'JUST SAY NO': AN EXCHANGE

To the Editors:

Malcolm Gladwell, reviewing The Fix in "Just Say 'Wait a Minute"'
[NYR, December 17,1998] and author Michael Massing distort reality by
misrepresenting facts and ignoring science in their analyses of drug
policy. Both accuse the parent movement of ending a policy initiated
in the Nixon administration to treat heroin addiction. (Treating
heroin addicts didn't end.) "The focus was on the hard-core user of
drugs like heroin," Mr. Gladwell writes, "not casual users of 'soft'
drugs like marijuana.... The parents' movement turned that policy
upside down. Their concern was not with inner-city addicts, but with
suburban teenagers, not with heroin but with pot, and not with
treatment but with 'zero tolerance."' Mr. Massing writes that for
parents; "the notion of recovery meant that addicts could get well---a
message that, they felt, undermined their warning to young people not
to use drugs."

What nonsense. Parents mobilized in 1976-1977 in response to the
greatest escalation in adolescent drug use in history, from less than
1 percent of twelve-to seventeen-year-olds in 1962 to 34 percent in
1979. By then 65 percent of high-school seniors had tried an illicit
drug, 39 percent were using drugs monthly, and 1 in 9 smoked marijuana
daily. Young peoples' alcohol use paralleled their drug use, and the
combination was deadly. While the death rate for all other age groups
declined, adolescents' death rate rose by 8 percent, an increase
fueled by the unprecedented upsurge in drug use. With 11 percent of
seniors smoking pot daily, a level of use that can hardly be called
"casual," parents learned from their children what scientists only now
are confirming in their laboratories: marijuana produces an addiction
that requires treatment. Parents were not against treatment, they were
desperately seeking treatment for their drug-addicted children. Their
goal was not to end treatment for heroin addicts, but to expand
treatment for all addicts, including adolescents.

National Families in Action, one of the parent organizations both
reviewer and author accuse of eschewing treatment, has referred
thousands of parents seeking help for their children to drug-treatment
facilities across the nation. Two decades ago, this was no easy thing
to do. Most treatment available then was for adult men addicted to
heroin, the one drug few adolescents were abusing. Few facilities had
slots for adolescents, or any expertise in treating them. That left
private, non-drug-specific therapy, where parents reported repeatedly
that the focus was on their children's "underlying problems" rather
than their drug use, allowing their addiction to continue unabated. In
fact, the parental demand for adolescent drug treatment was so great,
it spawned a new industry: residential facilities that (1) treated
addiction to all drugs, (2) treated addiction as the primary problem,
and (3) treated adolescents.

Mr. Massing ignores, and Mr. Gladwell seems incapable of grasping, the
real contribution the parent movement made: convincing the nation that
preventing drug use is a crucial component of the comprehensive
approach needed to reduce drug abuse, drug addiction, and drug-related
death. Parents initiated a drug-prevention effort that eventually grew
to include government agencies, private industry, private foundations,
and nonprofit organizations. Between 1979 and 1992, this effort cut
regular drug use in half among all Americans (from 25 million to 11
million), by two thirds among adolescents and young adults, and cut
daily marijuana use among seniors by 500 percent (from 11 percent to 2
percent), facts both author and reviewer choose to ignore.

Given National Families in Action's decade-long work in Atlanta
public-housing communities, to cite just one example, Mr. Gladwell's
assertion that parents are "not concerned about inner-city addicts" is
simply wrong. Also wrong is his view of addiction. He accuses parents
of irrationally fearing that drugs might be "fun" and sets out to
prove that they aren't, betraying a stunning ignorance of science.
Neuroscience has now shown that addictive drugs act directly on a part
of the brain called the brain reward system, which, among other
things, produces feelings of pleasure. Drugs turn this system on
powerfully by mimicking the way brain chemicals work. Because the
brain reward system is part of a larger brain circuit that underlies a
primitive form of learning called operant conditioning, activating it
not only produces pleasure, but also teaches people to repeat the
drug-taking behaviors that turned it on in the first place. Despite
Mr. Gladwell's personal experience, the vast majority of drug users
confirm that drugs are indeed "fun," at least initially, and one of
the fundamental reasons they are is because they activate the
biological substrate of pleasure.

