Treating hard-core drug addiction often seems an exercise in futility. Eight years and $1 billion into a massive drug-treatment campaign, Governor Nelson Rockefeller conceded all-out failure. "Let's be frank," he said in 1973. "We have achieved very little permanent rehabilitation—and we have found no cure." Two decades later, volumes of published clinical evidence make it luminously clear that relapse to cocaine and heroin following treatment is the rule, not the exception, among hard-core addicts. Even the best treatment clinics typically see a majority of their patients drop out prior to finishing the program; of those who do complete treatment, between 50 and 70 percent relapse into addiction.
So why bother? First, because scientific studies demonstrate powerfully that, for society as a whole, drug treatment is a worthwhile investment. By reducing drug use, even temporarily, treatment programs diminish the social costs of addiction: health care, failure to work, and, chiefly, crime.
More important, under the right circumstances, treatment can bring about dramatic, permanent recovery. One form of drug treatment, the "therapeutic community"—a long-term residential program that aims at nothing less than remaking the individuals who enter it—has shown impressive success, reforming many addicts who complete the program.
The problem is that the circumstances seldom are right. In this matter, social policy has long had it backward. Since most addicts don't make it through the therapeutic community's long and strenuous program, what they need is some external incentive, sometimes even compulsion, to stay there until they complete the program. Instead, what they get is a host of welfare benefits that support their drug habit on the outside. A wise policy, by contrast, would press addicts to complete treatment and stop supporting those who don't. The success rate of treatment programs would soar.
The economic case for drug treatment's social utility—imperfect as existing treatment programs are—is surprisingly compelling. A 1993 Office of National Drug Control Policy review of the published research on treatment outcomes concluded overwhelmingly that addicts who receive treatment—even if they don't recover—impose considerably less financial burden on society. "The cost-benefit ratios were very impressive," says Dr. James Langenbucher of Rutgers University, the review's director. "The data show that for every $1 spent on treatment, between $2 and $7 are either averted in public health and criminal justice costs or gained in productivity related to resumed employment. "
The most persuasive studies of the more than 50 in the review painstakingly checked each patient's past criminal, medical, and employment records. They collected data from the years both before and after treatment, allowing two vital conclusions: that the changes observed after treatment truly were a result of the treatment, and that the benefits persisted after the patient completed or dropped out of treatment.
The largest and most comprehensive study evaluated a national sample of more than 10,000 addicts while they were in treatment and at intervals over the subsequent five years. It found that serious predatory crimes dropped by 50 percent or more over five years among patients who stayed in treatment longer than three months, saving society an estimated $1 to $4 for each $1 spent on treatment. Additional gains arose from higher employment and lower health care costs.
Examining the outcomes of three types of public programs, the study found that outpatient, clinic-based programs that offered between one and five hours a week of counseling or group therapy for up to a year saved an average of $2,600 per patient of total costs to society for the treatment period and for the year thereafter. Outpatient methadone treatment for heroin addicts saved $1,500. By contrast, long-term residential treatment for 1X to 24 months saved an impressive $6,000.
A 1994 California study of 1,900 addicts found that it wasn't necessary to complete an entire course of treatment to yield savings. Only about one-third of the patients stayed in treatment beyond three months. But even for the dropouts, each day of treatment yielded a financial return to society. In all, by treating 150,000 Californians at a cost of $200 million, the state saved an estimated $1.5 billion, largely due to reductions in crime, during treatment and in the first year afterward. (Since the study relied on patients' self-reports of criminal activity, it likely overestimates the savings.)
What kind of case can we make for drug treatment if we switch our perspective and look at drug users not in the aggregate but as individuals? Consider the issue from the standpoint of a mother whose son abuses drugs. By the time she seeks help, she is typically exhausted and desperate. She cares only that treatment salvages her child, not that it saves society money. Is her hope in treatment justified?
The answer depends on what type of treatment she seeks, for there are many, some much better than others. Outpatient counseling programs have a poor track record with hard-core addicts, who need a stricter clinical discipline than these programs are able to provide. A University of Pennsylvania analysis of 619 patients admitted to public outpatient treatment programs revealed that the typical weekly pattern of services consisted of one or two group therapy sessions, an educational session—meaning, usually, a film—and often, though not always, 20 minutes alone with a counselor. This is not, on the face of it, a life-transforming regimen.
Most outpatient programs rely heavily on 12step support groups like Alcoholics Anonymous and employ counselors with no formal education beyond a high school diploma or two-year community college degree to provide the bulk of the treatment. New York lacks even a certification procedure for counselors. Many outpatient programs do not perform regular urine testing; those that do often fail to supervise the tests to ensure that addicts do not circumvent them by supplying someone else's clean urine.
