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Ideas Governing Drug Policy
Three fundamental ideas about drugs, the people who use them, and
ways to respond to them lie behind drug treatment and virtually all other
instruments of drug policy in the United States. Embodied in criminal,
medical, and libertarian approaches, these governing ideas have dominated
the terms of public discussion and the gross allocation of public and private
funds. As a result, there can be no detailed analysis of drug treatment
without first understanding what these ideas are, where they come from,
how they relate to each other, and how they have shaped the role and
functions of treatment.
That the governing ideas are plural reflects two underlying realities
concerning drugs and society. The first is that psychoactive drugs have a
multiplicity of medical and social uses and consequences. Some of the uses
are clearly beneficial, others are clearly pernicious, and still others are a
complex mixture. Moreover, the pharmacopoeia is not static but growing.
New drugs and innovative technologies to administer them are constantly
arising from scientific research and foLk-pharmaceutical explorations.
The second reality is the persistence of social change, including the
dialectic of political parties and philosophies and the continuous renego-
tiation of relationships between different institutions of government. Such
change ensures the potential for different ideas to gain or lose potency.
Therefore, if the social arrangements supporting policies associated with
one fundamental idea turn unfavorable, the programs arising from those
policies may wither only to revive again if conditions change.
The climate surrounding drug problems appears to be changing in the
40
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IDEAS GOVERNING DRUG POLICY
41
United States, but its future direction is uncertain. A complex balance of
ideas and policies led to the current forms of drug treatment and treatment
delivery. The major lesson of this chapter's analysis of historical ideas and
their social roots is that a re-tuning of that policy balance appears to be in
order. Such a re-tuning is, moreover, a prerequisite to ensuring that these
programs and perhaps other instruments of drug policy will be able to
function at the most humane and effective level possible.
THE CHARACTER OF GOVERNING IDEAS
In a democracy, government policy is inevitably guided by commonly shared
simplifications. This is true because the political dialogue that authorizes and
animates government policy can rarely support ideas that are very complex or
entirely novel. There are too many people with diverse perceptions and interests
and too little time and inclination to create a shared perception of a complex
structure. Consequently, influential policy ideas are typically formulated at a
quite general level and borrow heavily from commonly shared understanding
and conventional opinions. (Moore and Gerstein, 1981:6)
Drug policy is no exception to the rule of simple ideas. For much
of this century, drug policies were—and still are—profoundly affected by
a body of conventional wisdom. Especially influential has been the belief
that drug problems are largely attributable to morally compromised or
pathological individuals who were not properly inculcated in childhood
with normal American values such as self-control and respect for the law.
These individuals must be disciplined and punished by authorities to deter
them from involvement (for pleasure or profit) with inherently dangerous,
addicting drugs. The power of ideas like these is apparent in that they
are widely treated as obvious facts that any well-intentioned, intelligent
participant in drug policy formation either subscribes to or treats very
seriously.
Much can be said for the wisdom of governance through shared ideas.
If many people understand and agree with an idea, its prima facie legiti-
macy is established. Moreover, widespread understanding and acceptance
of an idea establishes a necessary condition for effective policy implemen-
tation in any society in which governmental power is broadly dispersed.
Although shared simplifications generally fail to reflect or capture all the
important aspects of a problem, they at least focus attention on some of the
more significant dimensions. Thus, simplified conceptions help to concert
social attention and action something that more complicated ideas usually
cannot achieve.
Yet there is also a price to be paid for simple ideas. Simplification
inevitably distorts one's perception of a problem. Although some important
features may be enhanced, others that could plausibly claim equal signifi-
cance are subordinated. In turn, some avenues for social intervention may
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42
TREATING DRUG PROBLEMS
be brightly illuminated, whereas others that could well be as effective are
obscured or condemned to obscurity.
Such limiting approaches can be of two sorts. One simplifying strategy
is to select a narrow set of effects or objectives. One could then focus
on adverse health effects, for example, and promote policies that would
best reduce overdoses, withdrawal, and diseases such as AIDS that may be
associated with drugs, taking everything else as of secondary importance.
Alternatively, one might consider drug-induced crime to be of overriding
importance and concentrate on policies that would effectively punish and
isolate the drug user from society.
A different simplifying approach is to decide which causes are most
important in generating the adverse effects of drug use and then choose
policy instruments that operate most directly on these causes. One might
judge (on the basis of available evidence) that the total quantity of drugs
used is the main determinant of the observed pattern of effects and try
to develop policies that reduce overall drug consumption. Alternatively,
one might determine that drug problems are mainly due to a relatively
small number of unusually feckless or vulnerable users and tailor policies
specifically to keep such people away from drugs (or treat or pretreat them
in some fashion that would make them more problem resistant).
The most successful simplifications combine both kinds of limitations:
the major effect or objective of the policy and the judgment about what
causes it are tied together into a neat conceptual bundle. A few such
bundles have had widespread, durable appeal in U.S. society because they
proved compatible with common social views, evolving social experience,
and the interests and purposes of organized groups. These cognitive bun-
dles are referred to here as governing ideas. Each has had considerable
intellectual appeal and at some point succeeded in capturing the attention,
imagination, and actions of the broad population. They provide the crucial
context for understanding the nature of the drug treatment system, as well
as the goals set for it and the financial arrangements that underlie it.
