervised around the
clock, and the promise of early parole is a powerful reason to stay with the
program. Outside of prison, treatment providers have to be more creative.

Mr. Higgins has been experimenting with vouchers that can be redeemed for
goods and services. Basing his conclusions on studies in several cities, he
calls a voucher system "the most reliably effective approach to getting
cocaine addicts not to take cocaine. But people aren't sure how to use it in
our health-care system. It has not been widely adopted in community
clinics."

Treatment providers have been skeptical of research that "didn't take
account of the realities of the treatment world," says Merwyn R. Greenlick,
a professor of public health and preventive medicine at Oregon Health
Sciences University. He recently led a committee of the National Academy of
Sciences that decried "the gap between research and practice."

For example, he says, the voucher idea has prompted providers to say, "Even
if we believe your research, how can you expect us to implement something
that costs more than our entire budget?"

Kenneth Silverman, an associate professor of psychiatry at the Johns Hopkins
University, thinks he may have the answer. In a small-scale experiment in
Baltimore, he has already shown that a significantly greater proportion of
cocaine-using welfare mothers on methadone stayed clean after receiving
vouchers, worth up to $5,800 over one year, than did those who did not
receive them. Now he's trying to tackle the idea's biggest weakness: cost.
He has started a nonprofit company that trains and pays a modest wage to
those women to perform data entry. The longer they stay drug-free, the
higher their hourly rate, which will be paid by the clients who hire them
and by Maryland's welfare-to-work program.

Few treatment settings draw more urgent attention from scholars than
prisons. "A hundred years of research shows that there is a relationship
between drug use and other crime," says James A. Inciardi, a sociologist at
the University of Delaware.

For a society determined to curb drug use, prison is "a good place to
start," he says, estimating that 70 percent of the prison population in the
United States has a substance-abuse problem. "Prisoners have a lot of time
on their hands. They're a captive audience." And the residential costs of
treatment are, so to speak, already covered.

That makes prisons ideal for programs that, like Key/Crest, demand radical
changes from substance abusers. "Rehabilitation is the wrong word -- it
suggests that you're bringing them back to where they were before," says Mr.
Inciardi. Rather, the program "habilitates" users who never had the support
networks, emotional maturity, and coping skills to avoid the temptations of
drug use in the first place.

The Key/Crest program tries to resocialize inmates to deal with their
negative emotions and to trust confidantes. They must sever ties with their
criminal cronies and repair those with family members. In Gander Hill,
inmates deliver ritual criticism of fellows who do not take all of those
responsibilities seriously. But this is always followed by expressions of
love and respect -- "You're a beautiful individual, and a role model in the
community." Many inmates wash out, but they are usually given second and
third chances. Most are young men serving short sentences, although one
convict has been behind bars for 18 years but volunteered for the Key
program because "I wanted to do something different with my life."

Therapeutic communities have been part of prison life for decades, but
Delaware's Key/Crest program and a few others like it build on a crucial
insight: They are demonstrably effective only when therapy continues during
the inmates' transition back into the community. That's why Delaware pays
for residential treatment during work release and makes the aftercare
treatment a condition of parole.

Mr. Inciardi's research shows that offenders who completed only the Key
portion of therapy were no more likely than drug users outside the program
to remain drug- and crime-free for a year after release. But those who
received all three stages of therapy were half as likely to be rearrested,
and two-thirds as likely to relapse, as the others. After three years, the
differences persisted.

For years, scholars say, their main message to policy makers has been:
Treatment works. But that hasn't been enough to win over lawmakers partial
to get-tough approaches to drug abuse. Programs like Key/Crest are a hard
sell to most state legislators, says Mr. Inciardi. "Providing treatment, for
many, suggests that they are soft on crime. 'Lock 'em up and throw away the
key' is what they think their constituents want to hear."

The same could be said of drug policy on the federal level. Although annual
federal spending on drug control has doubled to about $19 billion in the
last 10 years, the proportion spent on treatment has remained steady at
around 20 percent. The rest finances efforts to disrupt the supply of
narcotics and enforce drug laws. Advocates of greater support for treatment
wish that lawmakers would view drug abuse more as a public-health problem
and less as a criminal-justice problem.

Scholars of drug policy have recently begun building a new argument for
drug-treatment programs: They are cost-effective.

Consider efforts to reduce cocaine use in this country. "In order to
decrease the consumption of cocaine by 1 percent from current levels," says
Martin Y. Iguchi, an economist and co-director of the RAND Corporation's
research center on drug policy, "we would have to spend [either] $783
million more on source-country controls, $366-million more for interdiction,
$246-million more for domestic enforcement, or $34-million more for
treatment."

In other words, one dollar spent on treatment delivers as much bang as seven
bucks spent on the next most cost-effective option.

Furthermore, researchers say, effective treatments not only reduce drug use
but also lower the costs of crime, child neglect, disease, unemployment, and
other social ills associated with drug abuse -- more than $100 billion a
year, according to a 1995 estimate. Those savings, they say, should also be
calculated in any cost-benefit analysis of treatment.

"When you take a societal perspective, there's incredible cost savings
associated with criminal-activity prevention," says Michael T. French, a
health economist at the University of Miami. "You only have to avoid a few
predatory crimes to, quote-unquote, pay for several treatment slots. There
are very few treatment programs that don't show that."

Cost-benefit analysis is unlikely anytime soon, however, to supplant the
widespread notion that effective treatment means permanent abstinence.

"Most people in the general public think drug addicts are just bad actors.
Therefore they should just cut it out," laments George E. Woody, a professor
of psychiatry at the University of Pennsylvania. "It's an all-or-nothing
phenomenon in judging success: Either they stop or they don't stop," he
says.

In fact, experts urge society to take a more realistic view of drug
treatment. They know that many drug abusers will relapse -- but that those
who manage to moderate their habit still have a better shot at productive
lives. "As treatment-evaluation scientists, we cannot use the word
'success,' because success is defined so many different ways," says Mr.
Simpson, of Texas Christian University. Most clients of public clinics, he
says, are drug users from high-crime neighborhoods with a poor education and
few job skills. The popular expectation "is that the person becomes
abstinent, crime-free, employed, and tax-paying. Well, that's nothing short
of a biblical miracle."

You certainly won't find the inmates of Gander Hill talking about their
treatment as a permanent cure. "This is a mere training session," says
Derrick, a garrulous "senior resident" of the Key program, "so in life you
won't be left guessing."