Abuse In America: The War on Addiction 

Abuse In America: The War on Addiction 
Posted by FoM on February 05, 2001 at 17:11:19 PT
By Jonathan Alter, Newsweek
Source: Newsweek
Maybe you’ve seen the movie: Dad, an Ohio judge and the nation’s new drug czar, needs a cocktail to “take the edge off.” Mom has her own youthful history with drugs and scoffs at Dad’s suggestion that she was just “experimenting.” Their 16-year-old daughter, a lovely straight-A student at a fancy private school, starts freebasing cocaine, then turns tricks to pay for her habit.
    Whatever happens next month at the Oscars, the movie “Traffic” is a cinematic IV injection—a jolting reminder of the horrors of drugs and the drug war. After a campaign in which both parties all but ignored the drug issue, director Steven Soderbergh manages the nearly impossible feat of illuminating a national debate without taking sides (both reformers and hard-liners like the movie), beyond attaching a patina of hopelessness to the whole issue.    Actually, the future may not be quite as bleak as the film suggests. While policy revolutions—like legalizing narcotics or somehow eradicating supply—are pipe dreams, change is coming to the world of addiction and drug policy. Voters in several states are far ahead of the politicians, approving ballot initiativesthat offer more treatment options. “Drug courts” that allow judges to impose substance-abuse treatment in place of jail have grown fiftyfold since the mid-1990s, part of a new understanding that, even with frequent relapses, treatment is much less expensive for society than prison and interdiction. All of the former drug czars as well as the man rumored to be President Bush’s choice for the job, retired Col. James McDonough, stress treatment and demand-side reduction as their first priority, though the funding decisions have yet to catch up to the new rhetoric. More broadly, this relatively peaceful interlude in the nation’s drug history (half as many regular drug users as in 1979 and the crack epidemic ebbing) offers a rare chance to rethink old approaches not just to renewed threats like heroin but to the mother of all abused substances—alcohol. Science is yielding clues about the “hedonic region” of the brain, while breakthrough medications and greater understanding of the mental-health problems that underlie many addictions are giving therapists new tools.    Inner Demons:    Addiction is hardly an American affliction, but it sometimes looks that way. The master narrative of public life these days seems to be all about abuse and recovery, with inner demons replacing outer enemies or forces of nature as the dramatic foils of choice. After leaving drug rehab, Jennifer Capriati stages an improbable tennis comeback to win the Australian Open. Robert Downey Jr. relapses once again, a haunting symbol of the limits of treatment. The departing president of the United States appears to have been addicted to sex, while the new president—by his own account—once had a drinking problem. In the real America, the toll is incalculable. Consider Areina Garcia, 34, mother of four children ages 1, 2, 4 and 7. She admits she was “selling my ass for drugs” and getting high in front of her kids. She didn’t stop until her husband reported her to family court. Or Brian Kelly, 31, who started drinking at 8 while tailgating with his alcoholic parents at Notre Dame games. His crack habit landed him in a $14,000-a-month “country club” treatment program with a pool, tennis courts and nothing but what he calls “appeasement” of his problem. Now both Garcia and Kelly are midway through a no-nonsense, 12- to 15-month residential treatment program at Phoenix House, still at real risk of relapse, but with at least a fighting chance to salvage their lives.       The aggregate consequences of addiction are staggering. Consider that the number of inmates in American prisons more than tripled over the last 20 years to nearly 2 million, with 60 percent to 70 percent testing positive for substance abuse on arrest. These inmates are the parents of 2.4 million children, all of whom are disproportionately likely to follow their parents to jail. According to the exponential math of a Brown University study, if the prison population were to continue growing at the current rate, by 2053 the United States would actually have more people in prison than out.        Even greatly expanded prison capacity that consumes billions can’t accommodate this flow. So over the next few years, as sentences from the high-crime 1980s are completed and reform of drugs laws accelerates, hundreds of thousands of offenders will be released or sentenced more leniently. Hard-core addicts in some jurisdictions are estimated to commit 100 petty crimes each per year. If their substance-abuse problems aren’t addressed, the country will face another crime wave soon.    Disease or Crime?    In an attempt to break the vicious cycle, drug addiction is increasingly being viewed more as a disease than a crime. (Drug trafficking is a different matter.) California approved Proposition 36 last fall, a landmark referendum that offers treatment options in place of jail for nonviolent offenders. New York is rewriting its draconian Rockefeller-era drug laws. The outgoing drug czar, retired Gen. Barry McCaffrey, says the phrase “drug war” should be retired in favor of “drug cancer.” The straight-talking military man has little to say about interdiction. His No. 1 recommendation on leaving office last month was that insurance companies offer the same level of coverage for mental-health and drug disorders as they do for any other illness. This is unlikely (managed care has led to lower reimbursements for treatments). But even hard-liners are beginning to say that we can no longer incarcerate our way out of the problem.       Of course old habits die hard. Washington still directs two thirds of the federal drug budget (including $1.1 billion in military aid to Colombia) to law enforcement, while state legislatures—leery of seeming to coddle criminals—lag behind public opinion on funding treatment. So-called harm-reduction strategies like needle exchanges (common in Europe) have a tough time winning approval, despite many studies proving that they save lives. The new attorney general, John Ashcroft, has opposed not just needle exchanges, but a taxpayer-supported media campaign aimed at teens. The early signs are that the Bush team will essentially maintain the status quo on drug policy.    