THE SPECTRUM OF IDEAS ABOUT DRUGS
The evolution of drug policy in the United States can be concisely
and usefully described in terms of a simple spectrum or continuum of
concepts that ranges from the least restrictive in approach to the most
restrictive (Figure 2-1~. Of course, reducing ideas to a one-dimensional
continuum distorts them somewhat, stripping them of nuances and cross-
fertilizations. Furthermore, the placement of ideas along this continuum
does not necessarily refer to the actual consequences of policies but only
to the character of the ideas that inform them. The determinants of policy
consequences are more complex than ideas alone, embracing economic
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IDEAS GOVERNING DRUG POLICY
Less LIBERTARIAN MEDICAL CRIMINAL More
restrictive I I I restrictive
ideas l I I l l I ideas
1 850
1890
1 909
1923
1965
1 990
43
= , r ,
N 0 = 53, 0 S N' o S _ ~
50. ~ tD = As o O ~ CD =
Government role limited
to taxation
Increase of municipal and state
~ regulation; growing medical interest
Criminal idea
challenges medical
approach as drug-
taking population changes
The classic era of
narcotics control;
increased minority
involvement with
drugs
The rise of
modern treatment
modalities
Major expansion of
\` the criminal justice
~ system
FIGURE 2-1 A simplified spectrum of governing ideas about drugs. The historical changes
represented in this figure by a continuous trend line constitute the committee's summary
judgments about the ideological "center of gravity" in the country from 1850 to 1990, based
on the evidence reviewed by Courtwright and Besteman (both 1990) and elsewhere in the
report, particularly Chapters 4 and 6.
conditions, political mobilization, religious movements, and the educational
level and degree of alienation or frustration of the population.
Although the spectrum is continuous and shows that ideas shade into
one another at their edges, simplification demands that sharper boundaries
be drawn. Three main parts of the spectrum are thus distinguished, consti-
tuting the three major governing ideas that underlie the historical evolution
of drug policy in the United States. As little as 100 years ago the left side
of the spectrum was mainly in evidence. Only after the middle and right
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44
TREATING DRUG PROBLEMS
side had developed could drug policy be compared across the broad range
of options.
Libertarian Ideas
Libertarian approaches to the drug problem are the oldest of the three
sets of governing ideas. Until after the Civil War, imported drugs such as
opium were relatively cheap and available without much restriction to those
whose cultural customs, personal tastes, or medical needs motivated their
use. This state of affairs was less a reflection of positive ideas about drugs
than an outcome of the methods of governance in the new nation. American
constitutionalism prescribed a weak rather minimal federal government
whose attentions had to be concentrated on a few matters where they
could have an impact. The libertarian ideal is Jeffersonian at its heart,
advocating minimal interference by government in private affairs or political
expression. It envisions a relatively small government apparatus concerned
for the most part on the national level with foreign affairs, national security,
and the currency, and on the local level with protecting property rights
and maintaining civil order. Libertarian ideas were, and still are, the
default value in American political life; thus, minimal policy, expressed as
a practical lack of interest in the actual or potential significance of drugs
in society, was the reality for much of the nineteenth century.
Only from the middle to the late 1800s, as the country's concern with
the problem of alcohol was culminating in major legislative measures, did
the libertarian approach (or nonapproach) to drugs begin to lose ground.
This decline coincided with the growth of two other governing ideas: the
criminal that drug abuse is a problem of shiftless living closely associated
with crime and violence and the medical—that drug abuse is a medical
problem arising from a misguided but understandable search for relief from
painful or oppressive circumstances.
Yet even before these newer ideas were articulated, libertarian thinking
itself had begun to respond to shifts of several kinds that were stirring in
the mid-nineteenth century. First among these currents of change were
social and political developments. The abolition of slavery by the Union
during and after the Civil War was a clear signal that the boundaries of
political permissiveness were contracting. The spread of industrialization,
the growth of American military (especially naval) power to world-class
status, and the immigration of Asians and eastern and southern Europeans
in unprecedented numbers from 1880 to 1920 remade the face of the
country that the Jeffersonians had fashioned. In the end, the libertarian
ideal of minimal government was shattered by the pressures of a growing
and increasingly diverse population and especially by convicts over the
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IDEAS GOVERNING DRUG POLICY
45
proper role of the national state the federal government—in organizing
economic life and aligning local political culture with a national vision.
The libertarian view of drug use was further assaulted by a second,
technological line of development. Modern chemistry and metallurgy iso-
lated psychoactive botanical alkaloids such as morphine and cocaine and
made their injection possible. The twentieth century saw the creation of
exotic, mood-altering drugs, although these substances were not fundamen-
tally different in effect from the nonsynthetics. Nevertheless, these new,
more concentrated products altered the drug picture in numerous ways that
included increasing the potential of drugs to induce addiction and a variety
of unanticipated disease implications. (In the same way, the invention of
shredded-leaf, flue-cured, machine-made tobacco cigarettes greatly changed
the economic and epidemiological significance of tobacco products.)
