Source: New York Sunday Times Magazine
Pubdate: 7 September 1998
Contact:  Letters to the Editor, Magazine, The New York Times, 229 West 43rd
Street, New York, NY 10036
Author: Michael Massing


Don't let Rudolph Giuliani fool you: methadone works.  Since its
introduction in the mid-1960's, studies have consistently shown that the
synthetic narcotic cuts addicts' craving for heroin, enabling onetime
street junkies to restart their lives.  In so doing, methadone helps boost
employment, inhibit the spread of H.I.V and cut crime.  That's why the New
York City Mayor's recent attacks - he denounced methadone as 'a chemical
that's used to enslave people' and promised to abolish it from the city
over the next few years - have left experts scratching their heads.

The Mayor appears driven by a moral conviction that complete abstinence
from drugs is the only acceptable course.  Yet if Giuliani were truly
interested in promoting abstinence from drugs, he would have not simply
condemned methadone but also announced a major expansion of treatment
programs whose express goal is to wean addicts from the substance. (The
city has virtually no such programs now.) He would also have announced the
creation of more residential programs that seek to change addicts'
behavior. The Mayor's failure to do any of this raises the suspicion that
it is not just methadone he dislikes -but drug treatment in general.

In this respect, Giuliani reflects a national mood.  For nearly 20 years,
the United States has waged a relentless war on drugs, with treatment
discounted as a weak weapon.  Instead, the Government has sent spy planes
swooshing over the Caribbean, built a paramilitary base in Peru, mounted
coca-eradication programs in Bolivia - and invaded Panama.  On the home
front, narcotics agents have infiltrated hundreds of drug gangs and busted
countless drug dealers.  In 1996, more than 1.5 million people were
arrested for drug offenses; the nation's prisons, which in 1980 housed
fewer than 30,000 drug offenders, today harbor nearly 300,000.

But this punitive approach has failed.  Cocaine is cheaper than ever, and
heroin is selling at purity levels three times greater than those of the
mid1980's.  And drug abuse remains rampant.  In 1996, the number of
cocaine-related visits to hospital emergency rooms topped 144,000, an
all-time high.  This despite an increase in the Federal antidrug budget
from $1 billion in 1981 to $16 billion in 1998.

Looking at numbers like these, it may seem as if the nation's drug problem
is all but intractable.  But it isn't.  Our penchant for punishment has
blinded us to the most effective strategy for combating drug use: offering
comprehensive treatment to every addict who requests it.

Unfortunately the case for expanding our commitment to treatment programs
frequently gets drowned out by more extreme voices. Law-and-order types
like Giuliani call for ever more police dragnets and undercover
investigations.  On the opposing side, reformers push for drastic measures
like drug legalization.  Legalize drugs, they say, criminal networks that
traffic in them will disappear - much like the repeal of Prohibition led to
the demise of speakeasies and bathtub gin. The end of Prohibition, however,
also led to a sharp rise in alcohol use.  Between 1934 and 1944, per capita
consumption in the United States rose from 0.97 gallons to 2.07 gallons.
(Today it is 2.25 gallons.) If illicit drugs were suddenly legalized, might
not consumption similarly rise?

By now, the risks of legalization have become so evident that many one-time
advocates have flocked to a new standard: harm reduction. Drugs, it is
argued, are here to stay, and society needs to learn how to live with them.
 Our goal should be to reduce the harm that drugs cause.  To that end, they
advocate a variety of reforms, like expanding needle-exchange programs and
creating "safe injection rooms" as alternatives to shooting galleries.

Some of these ideas clearly make sense.  Needle-exchange programs, for one,
have been shown to reduce the transmission of H.I.V.  Yet harm reduction
has serious limitations.  For the most part, it does not seek to get people
off drugs but merely to help them use drugs more safely. To express
disapproval of addiction would, in the harm reductionists' view, reinforce
society's intolerance of drug addicts.  While promoting tolerance is
admirable, the harm reductionists take it too far: if you should not
stigmatize addicts, neither should you condone addiction. And with its
learn-to-live-with-drugs approach, harm reduction offers no guidance on how
to bring down the appallingly high levels of drug addiction in this country.

Harm reduction does, at least, acknowledge one key fact: helping chronic
users should be the target of drug policy.  Washington doesn't understand
this.  From recent actions in the nation's capital - like Congress's
decision to earmark $1 billion for antidrug advertising aimed at teenagers
- - you might logically conclude that the threat drugs pose to the nation
consists mainly of adolescent use.  In fact, teen-age drug use, while up
some in recent years, remains well below the peak levels of the late
1970's.  What's more, most of that increase consists of marijuana use.  And
while pot is not harmless, and young people should be discouraged from
using it, it is not the problem heroin and cocaine are.

In contrast to teen-age pot smokers, adults who regularly use heroin,
cocaine and crack do pose problems: they commit muggings, abuse children,
suffer overdoses and spread disease.  In all, there are an estimated 3.6
'Ilion hard-core users in the United States.  While these addicts
constitute only 20 percent of all drug users in the country (most of the
rest being casual, occasional users), they consume about three-fourths of
all the cocaine and heroin used here.