Even so, a “third way” consensus between liberals and conservatives is emerging, especially at the local level where the real money is spent. It combines flexible enforcement with mandatory treatment. The drug-court idea, which comes with strong backing from most prosecutors, is sometimes known as “coercive abstinence”—using the threat of jail to motivate substance abusers to get help. “The real, nut-cutting issue is motivation,” says Joseph Califano, chairman of the National Center on Addiction and Substance Abuse. The research shows that those forced into treatment do at least as well as addicts who enroll voluntarily—often better, because they must stay in therapy longer or risk reincarceration. In all recovery programs, the best predictor of success is the length of treatment. While relapse is common, those who remain at least a year are more than twice as likely to stay clean.    ‘Resistent To Treatment’    So drug-treatment experts now often favor the “big foot” of law enforcement. “The legalizers don’t understand the psychodynamics of addiction,” says Dr. George De Leon, author of the National Institute on Drug Abuse’s most thorough study of treatment. “The nature of the disorder is that the client is resistant to treatment.” This suggests the need for intensive drug treatment not only in jail, where addicts are a captive audience, but after release, with sentences shortened in exchange for successful enrollment. Drug-court judges use carrots (gift certificates; the promise of fewer court dates) and sticks (return to jail) to change behavior.    Drug-policy reformers like Ethan Nadelman of the Lindesmith Center don’t buy the approach: “Alcoholics don’t have coerced treatment,” Nadelman says. “So why should drug abusers?” But those who actually provide treatment say they have fewer empty beds when the courts are involved. They worry that California’s Proposition 36 doesn’t do enough to compel long-term treatment. Addicts will “get kind of a driver’s-ed course in drugs that isn’t going to force them to take a self-inventory and change themselves,” says Dr. Mitchell Rosenthal, founder of Phoenix House, which operates residential-treatment centers in eight states.    Rosenthal says Phoenix House has relied on the criminal-justice system for its recent growth spurt. As in all treatment, the vast majority drop out before completing the program, but those who make it through the whole year have a surprisingly good prognosis. The research shows that about three quarters of those who graduate from 12-month residential programs are employed, drug-free and not in jail five years later. The results for in-prison programs and outpatient therapy are worse than for long-term residential care, but there, too, the key variable is length of treatment.    What's Most Cost-Effective?    At the same time, all but the fanciest 28-day residential programs are less expensive than prison, and outpatient care is much cheaper. Even when you throw in the costs of the drug court, the total expense is less than half as much as jail, and the results are far more effective. Inmates assigned to drug courts in Los Angeles and Washington, D.C., were 30 percent less likely to be rearrested than those who went through conventional courts—a huge savings to society. In another survey, only about 10 percent of those under drug-court supervision tested positive for drugs; for those in regular probation, the “dirty urine” figures were one third.    Meanwhile, hundreds of laws remain on the books that make it hard to treat substance abuse as a public-health matter. Consider heroin addiction. In nine American cities, men 20 to 54 are more likely to die of a heroin overdose than in a car accident. But courts won’t often authorize methadone treatment, and junkies routinely fail to report overdoses to the authorities for fear of being arrested. In “Traffic,” the kids leave their overdosed friend at the hospital and run—a common response.    In New Mexico, where GOP Gov. Gary Johnson is an outspoken drug reformer, the authorities are trying a new harm-reduction strategy to fight overdoses. Last month New Mexico doctors began giving addicts syringes full of Narcan, an easy-to-inject medication that counteracts the heroin, often saving lives. One test of the new public mood on drug-policy reform will be if other states follow suit.    Reassessing The Hard Line Approach:    New York is beginning to reassess its tough drug laws, which date from the 1970s. Last month Gov. George Pataki, once a major hard-liner, proposed cutting the minimum sentences for serious drug felons from 15 years to eight and giving judges more discretion. In reviewing the clemency process, Pataki says he found “dramatically unfair sentences—people sentenced to 15 years when their involvement was minimal.” But at the federal level, so-called mandatory minimum sentencing requirements are in no danger of being repealed any time soon.        Spending priorities right now look pound foolish. The Center on Addiction and Substance Abuse released a study last week showing that states spend more than 13 percent of their total budgets just “shoveling up” the wreckage of addiction—as much as they appropriate for higher education and 100 times what they spend on prevention and treatment. Another study by Rand Corp. shows that every dollar spent on treatment saves seven dollars in services. That’s because even if addicts eventually relapse, they are clean during their time in treatment, saving millions in acute health-care costs and law enforcement.    For all its promise, treatment remains a spit in the ocean of national substance abuse. Phoenix House, the nation’s largest network of treatment centers, has only about 5,000 residents—out of more than a million people arrested every year on drug-related charges. California’s Proposition 36 will fund 10,000 new treatment slots. But that’s out of 160,000 inmates who need it. While drug courts are multiplying fast, they still make up a tiny percentage of all criminal courts. In other words, like treating addiction, changing national drug policy will take patience, commitment and time. All we know for sure is that we have no choice but to try.Note: Fresh research and shifting views of treatment are opening new fronts in a deadly struggle.    With Michael Isikoff, Mark Hosenball and Suzanne Smalley    Source: Newsweek (US) Author: Jonathan Alter, NewsweekPublished: February 12, 2001Address: 251 West 57th Street, New York, N.Y. 10019 Copyright: 2001 Newsweek, Inc. Contact:  letters Website: Related Links: Join Geoffrey Cowley for a Live Talk on Wednesday, Feb. 7 at noon, EST to discuss the latest addiction treatment methods. - DPF Articles - Governor Gary Johnson
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