FOR ADDICTS, FIRM HAND CAN BE THE BEST MEDICINE

Mel Gibson is the latest reminder of the perils of drunken driving.
But in his case it was talking while intoxicated that attracted so
much attention.

Typically, of course, it is not what someone says under the influence
that concerns the public, but what he does. Safety is our main worry.
And the goal is to keep the person from driving while intoxicated.

That was the aim of the judge who in June handled the case of another
high-profile arrestee, Representative Patrick J. Kennedy of Rhode
Island. Mr. Kennedy pleaded guilty to driving under the influence
after crashing his Ford Mustang on Capitol Hill.

The congressman, it turns out, received a lucky break. No, the judge
did not treat him with kid gloves. Quite the opposite. For a year,
Mr. Kennedy must take weekly urine tests, meet with his probation
officer twice a week, and attend frequent Alcoholics Anonymous meetings.

On 10 minutes' notice, a probation officer can drop in at his Capitol
Hill apartment. Should Mr. Kennedy violate any of these terms, and
others the judge imposed, he will face her again.

One of my patients, Ralph, is envious. He, too, is on probation.

"When I have someone breathing down my neck, I just do better," said
Ralph, who was arrested three years ago for possession of heroin with
intent to distribute.

He knows because he just participated in a one-man natural
experiment. For the first four months of Ralph's probation sentence,
his probation officer was tough.

"She even made me get a job," he said.

Ralph held that job and turned in clean urine specimens.

Then the probationary division was restructured and Ralph got his
current probation officer. "He doesn't pay attention, and neither do
I," Ralph said.

He sees the probation officer monthly, but he is not expected to
attend Narcotics Anonymous meetings. His urine tests were dirty for
cocaine three times within the last four months, but nothing
happened. And forget home visits.

This is a shame, because strict monitoring, with predictable and
meaningful consequences, is so often the best medicine for people
with addictions.

Compelling evidence comes from two sources. The first are programs
run by state medical boards that oversee substance-abusing physicians.

These programs mandate treatment attendance, frequent assessment and
random, observed urine testing for up to five years. Noncompliance
may result in the loss of the doctor's medical license.

A vast majority of physicians in these programs do well -- 70 percent
to 90 percent remain abstinent throughout the two-to five-year
observation periods and resume their practice.

The second type of monitoring arrangement exists within the criminal
justice system. In drug court programs, nonviolent addicted offenders
plead guilty and submit to monitoring and treatment under close
oversight by a judge.

Infractions put in place graduated sanctions -- extra A.A. meetings;
a night in jail; a week of roadside duty picking up trash --
culminating in incarceration if the offender continues to flout the rules.

Swift response to infractions drives home the message that actions
are taken seriously and that the addict controls his fate. Also,
sanctions decrease the dropout rate from treatment.

Studies of drug courts published in peer-reviewed journals
consistently reveal significant reductions in criminal recidivism,
lasting up to two and three years after admission. A 2005 report from
the Government Accountability Office cited recidivism reductions as well.

Mr. Kennedy seemed to welcome tight control, but many offenders
resist it. No matter. A myth is that the addict must be motivated to
quit -- that, as it is often put, "You have to do it yourself."

Not so. Volumes of data attest to the power of coercion in shaping
behavior. With a threat hanging over their heads, patients often test
clean. On our own, however, we clinicians have precious little
leverage to exert.

Sometimes my patients create their own oversight. A young patient,
Karen, told me that she gave custody of her 8-year-old daughter to
the girl's grandmother precisely so that she could fight to get her back.

"The only way I can prove to social services and my mom that I can
take care of Laura is to clean myself up," Karen said. "I need a goal
like that to keep me focused."

Karen put her finger on the need for built-in controls and individual
accountability. What they probably don't realize is that it helps me too.

The patient and I don't waste time bargaining over how many drug
tests he can fail -- "C'mon, Doc, next week I'll be clean."

I don't have to risk straining the treatment relationship by issuing
sanctions; I am much more the patient's ally helping him to meet
demands that others have set for him.

As for Mr. Kennedy, shortly after his arrest, he told the news media,
"I never asked for any preferential treatment."

He is getting it nonetheless. The crime is that his fellow
probationers don't get the same attention.