Who are these problem users? Contrary to the many media accounts of
strung-out stockbrokers and models, addicts tend to be found not in posh
condominiums or suburban split-levels but in the housing projects of urban
America.  Heavy users are disproportionately poor, unemployed and members
of minority groups.  No headway can be made in alleviating the nation's
drug problem without finding a way to get such users off drugs. A good
place to begin is suggested by a 1994 RAND study.  The researchers C. Peter
Rydell and Susan Everingham set out to compare the effectiveness of four
types of drug-control programs: source-country efforts (attacking drug
production abroad), interdiction (seizing drugs in transit to the U.S.),
domestic law enforcement (arresting and incarcerating sellers and buyers)
and drug treatment.  How much additional money, they asked, would the
Government have to spend on each approach to reduce national cocaine
consumption by 1 percent? Rydell and Everingham developed a model of the
national cocaine market, then fed into it more than 70 variables, from
seizure data to survey responses.

They were amazed at the results.  Relying solely on domestic law
enforcement, the Government would have to spend an additional $246 million
to reduce U.S. cocaine consumption by 1 percent.  Relying on interdiction,
it would have to spend $366 million, and on source-country programs, a
whopping $783 million.  Relying solely on drug treatment, however, the
Government would have to spend just $34 million more.  In other words,
treatment was 7 times more cost effective than domestic law enforcement, 10
times more effective than interdiction and 23 times more effective than
attacking drugs at their source.

Such results contradict the convention wisdom that treatment does not work.
 Many Americans know of someone who entered a program and did well while in
it, only to relapse afterward.  Nevertheless, failed treatments do not cost
very much and so do not dilute the cost-effectiveness of treatment overall.
 More important, study after study has demonstrated the efficacy of treatment.

In one recent analysis, the Government tracked the performance of 4,400
clients who entered treatment between July 1993 and October 1995.  Those
clients were interviewed at the time they began treatment, at the time they
finished and a year later; the accuracy of their responses was checked by
random drug tests.  Seeking to study the most severe cases, the researchers
concentrated on programs serving people in public housing, on welfare and
in the criminal-justice system.  The number of clients saying they used
crack dropped from 39.5 percent prior to treatment to 17.8 percent a year
later; for heroin, the number went from 23.6 percent to 12.6 percent.  All
told, drug consumption decreased by roughly 50 percent.

Well, skeptics will say, treatment might be effective for addicts who
receive it, but how many really want it? junkies, it's commonly believed,
simply do not want help.  And to an extent, that's true. Drugs not only
impart intense pleasure but also provide great comfort to people coping
with various crises in their lives.  Yet for many, the point eventually
comes when the drugs themselves begin to cause problems, from physical
ailments to family quarrels to legal troubles. And when that happens,
addicts are often open to help.  That openness, however, is usually quite
fleeting, and unless it is exploited immediately, most will end up back on
the streets.

Alas, help is rarely available immediately.  Consider the situation in New
York State.  An estimated 1.6 million residents have a drug or alcohol
problem serious enough to require treatment.  In any given year, roughly 25
percent of that number, or 400,000, will seek help.  To serve them, the
state has 121,000 publicly funded slots.  With those slots turning over
throughout the year, the state can accommodate nearly 300,000 people
annually.  That leaves more than 100,000 people a year unable to get help.

Scarcity is just the start of the problem.  In the world of New York health
care, drug treatment is the Balkans: a chaotic realm full of internal
strife and rivalries.  Each treatment program features a different regimen
and serves distinct populations.  Not every program is right for every
individual.  Yet the city has no central place where addicts can go to
apply for admission.  There is not even a registry listing openings.  If a
Holiday Inn is full, it will at least call the Ramada down the street to
see if it has a vacancy; not so two treatment programs.  As for addicts who
do enter the system, there's no one to monitor their progress and make sure
they stay on course.

Fortunately, there exists a remedy to such problems: 'central intake
units,' places where addicts can go to get immediate attention. Appearing
here, addicts would meet with the first available counselor to discuss the
nature of their problem and the best way to address it. After deciding on
the proper therapy - a detox, a methadone program, a residential facility -
the counselor would consult a computerized directory of openings.  Once a
specific program was selected and the client accepted for admission,
central intake would arrange transportation and assign an escort.  If a
program didn't work out, central intake could arrange an alternative.
While such units might seem to constitute yet another layer of bureaucracy,
their coordinating role would actually help reduce red tape.

In addition, central intake could dispatch outreach teams into drug markets
to recruit addicts into treatment.  Approaching users on the street, such
workers would inform them of the services available and encourage them to
visit central intake.  If these teams worked in the early morning hours,
when many addicts are coming down from their drugs, they could
significantly boost the number of people entering the system.

Of course, recruiting addicts into treatment will accomplish little if
there is nowhere to put them.  And sadly, the treatment shortages present
in New York are common throughout the country.  According to the U.S.
Office of National Drug Control Policy, fully half of the nation's
hard-core users - 1.7 million people - cannot get help due to the lack of
slots. (Methadone is in particularly short supply, with just 1 1 5,000 of
the 800,000 chronic heroin users receiving it.  In New York City, only
35,000 out of 200,000 users do.)

