A Grueling Waiting Game for Addicts Seeking Help

Drug Treatment is highly cost-effective, data show, but programs for the
indigent fail to meet enormous demand.

For thousands of weary addicts, sobriety has become a grueling waiting game.
No one knows this better than Gilbert Saldate, a social worker for Homeless
Health Care Los Angeles.

Twice a week, clipboard in hand, Saldate is down on skid row
trying to coax a neverending supply of crack heads and junkies
into drug rehabilitation. Eight to 10 people sign up on each outing,
yet only one or two will get helplargely because there aren't
enough treatment programs to meet the enormous demand.

"Society wants addicts to change," says Saldate, himself a
former heroin addict. "But I have to ask myself whether society
really wants to help them make that change."

Drug treatment advocates wonder the same thing. While national
studies show that drug abuse among teenagers and heavy users is
rising, governmentsubsidized rehabilitation for indigent addicts
remains hamstrung by unstable funding, concerns about quality of
care, and a skeptical public that believes police and prisons are the
answer to the nation's drug crisis.

In urban centers such as Los Angeles County, large numbers of
hardcore addictsthose who spread the most crime, disease and
turmoilnever make it into a program because the wait can take up
to six months, a potentially expensive delay for society.

Studies show that an untreated addict can cost taxpayers as
much as $90,000 a year in welfare, medical care, law enforcement
and losses resulting from crime, eclipsing the $21,000 annual cost
for longterm residential treatment.

"I just kept stealing, shooting heroin and running the risk of
getting AIDS," says Heather, a 21yearold addict who spent
almost three months on the street while trying to get into Impact
House in Pasadena.

Barely five feet tall with wavy brown hair and darkrimmed
glasses, Heather looks like a schoolgirl in a class photograph. But
the innocence stops there. Homeless since age 12, she has spent
almost half her life hooked on heroin and cocaine.

Like many addicts on waiting lists, Heather almost didn't make it
into treatment. The day before her admission date, she was arrested
for theft. Instead of sending her to prison, the judge gave her 30
days in jail and the chance to enter Impact House, where she
completed a sixmonth course of treatment.

"The wait was horrible," says Heather, who used to live in a
battered Toyota Tercel. "My whole life had become heroin. I
wanted to feel different from what I was feeling."

The same was true for Richard, 28. He waited almost two
months before getting into Pacifica House, a residential treatment
center in Hawthorne, in September. About a week before a slot
opened for him, Richard stopped taking his medication for
depression and ended up in Glendale Memorial Hospital after
becoming suicidal.

"I doubted I would stay alive long enough to get into a program,"
he says. "You make this big decision in your life to get help, then it
just isn't available."

In recent years, numerous researchers have concluded that
substance abuse treatment is one of the most powerfuland
costeffectiveweapons in the nation's war on drugs.

A 1994 Rand Corp. study, for example, found that drug
rehabilitation is far more efficient in reducing cocaine consumption
than anything law enforcement has thrown at the problem. Other
researchers, meanwhile, have reported that after addicts undergo
treatment, violent behavior drops dramatically, along with arrests.

The California Department of Alcohol and Drug Programs
concluded in 1994 that for every $1 invested in treatment services,
taxpayers saved $7 in law enforcement, welfare, public health and
crime costs. The same conclusions have been reached in other
states.

Yet despite such promising findings, government spending for
rehabilitation amounts to a fraction of the $290 billion spent since
1980 on drug enforcement by local, state and federal agencies.

"Drug treatment has been and still remains a very hard sell," said
David Mactas, director of the federal Center for Substance Abuse
Treatment, which administers grants to state rehabilitation programs.
"Addicts are a highly stigmatized population. People would rather
lock them up than give them a chance for recovery."

Indeed, a recent Gallup poll found that a majority of Americans
think treatment is less effective than education, traditional law
enforcement efforts and the interception of foreign narcotics
shipments.

