FOR ADDICTS, FORCE IS THE BEST MEDICINE

Autopsy reports confirmed last week that actor and comedian Chris Farley
died Dec. 18 of an overdose of cocaine and morphine. Farley was 33, the
same age at which his idol, Jdhn Belushi, fatally overdosed on cocaine and
heroin in 1982. Two weeks before Farley's death, another actor, Robert
Downey Jr., came before a Los Angeles County municipal judge in a Malibu
courtroom on a drug-related charge. The judge,, Lawrence Mira, jailed him
for six months, having gone easy on him after several earlier convictions.
"I'm going to incarcerate you in a way you won't like," Judge Mira told
Downey, "but it may save your life."

'Chris Kept Trying'

Indeed it may. And if Farley had had the good fortune to be arrested and
come before a tough judge, he might well be alive today. As a psychiatrist
who treats drug addicts, I have learned that legal sanctions-either imposed
or threatened -may provide the leverage needed to keep them alive by
keeping them in treatment. Voluntary help is often not enough. After all,
Downey and Farley had already been to some of the nation's finest
rehabilitation centers, but their stays were far too brief. "Chris kept
trying, and he would go into rehab and he would come out, and sometimes
he'd be really healthy," Al Franken, who worked with Farley on "Saturday
Night Live," told a reporter after his death.

It's an all-too-typical story: Addicts avoid treatment for years or take it
in small doses, enough to refresh themselves before starting out on another
binge. According to the federally funded Drug Abuse Treatment Outcome
Study, patients report being addicted for 10 to 15 years on average before
first entering treatment. When they do enroll, only one in seven completes
a program. Downey, for example, once bailed out after a few days.

At the root of the problem are the misguided though well-meaning attitudes
of many drug-treatment professionals. They believe in waiting until a drug
user is "motivated" to get help, allowing him to reject help until he is no
longer "in denial," and telling addicts that treatment won't work until
they "want to do it for themselves."

At the same time, the prevailing view holds that an addict is someone
suffering from a chronic illness, rather than someone whose behavior can be
influenced by meaningful consequences. The National Institute on Drug
Abuse, part of the National Institutes of Health, even goes so far as to
call addiction a "brain disease." In truth, drugs do affect the brain, but
even many of my patients know that stopping is a matter of personal
responsibility. In encouraging users to take that responsibility, coercion
can be the clinician's best friend. Without it, our work is often in vain.

In the methadone clinic where I work, many patients continue to use cocaine
and heroin while receiving counseling and group therapy. Short of ejecting
them from the clinic, there is little we doctors can do about this. But
sometimes a patient will get a lucky break: He'll get arrested and put on
probation with the requirement that he take frequent urine tests and the
stipulation that he goes to jail if he fails. With this threat hanging over
their heads, patients often test clean-no great surprise to anyone not
steeped in therapeutic ideology.

Some addicts themselves recognize the benefits of coercion. One patient
told me he planned to get a job as a truck driver. "At least they'll test
my urine, and I'll know someone's watching," he said. This patient put his
finger on the crying need for built-in controls and individual
accountability. When they're there, imposed by a judge or an employer, I
can do my job better. 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 threatening the
patient with discharge from the clinic. Instead, with externally imposed
limits and expectations, I am clearly the patient's ally. We are working
together to- ward his recovery, developing strategies to resist temptation
and ultimately discov- ering larger reasons to stay clean, because we both
know that there are serious con- sequences for failing. And it's a myth
that addicts have to want treatment. Ample evidence from large-scale
studies shows that when they are compelled to treatment by judges or
mandated by their employers, these coerced addicts do at least as well as
their counterparts who voluntarily enter and complete the program.

It is also well documented that the longer a patient stays in treatment,
the more likely he is to avoid future criminal activity and drug use. For
example, any patient-whether treated voluntarily or under court order
- -staying 18 to 24 months in Phoenix House, a residential community program,
has a 90% chance of being employed and out of legal trouble and a 70%
chance of being completely drug-free five to seven years after discharge.
The Brooklyn, N.Y.. district attomey, who routinely sends nonviolent drug
felons to mandatory residential treatment programs instead of prison, finds
they remain in treatment two to four times longer than their noncoerced
counterparts. They also fare better than their imprisoned counterparts,
whose re-arrest rate one year after release is more than twice the rate of
those who have completed treatment. Treatment is one-third cheaper than
incarceration, to boot.

The idea of "harm reduction" -decriminalization, along with medically
supervised heroin distribution, needle exchanges and other such
measures-has been gaining currency in the drug debate of late. But addicts
would be better off if more of them were arrested and forced to enroll in
treatment programs. "I wish the cops could bust an addict for jaywalking or
littering," a colleague of mine says, only half-jokingly. "At least then he
would get placed in a treatment program where the court would make sure
he'd stay." Civil judges can, without arrest, commit some addicts to
treatment for their own protection if they are clearly out of control-as
Farley appears to have been. More than half the states have statutes,
seldom used, that allow civil commitment for alcoholics and drug addicts on
the basis of grave disability or a threat to oneself or others.

Payoff Is Immense

To be sure, being forced Into a program and losing autonomy-either in a
residential, a jail-based or a probationary treatment program-can seem
harsh. But the payoff is immense: an opportunity to develop the social
competence, trust in others and optimism about the future that are the
prerequisites for a life without drugs. The payoffs for society are
substantial, too. Numerous large-scale cost-benefit analyses reveal that
every dollar spent on, drug treatment saves between $2 and $7 on law
enforcement, corrections, health care, lost productivity and welfare.

To my dismay, some of my treatment colleagues oppose coercion as
"punitive." I suppose it may seem that way if one thinks addicts are
helpless victims of a brain disease. But addiction is a moral condition as
well as a medical one. If we view it in this light, then predictable
consequences for failure and rewards for success are the essence of humane
therapy.