The third development was the increasing concern about a new type of
drug user: the "pleasure user," for whom drugs were neither bound to tradi-
tion or custom nor a source of relief from physical pain. Although the plea-
sure user was sometimes stereotyped in racial terms associated originally
with Chinese immigrants, later with African and Mexican Americans the
model was just as often the European American urban criminal, a member
of the underworld linked to prostitution, thievery, and saloon-going.
The libertarian indifference to drugs was challenged by these develop-
ments and began to give way before pressure for some kind of governmental
action. Early legislation tried to discourage opium smoking by outlawing
opium dens or levying high taxes on imports of opium prepared for smoking.
In 1906 the federal government passed legislation that required nostrum
makers to list all ingredients, including narcotics, on the label. A number
of states also passed laws requiring that narcotics be sold only by pre-
scription and that pharmacists record all transactions. Ultimately, the U.S.
Congress passed legislation to ban imports of opium prepared for smoking
and attempted to confine other narcotics transactions entirely to medical
channels.
Idday, there are still some adherents to libertarian views regarding the
problem of drugs, particularly in regulatory approaches, and these ideas
have experienced something of a renaissance in the past several years. Yet
the actual policy contributions of this idea are now largely constraining
rather than leading. For example, libertarian ideas have limited the spread
and influenced the character of employee drug testing (see Roman and
Blum, 1990~. On only one issue, the reduction of statutory penalties from
the felony level to misdemeanors or infractions for the possession or transfer
of small amounts of marijuana, has the libertarian idea attained a semblance
of governing force in recent years—an effect that reached its current
perimeter of authority in 1973 with the last of 11 state decriminalizations.
On a more abstract level, the decision-making logic characteristic
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TREATING DRUG PROBLEMS
of libertarian thought namely, its calculus of utility—has retained some
influence. In this theory of action, an individual, operating within the
bounds of law and civility (noninfringement of others' fundamental rights),
makes those expenditures which may include the purchase of treatment
that in the individual's view will provide benefits that most exceed the cost
of purchase. On an aggregate level, the polity, in its collective decisions,
should at the least permit (if not encourage outright or, under appropriate
circumstances, spend collective funds for) the supply of those goods or
services whose aggregate benefits most exceed their costs. This logic implies
an economic cost/benefit standard by which to measure the worth of public
or private purchases of drug treatment. It has been used in some analyses,
although it has not played a primary role in treatment policy.
Medical and Criminal Ideas
The medical idea arose in the 1870s and 1880s as physicians began
to realize that a significant number of citizens, mostly middle-class, "re-
spectable" women, were addicted to powdered morphine sulphate and
other opiates. (The number was later estimated at several hundred thou-
sand, but lower figures were actually more realistic [Courtwright, 1982,
1990~.) Many of these individuals began to use these drugs on the advice
of physicians to deal with a physical problem or a "nervous" complaint.
I'here was widespread medical prescription, promotion, and sale of opiates
and other substances for a variety of ailments and as routine "tonics." It
gradually became clear to observant practitioners that individuals who had
become accustomed to using these compounds became ill, agitated, and
despondent if they tried to do without them; yet these same individuals
functioned reasonably well with continued regular doses, even though these
doses often reached high levels.
Opiates were very much a staple of nineteenth-century medical prac-
tice—one of the few truly effective medicines of the day, capable of re-
ducing the suffering of many patients for whom no other useful medical
intervention was known. As a result, this observation of the addictive effects
of chronic use was viewed as regrettable but not catastrophic, particularly
because so many of those affected were older women, many of whom had
begun using the habit-forming drugs under medical or pharmaceutical ad-
vice or supervision and who on the whole seemed harmless. One standard
medical response to this problem was maintenance on a prescribed dose,
with the goal of continuing the patient on a course of normal, comfortable
functioning. A variety of detoxification therapies, some sensible and some
quite exotic, were also attempted, but relapse to habitual use was common,
malting maintenance appear even more reasonable as an alternative.
Of much greater concern were "opium habitues" of the lower social
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IDEAS GOVERNING DRUG POLICY
47
classes whose lives centered around multiple, daily periods of intoxication
achieved through the opium pipe, the needle, or tinctures of high opiate
(and alcohol) content. These individuals were quite different from re-
spectable middle-class users but their agitated responses to a threatened
loss of access to the drug were quite similar. From these observations,
physicians formulated the medical view of narcotic drugs: whatever the
origins of opiate use or the prevailing moral judgment regarding it, indi-
viduals invariably display an addiction withdrawal syndrome if they have
consumed powerful intoxicants such as narcotics for a long enough period.
This syndrome involves physical distress when the drug is withdrawn, which
is relieved when it is taken, and craving for the drug when the individual
is abstinent. The similarity between the alcohol and narcotic addiction and
withdrawal syndromes was recognized in many quarters.
