Pubdate: Wed, 28 Aug 2002
Source: Star-Ledger (NJ)
Copyright: 2002 Newark Morning Ledger Co
Contact:  http://www.nj.com/starledger/
Details: http://www.mapinc.org/media/424
Author: Kitta Macpherson
Bookmark: http://www.mapinc.org/find?159 (Drug Courts)
Bookmark: http://www.mapinc.org/rehab.htm (Treatment)

DRUG-HABIT DEBATE: WIRING VS. WILLPOWER

Experts Argue Over Effects Of Chemistry And Character

Every Thursday in his Newark courtroom, Essex County Superior Court Judge 
Harold Fullilove weighs more than mere evidence.

Presiding over one of 10 "drug courts" in the state, Fullilove balances 
lies against truths and compulsion vs. determination. He can write off a 
life or try to save it.

Addiction is no joke to Fullilove, who lost a brother to a cocaine overdose.

On drug court days, when he removes himself from normal criminal trial 
division matters, he is both jurist and drug abuse counselor, as part of a 
five-year-old program designed to de-criminalize addiction in nonviolent 
drug defendants and find them treatment.

His participation also places Fullilove and other like-minded legal 
practitioners squarely in the center of a deep and developing medical debate.

On one side are people like Francis Vocci, a neuroscientist at the 
federally funded National Institute on Drug Abuse, who says research over 
the past 10 years proves that addiction is a brain disease that compels 
users to continue. Drug courts, he believes, are "high-minded efforts."

On the other side are people like Stanton Peele, a Morristown author, 
attorney and licensed psychologist, who contends people choose to become 
addicts and can break their habits if they have enough willpower. Blaming 
it on the brain, he says, will lead to coddling people who need it least.

People subscribing to Peele's point of view tend to like drug courts, too.

Something Missing

People become addicts, says Peele, because there is something missing in 
their lives. Addiction, he says, is a symptom, not a disease. When he works 
with patients, he tries to help them fill the gap that led to the aberrant 
behavior in the first place.

People are addicted to far more than just substances, he said, noting that 
his first book, "Love and Addiction," written in 1975, details the power 
that toxic relationships have over people.

Deciding whether addicts can help themselves and how deeply society should 
become involved in this treatment is not merely a matter of philosophical 
debate. Hundreds of scientists, inspired by the latest brain research, are 
working to develop drugs to treat heroin, cocaine, tobacco and alcohol 
abuse, changing the very nature of drug treatment.

Modern neuroscience, researchers say, has come up with a new twist on the 
old conflict of free choice vs. fate, long described under various guises 
in literature.

Those who believe addiction is a disease generally favor a treatment plan 
that includes both counseling and medications. They also maintain that 
abstinence is the best approach to break an addiction to drugs or alcohol.

In contrast, opponents of the disease model point out that many people kick 
a habit without any help, professional or otherwise. Some are even able to 
moderate their intake, they say, without going "cold turkey."

Addiction must be behavioral, according to Sally Satel, a psychiatrist who 
is a research fellow at the American Enterprise Institute in Washington, 
D.C. After all, so many addicts respond to rewards and consequences, not 
just to physiology, she said.

As a result of new insights into addiction, many new medications that alter 
brain activity directly related to addiction will be coming on the market 
over the next few years. Some physicians see this as a godsend, helping 
addicts climb out of the wreckage of their lives.

Others are not so sure.

"We have overmedicalized addiction," said Satel. "I think we have too much 
faith that these medications are going to change the face of addiction 
treatment." She treats patients at a methadone clinic in Washington and 
views the heroin treatment as a "qualified success." But at least half her 
patients, she said, are still using drugs.

"So half are, half aren't -- it depends on how you look at it if you are 
going to decide whether that's good or bad," she said.

Blaming The Victim

Federal researchers have long suggested that the stigma of addiction should 
be removed, since the behavior is based in the brain. How, they reason, can 
people be blamed for following through on a compulsion that their brain is 
wired to slavishly follow?

Satel is opposed to this thinking. "You can't remove the stigma," she said. 
Fear of being stigmatized and being ostracized by society is what keeps 
many people from using addictive substances, she said. "They are not doing 
something that is good when they use. Why can't we say that?"

The notion that addiction may be rooted in biology also throws her, she 
said, because it makes it sound as if addicts didn't have a choice. 
"Addiction is self-induced -- that's not inevitable," she said. "It's not 
like bipolar illness or something."

Bankole Johnson, a neuroscientist at the University of Texas who has been 
working to develop a medication to treat alcoholics, said the same kinds of 
criticisms were raised about schizophrenia and bipolar disorder a few 
decades ago. Both were viewed by many as behaviors that were not 
necessarily provoked by brain processes -- until brain scans showed 
otherwise. The history of medicine, Johnson said, is marked by case after 
case of physicians misunderstanding the roots of a disease, then coming to 
an understanding as the scientific results poured in.

"The same will happen with addiction," he said. "These criticisms will be 
disproven."