San Francisco County stands alone in California as the only
place that seems willing to challenge convention and gamble millions
of dollars on expanding drug treatment. In an unprecedented move,
officials there plan to raise enough money to provide treatment on
demand for indigent addicts. The goal: Reduce the average wait
from three months to 48 hours.

"We are not just talking the talk, but trying to allocate funding to
solve the problem," said Larry Meredith, director of Community
Substance Abuse Services in San Francisco. "You just can't have a
front door that empties onto a vacant lot."

For Some, a Way Out

For more than 20 years, Josie Gann was a heroin and cocaine
addict. Today, at 43, she is living proof that, in her words,
"treatment works."

Gann started smoking pot and sniffing glue at age 12. She hit
bottom three years ago in Anaheim. Unable to stay awake at work
because of her nightly drug binges, she lost her job as a stock clerk
for a computer company and moved into a cheap motel room in the
shadow of Disneyland.

To make ends meet, Gann sold heroin and shoplifted until she
was arrested in 1993 for commercial burglary. Because of her
lengthy police record, she faced a minimum prison term of 18
months. Instead, an Orange County judge ordered her into
Prototypes, a residential treatment program for women in Pomona.

"At first I didn't want to go," Gann says, "but then I saw people
there with shiny hair, clean clothes and a twinkle in their eyes. I
wanted that."

Her path to sobriety included a strict routine of work and
counseling designed to develop selfconfidence, job skills and
solutions to some of the personal problems that contributed to her
addiction.

"Until I got there, I did not know how to live a day without doing
drugs," Gann says. "Treatment teaches you a new way of life. It's
about responsibility and accountability. By learning to discipline
yourself, you can do things you never thought you could do before."

Like holding down a job.

After working in the Prototypes kitchen under the tutelage of a
chef, Gann became so adept at baking cakes and pastries that she
developed a catering business on the side. Sober for three years,
she now works as a drug and alcohol counselor in Dana Point and
picks up a few extra dollars baking cakes for friends.

"I'm doing . . . better than ever," she says. "I know now that I
don't have to live like I used to."

Because treatment slots are limited, many of those who enter
programs do so only after hurdling obstacles designed to deter the
least disciplined. Many centers winnow out applicants, about a
quarter of whom are alcoholics, by requiring them to call in regularly
and attend weekly meetingsor lose their place in line.

For those in the late stages of addiction who may be homeless
or in trouble with the law, the process is like climbing Mt. Everest.
When someone's life is a mess, it's easy to miss a call. And the
longer the wait, the more ambivalent people get about treatment.

"Many addicts have second thoughts as the process drags on,"
says William Edelman, the director of drug and alcohol services for
Orange County. "If they show some interest, we should be able to
get them into treatment right away. It would save taxpayers money
in the long run, and families a lot of misery."

Unstable Funding

It is difficult to say how much money is needed to close the
"treatment gap." An exhaustive study published in 1990 by the
National Academy of Sciences' Institute of Medicine recommended
that the federal contribution to rehabilitation services be increased
by up to $3 billion a year to be effective.

That kind of money has been hard to come by. Part of the
problem is that federal funding, which provides most of the money
for drug treatment, has fluctuated with the philosophies of those in
power.

The Reagan administration, which emphasized a gettough
approach to drugs, pared millions of dollars from rehab budgets
during the 1980s. The Bush administration reversed Reagan's
policies and more than doubled spending for treatment.

President Clinton raised funding for drug rehabilitation by almost
$100 million in 1994, but Congress erased those gains in 1995 with
a $250million cut. Last year, the funds were restored with a slight
increase, and Clinton has asked Congress for an additional $194
million for treatment next year.

While directors of county drug programs welcome the additional
funding, they complain that it has not kept pace with inflation or the
rising costs of care because of increasing professionalization of the
field and a client population that is harder to treat.

Today, treatment centers are dealing with more pregnant
addicts, addicts with small children, and drug abusers who are
mentally ill. More clients are infected with the AIDS virus or other
communicable diseases such as hepatitis and tuberculosis.

"Annual increases of $500,000 or a million dollars a year for a
county program are really pointless," said Robert Garner, director
of drug and alcohol services for Santa Clara County. "We should
either double the investment in drug treatment or stop talking about
it."