The initial explanation developed for these phenomena was an exten-
sion of psychiatric theory of the period. The middle-class people who sought
opiates seemed to belong to the ~`neurasthenic', personality type people
of weakened and unstable temperament who needed pharmacological as-
sistance to endure the rigors of modern life. In the 1920s, as physicians
saw more and more urban "pleasure users," a darker assessment arose:
these users seemed more and more to be afflicted not with temperamental
weakness but with psychopathic dispositions.
This darker medical assessment of the drug problem began to resemble
the view taking shape as modern "scientific" police forces were organized
in the rapidly growing cities of the late nineteenth and early twentieth
centuries. Formulators of a view of drug use as a criminal matter were more
impressed with the criminal associations and irresponsibility of disreputable
drug users than with the commonalities in symptomatology with respectable
users. The criminal view held that narcotic drug use was fundamentally
immoral, ruinous behavior. The lower class user was seen not only as
self-destructive but also as someone who might encourage and lure others
into drug use and who could be emboldened by drugs to commit more and
graver crimes.
In the criminal view of the drug problem, families, with churches
and schools as social backstops, are fundamentally responsible for teaching
children to behave responsibly and morally, behavior that includes shunning
intoxicating drugs. The presence of moral anchors most generally, the
capacity for self-control in the face of temptation and a generalized respect
for the law—is the vital element that separates the good citizen from the
pleasure-seeking drug user. If the family or school, for whatever reason,
fails in its responsibility to provide moral education, the problem must be
dealt with by another authority. The main such agencies are the police,
the courts, and prisons; there may, however, be room for intermediate
socializing agencies (guidance counseling or social work) to supplement or
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TREATING DRUG PROBLEMS
substitute for the family, especially in cooperation with the juvenile justice
system.
The criminal and medical views of the U.S. drug problem during
the late nineteenth and early twentieth centuries had two rather different
perceptions of drug users. The medical observers who originally developed
the idea of addiction viewed the user population largely as members of
the middle class and majority ethnic groups who were unfortunates worthy
of help. But increasingly, from 1895 to 1920, the medical profession, the
police, lawmakers, and the public in general saw the ranks of users as
predominantly lower class in income and occupation and often of minority
ethnic composition (that is, minorities not originating in northern and
western Europe). The association of pleasure drug use with poor Chinese,
Italians, Slavic Jews, Mexicans, and African Americans deepened the rift of
censure that divided official community moral guardians from drug users;
the compassionate impulse to comfort the wretched became more and more
a determination to administer a good swift kick to the wayward.
The Classic Era of Narcotics Control
The mixture of the two competing views, medical and criminal, was an
uneasy one. The Harrison Act of 1914, aimed at controlling the distribution
of narcotics, skirted the question of indefinite drug prescription for an
addict's personal use. In 1919, however, a critical court case, decided by
a Supreme Court vote of 5 to 4, firmly established the legal basis for
prosecuting addicts and physicians who maintained them. Once this bridge
was crossed, the criminal view quickly gained ascendancy in the debates
surrounding drug policy formulation.
The medical view, on the other hand, was set back dramatically during
the prohibitionist and xenophobic 1920s, as many physicians who prescribed
opiates to addicts were visited by federal agents, and several efforts to treat
addicts in morphine or heroin maintenance clinics were abruptly terminated.
Addicts were sought, prosecuted, and jailed in unprecedented numbers-
so many were imprisoned, in fact, that they strained the capacities of the
federal prison system. In response to this overcrowding, federal prison
wardens made a pact with advocates of the medical approach (represented
by the U.S. Public Health Serviced, and the U.S. Congress agreed to fund
two massive new "farms" for narcotics addicts—federal prison-hospitals
that would accept both inmates and voluntarily committed patients. These
facilities were opened near Lexington, Kentucky, and Fort Worth, Texas, in
1935 and 1938.
The criminal view dominated the nation's drug control efforts for
more than 40 years, during most of which Federal Narcotics Bureau Direc-
tor Harry Anslinger was the leading figure of narcotics policy and dealers
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IDEAS GOVERNING DRUG POLICY
49
and nonmedical users were arrested at virtually every opportunity. Nev-
ertheless, the criminal view of drug problems was affected by changing
times and changing ideas about controlling criminal behavior. Within
this fundamental view of drug use as a criminal problem and users as
moral derelicts deserving of retribution, several variants have arisen that
correspond to philosophies resected in the broad streams of modern crim-
inological thought. The idea of rehabilitation—criminals may be redeemed
by appropriate arrangements, incentives, and lessons fashioned within the
penal environment is the basis of prison as a place of penitence, or "pen-
itentiary"; it is explicit as well in the term "corrections." Evidence of its
diffusion is also found in widespread acceptance of probation a period
of testing to discover the true character of the offender as an appropri-
ate response to first or minor offenses. The concept of deterrence draws
a sharper line: the lesson conveyed by punishment is intended not only
for the individual but also for the community as a `whole, or at least for
all others who might consider similar deeds. Finally, incapacitation takes
the bleakest view of the criminal, putting little stock in the possibility of
redeeming or deterring criminal behavior. Instead, this school of thought
calls for protecting society by isolating the criminally inclined for the longest
period consistent with community standards of "just deserts" for the crime,
or crimes, committed (in the extreme, a sentence of life—or death).
