Source: Wall Street Journal (NY)
Section: Bookshelf
Pubdate: Monday, 12 Oct 1998
Copyright: 1998 Dow Jones & Company, Inc.
Author: Sally Satel
Note: Dr. Satel is a psychiatrist and lecturer at the Yale University
School of Medicine.


New York Mayor Rudolph Giuliani hopes to eliminate methadone treatment in
city-run clinics, saying it simply replaces one addiction with another.
Meanwhile, the nation's drug czar, Gen. Barry R. McCaffrey, praises
methadone as one of the best ways of helping hard-core heroin addicts; he
wants to expand its availability. The methadone battles have begun. Again.

The history of this and other skirmishes in the war on drugs is recounted
in "The Fix" (Simon & Schuster, 335 pages, $25), Michael Massing's tour of
the modern era of domestic drug policy. He starts with the 1960s heroin
epidemic, takes us through the creation of a national treatment network
under Nixon, harsh drug laws in New York state under Rockefeller, softness
on marijuana under Carter, "Just Say No" and the crack explosion under
Reagan, and ends with the bounce in adolescent use under Clinton.
Well-written and lively, "The Fix" features an amazingly long subtitle that
says it all: "Under the Nixon Administration, America Had an Effective Drug
Policy. We Should Restore It."

That policy was a drug treatment system for hard-core addicts, a network of
methadone clinics, and other drug treatment facilities featuring detox
centers, outpatient clinics, counseling and residential supervision -- all
connected by an efficient referral system. Key to the project's success,
Mr. Massing says, was the steadfast commitment of Nixon aides to clinical
principles over politics. The threat of thousands of soldiers returning
from duty with habits they acquired in Vietnam made this policy especially
urgent. There is little doubt that treatment had a large role in curtailing
inner-city heroin epidemics of the late 1960s and 1970s.

"The Fix" is part ethnography, part policy. Animating the book are the
interwoven tales of Mr. Massing's two heroes: psychiatrist Jerome Jaffe,
the careful and creative architect of Nixon's treatment system, and Raphael
Flores, a tireless worker in today's Spanish Harlem who practically carries
his strung-out clients from clinic to clinic until he finds them help. Mr.
Massing followed Mr. Flores on his rounds and captures to perfection the
grittiness, desperation and squalor of addict life. He documents the
maddeningly byzantine process of trying to get enrolled in a detox program
or to find a treatment bed. Interspersed are data on the effects and limits
of drug treatment. Regarding Mr. Giuliani's plan, the reader can't help
predicting disaster -- a return to crime and heroin use, and a higher risk
of AIDS, for methadone patients who are jettisoned from the clinic rolls.

1 In contrast to many recent books and articles raging against the drug
war, "The Fix" is balanced. Significantly, Mr. Massing takes a sober look
at harm reduction -- the policy of making addictive behavior safer rather
than curtailing it. "Unfortunately, the harm reductionists . . . [refuse]
to acknowledge the perils inherent in drug addiction itself," he writes.
"Harm reduction, with its learn-to-live-with-drugs approach, does not offer
much guidance as to how to bring down the appallingly high levels of
addiction in this country." In his final chapter, the author offers some
pointed recommendations. Among them: scrapping the drug czar's office,
decriminalizing marijuana possession, ending prison construction, smoking
out foreign drug lords and spending more on the demand side of the drug
problem. Whether or not you agree, Mr. Massing has done a good job of
laying the groundwork for most of his arguments.

The author has one annoying habit, however: He tends to sentimentalize
addicts. He puts little emphasis on user accountability, plays down the
effect of law enforcement and falls into the trap of discussing addiction
as a medical rather than a moral problem, when it is clearly both. "It just
might become possible to usher in a new, more enlightened era of drug
policy, one in which the nation's drug addicts are treated with the care
and compassion they deserve," he writes. Ironically, the chaos and meanness
of addict life, which Mr. Massing portrays so well, is the very reason why
his recommendation of ever-available treatment, outreach workers and case
managers is good but not enough.

True, almost all addicts will use fewer drugs and commit less crime during
even the briefest exposure to treatment. Yet many don't want help, and even
those who seek it routinely drop out of whatever program they are in. Thus,
if treatment is to fulfill its promise -- and it does seem to work when
done properly -- addicts must not only enter treatment but "graduate."
Coercion can help -- exercised either through the criminal justice system
or as a condition of public support. Without such leverage, though, a
prescription for more treatment is incomplete, even naive.

Still, Mr. Massing is right about the importance of treatment, and it is
not naive to think that we can do better than we are doing now in the fight
against drugs.

- ---
Checked-by: Richard Lake