During the 1992 Presidential campaign, Bill Clinton promised to rectify
this.  "In a Clinton/Gore Administration, Federal assistance will help
communities dramatically increase their ability to offer drug treatment to
everyone who needs help," he wrote in "Putting People First." Six years
later, the nation is no closer to reaching that goal.  Under Clinton, fully
two-thirds of the Federal drug budget goes for law enforcement and
interdiction, with the remainder going for treatment and prevention - the
same proportion as under the Bush Administration.  The current drug czar,
Barry R. McCaffrey, is a retired four-star general who before taking office
had no experience with drug treatment, and while he has frequently
acknowledged the importance of treatment, he has made this a low priority.
And so the treatment gap persists.

That a focus on treatment can work is apparent from the one time it was
actually tried - during the Nixon Administration.  A staunch advocate of
law and order, Nixon deferred to no one in his strident pronouncements on
drugs, but during the 1968 campaign he promised to bring down the nation's
crime rate, and once in office, he faced the need to deliver.

At the time, the nation was in the throes of a raging heroin epidemic; if
something could be done to sap it, Nixon's advisers believed, the crime
wave might abate.  One obvious approach was to try to reduce the flow of
heroin into the country.  At the time, the main conduit was the French
Connection, a 5,000-mile pipeline originating in Turkish poppy fields and
passing through France.  The Nixon Administration began pressing the French
and Turkish Governments to crack down on local drug trafficking.

But the more Nixon's drug officials looked into the problem, the more they
became convinced that reducing the supply of drugs would prove futile
unless something was also done to reduce the demand.  On that front, a new
weapon was available: methadone.  Early studies showed that addicts
maintained on methadone were much more likely to hold jobs and far less
likely to commit crimes.  At the time, methadone, like drug treatment in
general, was largely unavailable in most cities.  An exception was Chicago,
where a young psychopharmacologist named Jerome Jaffe had set up a network
of treatment programs that was helping get addicts off the streets.  A
central intake unit was opened in downtown Chicago, and addicts appearing
at it were assigned to the type of program they needed - detox,
residential, methadone maintenance, methadone-to-abstinence and so on.

Impressed, President Nixon announced in 1971 the creation of a Drug Abuse
Prevention office; to head it, he brought in Jaffe from Chicago. Once in
place, Jaffe found that about 30,000 people were on treatment waiting
lists; resolving this problem became his top priority.  He faced resistance
from many quarters, including Congress, the bureaucracy and his fellow
mental-health professionals, but Jaffe - a brilliant if prickly iconoclast
- - managed to outmaneuver them all.  By the fall of 1972, treatment was
available to all those who wanted it.

The impact was immediate.  In New York City, the crime rate in 1972 dropped
18 percent, and in Washington, 26.9 percent.  Nationally, the crime rate
fell by 3 percent, the first decline in 17 years. Declines were also
recorded in the rate of heroin overdose deaths, hepatitis transmission and
drug-related hospital visits - strong testimony to the efficacy of a
national treatment system.

Yet from the moment it was created, that system came under attack.  And so
in the 1972 Presidential campaign, Nixon began shifting the focus back
toward drug enforcement.  During the Ford and Carter years, the treatment
budget suffered from the effects of both 'inflation and neglect.  The real
turning point came under Rea gan.  In his view, addicts were morally
responsible for their behavior and therefore undeserving of Government
help.  As Nancy Reagan toured the country, urging Americans to "just say
no" to drugs, her husband slashed the funding for drug treatment and
boosted it for drug enforcement.  By the time crack hit in the mid-1980's,
the treatment system Jaffe built had been gutted, and addicts - showing up
at clinics desperate for help - were regularly turned back onto the
streets, there to commit more crime.

It was not until the late 1980's that the Federal Government finally began
pumping more funds into treatment.  In fact, the nation's treatment budget
is now larger than it was in the 1970's.  Sadly, our drug problem is larger
as well, as long waiting lists attest.  It is time to follow the example of
Jerome Jaffe and make elimination of those lists a top priority.

But how much would that cost? According to in-house calculations by the
drug czar's office, filling the nation's treatment gap would require
increasing the Federal treatment budget by $3.4 billion a year.  Of the $16
billion Washington now spends to fight drugs, $10.6 billion goes for supply
reduction and $5.4 billion for demand reduction.  If the overall budget was
held constant but the allocation for these two areas equalized at $8
billion, the demand side would receive an additional $2.6 billion - close
to the sum in question.  But the Clinton Administration - worried about
looking soft on drugs - seems little interested in making such a transfer.

By itself, of course, such a change would not "solve" the nation's drug
problem.  Rooted as it is in low-income communities, that problem is
inseparable from the nation's other social ills, like inadequate housing,
poor schooling and unemployment.  Until these conditions are addressed,
drug abuse will remain a fixture of American life.  But by following the
public health approach outlined here, Washington could reduce that problem
to a far more manageable scale.  When it comes to drug policy, Americans
need not choose between their hearts and their heads; in this area,
compassion is itself cost effective.  Clearly, the war on drugs is not. 
- ---
Checked-by: Richard Lake