THE RISE OF MODERN TREATMENT
The nation's drug problem seemed to diminish slowly but steadily
during the Depression and World War II. The number of underworld
addicts did not change much during this period, but as the cohort of more
"respectable" medical addicts aged and died, they were not replaced. By the
turn of the century, the health professions had become more sophisticated
and scientific regarding the use of narcotic medications, cautions about
patent medicines had increased, and nonnarcotic analgesics such as aspirin
had come into widespread use. As effective medical therapies multiplied,
the use of narcotics for the symptomatic treatment of pain in a wide range
of illnesses declined.
Around 1948, however, active heroin markets began to resurface in
American cities. A wave of "drug epidemics" began, which continued into
the 1950s and early 1960s despite increasing criminal penalties. Dismayed
by the escalation of seemingly fruitless criminal sanctions, a series of blue-
ribbon government and private panels began urging a reconsideration of
the national commitment to a nearly exclusive criminal approach.
The beginnings of the national treatment effort lay within the federal
prison-hospitals at Lexington, Kentucky, and Fort Worth, Texas. These
facilities not only incarcerated criminals on narcotics convictions but also
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TREATING DRUG PROBLEMS
provided therapeutic services for their drug addiction. In addition, the two
facilities served as sites for fundamental research on the course of drug
dependence, the behavioral and physiological processes related to drug use,
and the properties of narcotics. The benefits of the programs, however,
proved elusive: evaluations indicated that the detoxification and unstruc-
tured psychotherapy delivered at these hospitals probably had limited if any
long-term effectiveness (e.g., Hunt and Odoroff, 1962; Vaillant, 1966a,b,c).
Still, the federal hospitals were pivotal in three respects in the evolu-
tion of the community-based treatment system. First, the narcotics "farms"
preserved the pre-control-era right of access that enabled addicts to com-
mit or admit themselves voluntarily to treatment for addiction without
being convicted of a criminal act. Second, the prison-hospitals established
the precedent of direct federal provision of specialized treatment. Fi-
nally, through Public Health Service research programs and psychiatric
residencies, Lexington and Fort Worth exposed a cadre of researchers and
psychiatric clinicians to the challenges of treating drug-dependent individ-
uals. When the new community-based treatment modalities of therapeutic
communities and methadone maintenance were introduced and dissemi-
nated, this group of clinicians and researchers, whose careers had dispersed
them across the country, were of critical importance in implementing and
evaluating the new programs and organizing training initiatives.
Methadone Maintenance, Therapeutic Communities,
and Outpatient Nonmethadone Programs
Methadone maintenance, a treatment modality first formally described
in the Journal of the American Medical Association (Dole and Nyswander,
1965), was originally based on an explicitly medical concept that substan-
tial heroin use created a persistent if not permanent imbalance of brain
metabolism, which could be stabilized by the right pharmacological treat-
ment. This notion was a more sophisticated version of the physiological
ideas current among some of the physicians who, for a short period after
1919, operated medical maintenance clinics using morphine in a number of
American cities until federal agents shut them all down by 1923. Federal
agents also wanted to stop methadone maintenance at its inception but
backed down from openly challenging its determined originators in court.
Vincent Dole and Marie Nyswander, a distinguished research en-
docrinologist and a Lexington-trained psychiatrist, respectively, discovered
during hospital studies of the effects of different opiates that giving heroin
addicts an appropriately adjusted, daily oral dose of a relatively long-acting,
synthetic opiate called methadone led to quite different effects than those
resulting from other opiates. (Methadone was invented by German chemists
as a morphine substitute during World War II; its addiction liability and
acute effects had been further studied at Lexington.) Heroin addicts who
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IDEAS GOVERNING DRUG POLICY
51
were maintained on oral methadone experienced neither euphoria nor
withdrawal, rarely displayed any toxicological side effects, and thus were
able, if so motivated, to begin or resume more conventional lives and with
Dole and Nyswander's therapeutic assistance, most of the early patients
were so motivated.
Dole and Nyswander were mainly concerned with individual patients
who could now forego their obsession with acquiring drugs, an obsession
that had led many of them to crime. But they and others saw broader
implications to their work for the entire community, which might be spared
thousands of criminal acts, once such obsessions ended. Thus, as the
Kennedy-Johnson era "War on Poverty" gave way to the Nixon era "War
on Crime," a rapid expansion of the methadone treatment program begun
by the city of New York in the wake of the Dole-Nyswander research was
underwritten by the federal government and implemented nationally. The
goal of the expanded treatment was to take crime-committing addicts off
the streets and out of the jails, on the theory, buttressed by substantial
amounts of evidence, that a large proportion of these addicts' crimes were
committed to support their addiction.
The Dole-Nyswander model soon evolved to a different stage as a
result of regulatory conditions imposed by the Food and Drug Adminis-
tration at the behest of the Bureau of Narcotics and Dangerous Drugs.
