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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 wereand still areprofoundly 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 medicalthat 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 governmentin 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 yearsan 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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46 TREATING DRUG PROBLEMS of libertarian thought namely, its calculus of utilityhas 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- ticeone 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 lawis 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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48 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 addictsfederal 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 rehabilitationcriminals 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 lifeor 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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so 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 problemexcept 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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52 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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54 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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56 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 conductnot 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.