Moreover, repeated drug use, reinforced by the rewarding effects all
addictive drugs produce, sets in motion a continuum of other
biological changes. Tolerance to drugs' pleasure-producing effects
develops, requiring larger doses and setting the stage for the
development of physical dependence. Continued drug use, especially to
deal with stress or emotional problems, can lead to psychological
dependence. Other factors, such as learning and memory, also play a
role. At some point towards the end of this progression, the user
becomes addicted and can no longer control his drug-taking behavior.
Mr. Gladwell is right when he says that not everyone who uses drugs
will become addicted. He is wrong, however, when he asserts that
"parents think the problem is about drugs, when it is really about
users." Such reductionism reveals an ignorance of the nature of
addiction that borders on arrogance.

Mr. Gladwell and Mr. Massing make the very mistake they accuse the
parent movement of making. They focus on a single factor to explain a
disorder that is multifaceted. At the very least, we must not only
consider the drug and the user, but biology and the environment as
well, to try to understand drug addiction, which is a complex problem
that requires a complex set of solutions. Focusing our effort on just
one solution, even one as important as treatment, is a prescription
for failure. When all is said and done, our nation's drug problem is
like a dike with several holes. Plugging up only one, or even a few,
still permits water to flood through the others, eventually
undermining everything. Until we can grasp this, we won't be able to
figure out how to fix the dike permanently. Attacking those who are
trying to reinforce it may sell a lot of books (and book reviews), but
it won't solve the drug problem.

Sue Rusche Co-founder and Executive Director National Families in
Action Atlanta, Georgia

Malcolm Gladwell replies: I am delighted that Ms. Rusche has chosen to
correct my "stunning ignorance of science" with such a brisk and
authoritative account of the addictive process. It was very
informative. I'm not sure how useful it is, how ever, to point out
that drugs really are fun because surveys of "the vast majority of
drug users" tell us so. Of course, drug users find drugs fun. That's
why they are drug users. As I recall, my interest was in why people
who aren't drug users don't seem to find drugs fun---which strikes me
as a far more pertinent question. What is it about the "operant
conditioning" system that Rusche talks about that makes drugs
irresistible for a select few, and eminently resistible for the rest
of us? Should Ms. Rusche come across an answer to that question in her
readings through contemporary neuroscience, I'd be very happy if she
would let me know.

The balance of her letter, I'm afraid, I find a little bit confusing.
Rusche seems quite upset that Massing does not give the parents'
movement sufficient credit for fighting the good fight against
middle-class marijuana use. The truth is---and I'm sorry if I didn't
make this clear in my review--- that he makes that very point over and
over again. Massing thinks that the parents' movement was so
single-minded in its pursuit of reducing marijuana use, in fact, that
it neglected the much more serious drug problems of the inner city.
Rusche also objects to the suggestion that the parents' movement was
anti-treatment. Not so, she says. The parents' movement spawned an
entirely new industry of residential drug treatment facilities.
"Parents were not against treatment," she writes, "they were
desperately seeking treatment for their drug-addicted children."

But that's just it. The treatment programs they created for their
children were in private facilities, which few except middle- and
upper-middle-class families could afford. Meanwhile, by the time of
the Reagan administration, federal funds available for public
treatment programs---for the programs that dealt with the real core of
the drug problem---had shrunk to about a quarter of what they had been
during the Nixon years. Massing's rather depressing conclusion is that
during a critical early period of the war on drugs, the lobbying
groups led by people like Ms. Rusche did not really understand what
war they were supposed to be fighting. It sounds, from Ms. Rusche's
letter, as if that is still the case.