These regulations, which were "interpreted" still further by the state in-
spectors who enforced them, reflected major concerns about the diversion
of methadone from closely supervised pharmaceutical administration to
street drug markets. Although these concerns were well grounded in evi-
dence, the possibility of such diversion was viewed with little alarm by some
clinicians who considered diverted, street-purchased methadone a less dan-
gerous substance than injectable heroin and who saw the street methadone
market as a potential step toward clinic admission. The regulations also
incorporated biases against indefinite maintenance, toward low dose levels
(of arguable efficacy), and toward certain therapeutic rigidities, including
specific staffing and facility parameters.
A completely different treatment approach originated in California
with Synanon, the original therapeutic community for drug addiction.
Charles Dedench, founder of Synanon, drew some of its central treat-
ment concepts from psychiatric therapeutic community in military medicine
(Jones, 1953) and from the fellowship of Alcoholics Anonymous. But the
therapeutic community was most clearly compatible with the psychological
rehabilitation concepts of the criminal view of the drug problem—except
that it was devoted to building a self-policing community as a path to-
ward redeeming addicts. In a move symbolic of this linkage with criminal
justice concepts, an important second-generation therapeutic community,
Daytop Village, was founded directly under the auspices of the Brooklyn
probation department with a community-based board of trustees (Joseph,
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TREATING DRUG PROBLEMS
1988), and therapeutic communities were soon implemented in numerous
prisons, including the Fort Worth facility (Maddux, 1988~. Over time, the
more rigidly punitive dimensions of the early therapeutic communities were
softened as clinical experience became more sophisticated and additional
professional components were integrated into the concept. Nevertheless,
the therapeutic community remains a remarkable merger of the therapeutic
optimism of psychiatric medicine and the disciplinary moralism of the
criminal perspective.
The third locus of expansion of the treatment network in the early
and mid-197Os, and the backbone of treatment efforts in most of the coun-
try today, was outpatient nonmethadone treatment. Comprising various
forms of counseling, psychotherapy, and supervision, this branch of the
treatment network developed originally in the 1960s in the matrix of fed-
erally supported community rehabilitation and community mental health
services. Outpatient nonmethadone programs were the most diversified of
the treatment approaches, both institutionally and therapeutically.
The Narcotic Addiction Rehabilitation Act (NARA) of 1966 was the
first major federal acknowledgment of the reemergence of the medical
perspective. Building on the examples of earlier California and New York
civil commitment initiatives, NARA took the significant step of authorizing
community-based supervision and treatment of addicts apter release from
incarceration (on parole). The authority of NARA was used to provide
grants-in-aid and contracts to community programs delivering treatment
and supervision. By 1970, roughly 150 local NARA programs were in
operation (Besteman, 1990~.
The next breakthrough for the application of medical ideas came with
a 1968 amendment to the Community Mental Health Centers Act. This
law mandated and supported the provision of treatment for drug abuse and
alcoholism within community mental health centers, a major health policy
initiative that originated during the Kennedy administration.
At roughly the same time as the 1968 amendment, the Office of Eco-
nomic Opportunity began to support community-based drug and alcohol
treatment programs, particularly those that offered a variety of treatment
alternatives. A model program in this respect was the Illinois Drug Abuse
Program in Chicago, which pioneered the "multimodality" approach. It was
characterized by a central point of program entry to assess the patient's
needs and living situation, followed by assignment to whichever of sev-
eral modalities within the program seemed appropriate. In addition, each
patient received an individualized treatment plan that called for gradually
decreasing program services as rehabilitative milestones were achieved. The
director of the Illinois program, Jerome Jaffe (a psychiatrist and alumnus
of Lexington), later became the first head of the White House Special
Action Office for Drug Abuse Prevention the first national "drug czar."
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IDEAS GOVERNING DRUG POLICY
53
Chemical Dependency Treatment
The final significant phase of the application of the medical idea to
drug use since the mid-1970s has occurred largely outside the public system
of drug treatment. The 1980s have seen the rapid expansion of a privately
financed network of programs providing chemical dependency treatment, a
derivation of ideas associated with a neighboring but generally autonomous
domain: the treatment of alcoholism using the 12-step recovery concepts
of Alcoholics Anonymous but operating under the umbrella of the health
professions. The idea of bringing recovered alcoholics into the hospital
setting as part of a therapeutic alliance was developed at Willmar State
Hospital in Minnesota; it was further extended and refined (to include,
for example, family therapy where indicated and a twoyear ambulatory
aftercare phase) at the Hazelden Foundation and the Johnson Institute,
nonprofit treatment agencies in that state. In consequence, this modality is
often called the "Minnesota model," and units implementing the modality
are often called "28-day programs," based on a figure for an average length
of inpatient stay reported at one time by the Hazelden center.
Although its origins were in the public sector, the chemical dependency
modality is now most widely provided by private for-profit and not-for-profit
hospitals and rehabilitation facilities that draw most of their revenues from
third-party insurance payments. The typical client in this system is not the
convicted criminal or sometime blue-collar worker generally found in the
public system, whose drug use frequently involves a combination of heroin,
cocaine, and amphetamines along with heavy alcohol consumption. Instead,
the typical client here is steadily employed, often a white-collar professional,
who is abusing or dependent on cocaine and alcohol. Alternatively, he or
she may be a marijuana-dependent middle-class teenager who is failing
school and is finally sent to treatment by worried parents. A third staple
client is the counterpart of the middle-class neurasthenic of days gone by
an older, female, nonworking user of depressants, including barbiturates,
tranquilizers, and alcohol.