Willpower

Satel understands how differences in brain structures can help explain why 
some people like a drug and others don't. What she can't comprehend is how 
such a theory accounts for a situation in which two people try cocaine, for 
example, and both enjoy it immensely. But one will want more and the other 
will ask that the drug be kept away -- it is too dangerously enjoyable.

Satel sees these acts as an example of differing levels of willpower. 
Johnson said the difference could be explained as brain-based, too. 
Impulsivity and control are clearly tied to levels of brain chemicals, he 
said. Some people may have genetic variations that induce them to respond 
differently to certain drugs.

Satel doesn't buy this logic. "It's not politically correct in some 
therapeutic circles to say this, but I'm going to ask it anyway: What about 
conscience and character and harnessing one's will? Aren't these involved, 
too?" she asked.

A study conducted by University of St. Louis researchers, she said, found 
that 85 percent of heroin addicts returning from Vietnam were able to quit 
the drug once they came home, indicating that cultural factors, the higher 
price of the drug and fear of arrest helped them end their addiction.

Viewing drug addiction as an uncontrollable behavior is not only incorrect, 
she said, but potentially damaging as well. "It's a fairly pessimistic 
message," she said. "The message that addiction is chronic and relapse 
inevitable is demoralizing to patients and gives the treatment system an 
excuse if it doesn't serve them well." She advocates treatment but prefers 
to call addiction a behavioral condition.

"The person, not his autonomous brain, is the instigator of his relapse and 
the agent of his recovery," she maintains. In this view, treatment is 
important but punitive measures also may deter drug abuse.

Drug addicts spend long periods each day when they are not using, she said. 
She tells her patients that they have the power to make a lot of decisions 
in one day. One of those decisions could have been to go to a drug 
treatment center, she tells them.

She is not opposed to addiction research. But she views the language used 
by many federal researchers to describe the biological model of addiction 
they subscribe to as a poor public health message and, worse, one that is 
self-serving.

"It serves a lot of purposes," Satel said. "It gives them funding. It takes 
personal responsibility away from patients. And what do you have? You have 
nothing. You have doctors colluding with patients in their desire to use 
drugs with no consequences."

The model in the middle, halfway between biological and behavioral issues, 
is drug court, she said.

Satel likes these programs because studies show that patients who have been 
ordered by a court to seek treatment will generally stay longer than those 
who have not been ordered there. The programs, she said, also emphasize 
personal accountability and moral issues that empower addicts.

"You work with them," she said. "You shape the incentive so that people 
make a choice that's in their best interest."

The Hard Way

The mission of drug courts is to stop the abuse of alcohol and other drugs 
and related criminal activity. They are unique in the criminal justice 
environment because they build a close relationship between law 
professionals and experts in drug treatment. Within a somewhat relaxed 
courtroom atmosphere, a judge heads a team of court staff, attorneys, 
probation officers, substance abuse evaluators and treatment professionals 
to support and monitor a participant's recovery.

Defendants generally dry out from their addiction in jail and then, through 
the courts, enter a treatment program such as Integrity House in Newark or 
Straight and Narrow in Passaic.

Though scientists promise they are coming, there are few medications 
currently available to help addicts curb their cravings. Most of the 
defendants going through drug court, as a result, dry out the hard way.

"They are basically locked up in these programs for 30 days so they can't 
get access to the drugs," said Carmine Centanni, a counselor who works in 
Fullilove's drug court.

The New Jersey Adult Drug Court program began in 1997 when Superior Courts 
in Camden and Essex counties started accepting participants. These local 
projects evolved into programs that have paved the way for additional pilot 
programs. By 1999, additional programs were established in Mercer, Passaic 
and Union counties. The effort has continued to expand.

As of April 2002, more than 2,000 offenders had gone through the state's 
drug court pilot programs. The current roster of drug court participants 
statewide is approximately 1,411.

About 72 percent of addicts in the program will stay to the end.

Most studies conclude that the longer a patient is in treatment, the better 
the chances for success. At least 90 days of treatment is what people need 
to get the highest rates of success, the studies show, which is why 
organizations like Alcoholics Anonymous and Narcotics Anonymous stress "90 
meetings in 90 days" to newcomers.

On any given day in Fullilove's courtroom, the scales of justice can tip in 
either direction.

When one defendant, at her weekly check-in, reads a selection from a 
Narcotics Anonymous handbook, he smiles and tells her to go and "have a 
good week."

When another appears, his head low after having been found drunk over the 
weekend by his probation officer, he receives the full tough-love treatment 
from the normally sunny judge.

"Are you absolutely crazy?" Fullilove asks with an exasperated air. "Why 
shouldn't I just throw you in jail?"

Threatening defendants with a stay in what he ordinarily calls the "Hotel 
Fullilove" -- county or state jail -- usually chastens them.

Then the addiction counselor in the judge comes out. "You have to 
understand that what other people do, you can't do," Fullilove said. "You 
can't drink. You can't."

He gives the defendant, Willie Nieves, an unemployed mechanic, one more 
chance. "Come back in a week," he said.
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