The budget for the California Department of Alcohol and Drug
Programs, which disburses state and federal dollars to the counties,
rose from $312 million in 1991 to $354 million in 1996. In Los
Angeles County, funding has remained relatively unchanged, rising
from $68 million in 1991 to $69 million in 1996.

Most of the government money that flows to treatment centers
pays for detoxification, methadone maintenance for heroin addicts,
outpatient counseling, hospitalbased programs and residence for
up to a year in drugfree settings known as "therapeutic
communities."

At the heart of the treatment is the 12step method developed
by Alcoholics Anonymous in the late 1930s. The approach helps
substance abusers confront their problems and change their
lifestyles under the guidance of former addicts.

Honesty, discipline, accountability, instilling a desire to help
others and a reliance on a spiritual force to overcome addiction are
all hallmarks of the 12step philosophy.

"At first it's difficult," says Gerald Boyd, 26, a methamphetamine
addict who is now in Pacifica House. "They get on you for every
little house rule you break. . . . Then you realize everything you do
has consequences, that you should do the right thing, no matter how
little the task. What you learn is selfcontrol and discipline."

Boyd was fortunate. Determined to clean up his life, he got into
Pacifica in less than a month largely by attending every orientation
meeting and calling the center more often than required.

Although Boyd's wait was relatively short, he says, it was long
enough to give him pause about pressing ahead with treatment,
especially since he had the possibility of getting a job at around the
same time.

"I had a drug problem I couldn't control and my life was totally
unmanageable," he says. "Yet here I was having second thoughts
that things would turn out better. Had I not kept calling I don't
know what would have happened."

In California, as many as 8,000 addicts and alcoholics are on
waiting lists for a chance at one of the 54,500 publicly funded
treatment slotsnearly half of which are in Los Angeles County.

Researchers say that those people represent a fraction of those
who want treatment but have been scared off by the wait or have
dropped off the lists for a variety of reasons. Studies conducted by
UCLA's Drug Abuse Research Center have found that the demand
for governmentfunded treatment in Los Angeles County might be
three to four times the 21,000 available slots.

The waits are particularly long for mentally ill drug abusers, who
require the most intensive kind of care. The same is true for juvenile
addicts.

Further hindering the delivery of drug treatment in California, a
federal judge ruled in 1994 that some counties were illegally denying
MediCal benefits to addicts in methadone maintenance programs.
MediCal is California's health insurance plan for the poor.

The decision prompted the state to shift tens of millions of
dollars away from some county drug programs to extend MediCal
services not only to more methadone users, but also to pregnant
addicts, addicts with infants, and those infected with the AIDS
virus.

Directors of county drug and alcohol services say the shift
"robbed Peter to pay Paul" as money was taken out of services for
indigent addicts who could not qualify for MediCal.

They contend that the state could have avoided the fiscal
calamity by seeking more money for treatment and restricting the
use of MediCal to methadone users, the only group to which the
court ruling applied.

Andrew M. Mecca, the director of the California Department of
Alcohol and Drug Programs, said state budget deficits at the time
precluded getting more money to compensate for the impact of the
court decision. Shifting resources to the MediCal program, he said,
enabled the state to get matching federal funds, which increased the
pool of money available for rehab services.

"Historically, treatment has been grossly underfunded," Mecca
said. "But California has provided the most demonstrative
leadership in the field. There is no government or state that has
come close to our level of investment."

Answers Remain Elusive

While support for rehabilitation has been on the rise, some
researchers warn that treatment is no cureall.

In 1993, for example, the federal Treatment Outcome
Prospectives Study showed that for every 10 cocaine addicts
admitted to treatment, eight relapsed into heavy use within three to
five years after their rehab.

In addition, critics say that there has never been a study
comparing treated and untreated addicts to determine whether
rehabilitation programs really make a difference.