The Medical/Criminal Idea of Treatment
and the Evolution of Governmental Roles
The most important single federal treatment initiative since the found-
ing of the Lexington and Fort Worth facilities was the "War on Drugs"
of the Nixon administration. This effort directly enlisted community-based
drug treatment in the task of decreasing criminal activity on the streets
of the nation's big cities. The concept of treatment as visualized in the
national strategy merged the criminal and medical ideas in a single frame-
work It drew on the popular impression that heroin addiction, because
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TREATING DRUG PROBLEMS
of its great expense, motivated addicts to take up criminal careers. Police
estimated that half of all major urban crimes were committed by addicts.
If the new forms of treatment were successful in eliminating the desire or
need for heroin, the criminal chain would be broken; if enough addicts
were treated, national crime rates would be dramatically reduced.
President Nixon, who had already made the war on street crime
a centerpiece of his domestic policy, became convinced that attacking the
drug problem would be the key to winning that war. By massively increasing
the number of both correctional and community-based treatment program
"slots" available to criminal addicts, it was felt that increased street-level
police activity (supported by a new federal Law Enforcement Assistance
Administration and Office of Drug Abuse Law Enforcement) could not
only incapacitate but also rehabilitate. Through an Executive Order in
1971 and subsequent legislation, the Special Action Office for Drug Abuse
Prevention (SAODAP) was created in the Executive Office of the President;
it was given an unusually broad mandate and the authority to organize,
direct, and evaluate the federally supported drug treatment effort.
The high point of federal commitment to drug treatment occurred
when the Special Action Office negotiated directly with local treatment
providers to "buy" their waiting lists (i.e., provide sufficient new funding
to admit these individuals for treatment). The Special Action Office also
required that preexisting levels of local funding be maintained and specified
the nature of treatment to be delivered. Moreover, it set reimbursement
rates prospectively on the basis of those specifications, monitored treatment
program performance in terms of both enrollment and patient status at dis-
charge, provided technical assistance to program managers, and organized
and delivered staff training.
Although this initiative marked the fullest commitment of the federal
government to building a national drug treatment system, it also laid
the groundwork for its dismemberment and subsequent parceling out to
the states. Under this initiative, the first grant program was established to
deliver funding to states instead of directly to communities or providers. For
the first time, states were required to designate a lead agency and develop
and submit to the federal government their own plan for establishing and
operating a treatment system. Furthermore, the contracts being made
with community treatment agencies at this time had explicit provisions for
progressive cost sharing, with the federal contribution to be reduced over
the life of the contract. The program or community was required to make
up the declining federal share from state or local appropriations or other
sources (including client fees).
In 1973 the narcotic drug abuse branch of the National Institute
of Mental Health was separated and elevated to become the National
Institute on Drug Abuse (NIDA), collecting from across a number of
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IDEAS GOVERNING DRUG POLICY
55
government departments all of the major treatment and prevention services
and drug abuse research programs. Although an Office of Drug Abuse
Policy continued to exist in the White House, NIDA assumed SAODAP's
responsibility for the national treatment system; Robert DuPont, the head of
SAODAP following Jerome Jaffe's departure, became NIDAs first director.
Responsibility and authority were given to state agencies progressively,
leading to the institution of relatively unfettered block grants to the states
in 1981 for allocation among alcohol, drug, and mental health programs.
Since 1981 the federal share of payment for drug treatment programs has
dropped well below the state share, and federal activities in the treatment
field, particularly the mission of NIDA, have concentrated on biomedical
and, to a lesser degree, behavioral and social sciences research.
More broadly, drug policy at the federal level has shifted its focus to
direct an increasingly greater proportion of attention and resources toward
enforcement and interdiction. This emphasis was apparent throughout the
Reagan administration and in the provisions of the 1986 Anti-Drug Abuse
Act. Passed in the wake of the deaths of several prominent athletes from
cocaine overdose, this bill symbolized heightened public and governmental
concern about the drug problem, particularly cocaine, and translated that
symbolism into large sums of federal dollars far more of which were
assigned to enforcement and prevention services than to treatment.
The 1988 Anti-Drug Abuse Act and 1989 emergency supplemental
appropriation for treatment and prevention signaled a reconsideration of
the balance of federal attention, driven by concern about the startling
increase in gunshot deaths in crack-selling areas in and around Washington,
New York and Los Angeles, and by the steep incidence of AIDS connected
with drug use in these and other areas. Along with continued large sums
for enforcement, the 1988 act authorized significantly increased funding
commitments to the alcoholJdrug/mental health block grant, together with
higher "set-asides" (funds specifically earmarked) for drug treatment. The
act also initiated a new temporary program specifically to reduce treatment
waiting lists through grants to providers (reminiscent of the approach
of SAODAP). However, as a consequence of Congress's deficit-driven
spending limits, not much of the authorized increase was appropriated.
The 1988 act also created a new Office of National Drug Control
Policy in the White House. The office is directed by a quasi-Cabinet-
level "drug czar," who is assisted by respective deputies for supply and
demand reduction; it has unusual budget control authority, high visibility,
and a statutory requirement to develop an annual National Drug Control
Strategy. The first director was appointed in 1989: William Bennett, a
lawyer and trained philosopher who previously headed the U.S. Department
of Education.
The new office is a chIysalis of the ideological elements of national
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TREATING DRUG PROBLEMS
drug policy. The first national strategy document (issued in September
1989) sweepingly rejected libertarian ideas and argued for much tougher
criminal approaches to drug users. Medical ideas were drawn upon in two
contexts: the public health argument that the casual or regular (nonaddict)
user is "highly contagious . . . a potential agent of infection" and that drug
addiction is a chronic disease with no permanent cure, thus presenting the
continuing possibility of relapse. The document defined treatment's role
in terms of the medical/criminal idea, leavened with additional concerns
characteristic of America in the 1980s, such as danger to the lives of
unborn children, AIDS, and the economy. In line with the overall stress on
a stronger criminal view, the document argued for a reexamination of the
effectiveness of voluntary (versus enforced) drug treatment. The second
document, which was released in January 1990, was more sophisticated in
its analysis of the treatment system, but it continued the major strategic
emphases of the initial edition.
CONCLUSION
It would be natural to assume that drug treatment is the kept creature
of medical approaches to the drug problem, that treatment programs are
compatible only with medical ideas and must stand in a relationship of
contradiction or antagonism to both libertarian and criminal ideas and in-
stitutions. Nevertheless, both in principle and in practice, drug treatment is
a flexible set of instruments capable of achieving several socially desirable
objectives and of serving more than one ideological master without neces-
sarily losing its essential rehabilitative character. Because of the complex
and constantly changing character of the drug problem, practical policies
to deal with it will always need to meld the fundamental ideas in some
way; as a result, policy differences over treatment are more often matters
of emphasis, priority, and allocation than of rigid ideological exclusion.
Each major governing idea is influential in determining the policy role of
treatment and what it should be expected to contribute.
In the case of each idea, the implicit standard of treatment success
looks to serve both the individual and the collective interest. Libertarian
ideas argue that, for the individual, treatment should maintain or increase
the individual's privacy and independence, which may have been diminished
by drugs; for the society, treatment should reduce net social costs (such
as public medical and criminal justice expenses) and increase productivity
(job earnings and tax receipts). Medical ideas also imply two standards:
for the individual, response to therapy is measured in terms of reduced
morbidity and mortality, that is, relief of suffering from somatic illnesses and
psychological distortions and compulsions, and greater longevity. For the
society, the public health should benefit through an overall reduction in the
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IDEAS GOVERNING DRUG POLICY
57
prevalence of drug morbidity and mortality, which have a disproportionate
effect among the young, and perhaps through reductions in incidence or
further transmission to the degree that drug problems are communicable Mom
the treatable population.
The criminal view focuses on the reduction of illegal conduct—not only
drug offenses per se but also associated personal, property, and public-order
crimes. The collective counterpart to individual treatment effects would be
a reduction in overall rates of criminal victimizations, prosecutions, and
incarcerations.
Libertarian, criminal, and medical goals overlap in practice. For ex-
ample, the calculus of social benefit and cost includes the costs of illness
and criminality. The therapeutic objectives of drug treatment include social
adjustment and satisfaction (including reduced criminal involvement); in
the prevention-oriented disciplines of mental health and public health, the
damaging effects of individual behavior on others through criminal activity
are important concerns. Finally, the missions of probation, corrections,
and parole authorities with regard to their supervisees often extend beyond
the prevention of criminal behavior to imparting legitimate job skills and
improving the fulfillment of family and community obligations.
The treatment system that was built under federal direction in the early
1970s and that continues today is based on a balance of ideological concerns.
The national policies of the early 1970s concentrated criminal justice efforts
on the drug judged most dangerous heroin while expanding the options
for treatment programs that could work cooperatively with criminal justice
institutions. Since 1975 the balance of public policy has moved steadily
back toward the criminal idea, while the momentum of the medical idea has
shifted into the private realm and led to increasing treatment of a segment
of drug problems in private hospitals and clinics. The movement on the
public side has been heavily responsive to larger political currents that have
favored security interests over other welfare concerns. There continue to
be strongly expressed as well as inchoate sentiments favoring libertarian
approaches, but the net movement has been a massive transfer of public
emphasis to enforcement and incarceration at the expense of the public
treatment sector. That pendulum appears to have swung to its limit, and the
opportunity for explicit reconsideration of the role, extent, and financing
of public and private drug treatment is greater now than at any point
since the mid-1970s. This is the context in which the following chapters
describe the problems that treatment can address, examine where and how
the treatment supply system has changed, present plans to restructure it
where needed, and define the costs and benefits that may accrue.
Representative terms from entire chapter:
drug treatment