Amid such questions, some drug policy analysts doubt that
major infusions of government dollars could significantly reduce
addiction. They point to federal statistics showing that past
increases in drugtreatment funding did not lead to significantly more
admissions to rehabilitation programs and did not curb drug use
among heavy abusers.

"Some very fine drug treatment programs have proven their
usefulness, but the government treatment bureaucracy is manifestly
ineffective," said John P. Walters, a highranking drug policy official
during the Bush administration.

Rehabilitation advocates counter that most of the increase in
federal funding has had to pay not for new treatment slots but for
improving the quality of patient care, which suffered from the deep
cuts of the Reagan years.

"I think there are very few examples of greater efficiency or
better investment of federal dollars," said Mactas of the Center for
Substance Abuse Treatment. "Look at the California study. For
every $1 invested, you save $7. You don't get that kind of return on
Wall Street."

Even so, questions have been raised about whether the payoff
could be bigger if financial oversight and controls of treatment
programs were strengthened.

Consider the experience of Santa Clara County, where up to
4,000 indigent substance abusers are treated each year.

In November, officials there began scrutinizing the county's drug
treatment programs. Since then, they have discovered people
receiving unneeded care or participating in expensive programs
when cheaper alternatives were more appropriate. In the future, the
county hopes to award contracts to treatment providers based on
their success rates and prices.

Advocates of governmentfunded treatment acknowledge that,
given the fiscal pressures on government, rehabilitation expenses
must be kept down. But they worry that too much attention to the
bottom line could leave patients shortchanged.

Already, they say, some county programs have begun reducing
treatment times whenever possible, even though research shows
that the longer people stay in counseling the better they do.

Cost-saving efforts also could prove especially selfdefeating for
hardcore addicts in need of fulltime residential care who are being
forced into cheaper outpatient facilities.

"Indigent clients are not the same as privatepay or insured
clients. They are harder to deal with and more expensive to treat,"
said Ellen M. Weber, a policy analyst for the Legal Action Center,
a nonprofit agency in Washington, D.C., that specializes in drug
treatment issues.

Many veterans of the substanceabuse field say one way to
reduce costs without jeopardizing patients is to make a fundamental
change in the treatment system. They contend that rehabilitation has
turned into an industry at the expense of cheaper approaches.
Today, the government is reluctant to provide funds to treatment
programs unless they are accredited and have credentialed staffers.

"The white coats, the degrees and accreditation are really just
frosting on the cake," said Al Wright, an attorney and former
director of alcohol programs for Los Angeles County.

Wright contends that treatment dollars could go much further by
relying more extensively on smaller "social model" facilities.

These programs use recovering addicts and alcoholics as
counselors, who may or may not have professional degrees. No
trained psychologists or medical personnel are on staff.

For six months or longer, 20 or so clients live in a drug and
alcoholfree home. The socialmodel programs work closely with
existing schools and social services in their communities to provide
education, medical care, psychological counseling and job training
for participants.

Public health researchers at UC Berkeley say this approach has
grown increasingly out of favor because state and federal actions
have professionalized substance abuse treatment.

Many drug treatment experts say that while they admire social
model programs, they typically do not have the accreditation and
the administrative staffs that are required to qualify for state and
federal dollars.

"You must become a bona fide health care service to get
government money today," says Dr. Richard Rawson, who runs the
Matrix Institute, a drug rehab center in West Los Angeles.

On the Streets, Battle Continues

Unless the philosophical debate is resolved soon or substantially
more money gets pumped into the system, Gilbert Saldate's work
on skid row will remain what it has always beena lesson in
frustration.

Saldate, 36, knows what treatment can do. Seven years ago, he
inventoried his life and all he saw were arrests, jail sentences,
overdoses and the crimes he committed as a member of Frogtown,
a street gang in northeast Los Angeles. He entered House of
Stephanas, a churchbased rehab program in Montebello, and
stayed four months. He has been clean ever since.

"I talk to people all the time on the row," Saldate says. "They get
interested in treatment. Then you tell them there is a wait, that it
could cost them $200 to get into detox and they start to walk. You
can see the hopelessness in their faces."