Many experts advocate clinic-based methadone treatment for heroin addicts. But it is no panacea either, though it is appropriate for some addicts and has made an important public contribution by reducing drug-related crime and preventing transmission of infectious diseases like hepatitis and HIV. For many addicts, methadone shifts rather than solves the drug problem. Cocaine abuse is rampant among methadone recipients: Dr. Herbert Kleber of Columbia University's Center for Addiction and Substance Abuse estimates that up to 60 percent of New York City's methadone population would test positive for cocaine on any given day.
But one form of treatment holds out immense promise: the therapeutic community, best exemplified by New York-based Phoenix House. One of the nation's two largest residential drug-treatment organizations, Phoenix House has 2,000 patients in 16 residential facilities in New York, California, and New Jersey; 700 in two prison-based programs in upstate New York; and, eventually, another 1,000 in two newly opened Texas prison-based facilities. The organization was founded in 1967 by psychiatrist Mitchell Rosenthal, still its president. It works because it starts with Rosenthal's clear-eyed recognition of what reforming a hard-core addict really involves: nothing less than resocializing him.
In a therapeutic community, patients are immersed in a comprehensive 18- to 24-month treatment regimen, built around the philosophy that the addict himself, not the drug, is the primary problem. Psychiatric orthodoxy holds that addiction is a discrete, self-contained "disease." The therapeutic community's approach, in contrast, recognizes that drug abuse is only a symptom of a deeper personal disturbance. Thus the strategy for rehabilitation is to transform the destructive patterns of feeling, thinking, and behavior that predispose an individual to use drugs.
The primary "therapist" is the community itself, including not only peers but also staff members, some of whom, graduates of such a program themselves, serve as role models. Mutual self-help is the dynamic: residents continually reinforce for each other the expectations and rules of the community. All residents must work, above all so that they learn to accept authority and supervision, vital to future success in the workforce. Residents win rewards for meeting the community's expectations: they earn privileges like weekend passes and take on increasing responsibility, culminating in leadership roles. If they defy the rules, they lose privileges and are required to perform the least desirable chores.
At first, patients often resist vigorously. Jack, a cocaine addict enrolled at Phoenix House, was accustomed to giving the orders when he was a high-level drug trafficker. He recoiled at taking an assignment from a more senior resident. But gradually he overcame his resistance as he saw that the "reliance system," as he called it, grew out of a culture of mutual respect. Soon after being admitted, Jack was paired with another resident, who was to be his personal mentor, confidant, and advocate. After a while, Jack himself was to serve as a mentor to a newly arrived resident. "I never had anyone depend on me because of what I, personally, could contribute. When I was selling, I had a function to perform. I was needed to do it, yeah; but if I got shot, they'd have someone to replace me the next morning."
During their treatment, residents must untangle the web of legal, occupational, and family problems in which they have enmeshed themselves over the years. Those who make it to the end typically have put their affairs in order and gotten a job. But in the early months of the program, residents are often disoriented, uncertain about how to act or feel, and lost as to how to express this confusion.
Juan, who recently quit using heroin, told his counselor, "When I was doing drugs, I had a whole routine, almost a ritual. I'd find my dealer two or three times a day, depending on the money I had. I'd shoot up, hang out about six hours, then do it again. That was my job. That's who I was—an addict. What do I do now?"
For heavy users the prospect of relinquishing their drug can be terrifying. Many addicts started using drugs during adolescence and never developed the skills to function without them. "It's hard for people like you to understand," one of my patients, a dropout from a therapeutic community, told me. "Even oxygen hurts my lungs unless I'm high. I don't know how to breathe, how to live. Heroin smooths everything out so I can bear it. If I killed myself, before I pulled the trigger, I'd pray that there are drugs in heaven."
Given the magnitude of change that therapeutic communities seek to bring about, 18 to 24 months of treatment isn't long. "It's only a fraction of the 21 years it normally takes to raise a person," Rosenthal says. "We have two years to teach industrial-strength values to those most likely to resist them—only two years to instill the social competence, self-respect, trust in other people, and optimism about the future that the addict's community and family did not."
Yet if a patient is able to last the two years in treatment, his chances for success are excellent. Among graduates of Phoenix House, the most extensively studied of the therapeutic community programs, 90 percent are still working and law-abiding five to seven years later, and 70 percent are completely drug-free.
Edward, 38, grew up in a working-class family in East New York. He started drinking and smoking marijuana at age 12; by 14 he was using barbiturates, amphetamines, and LSD. At 18 he moved in with a girlfriend, with whom he got high regularly. He bounced from job to job; he had two children with his girlfriend. At age 26 he took up heroin, which he used until he entered Phoenix House four years later. He worked his way up in the program, becoming head cook and head of education, and then took an outside job as a carpenter. Today he has a steady job for a Queens manufacturing concern, and he coaches Phoenix House's softball team.
Like virtually all drug-treatment programs, therapeutic communities have a high dropout rate—not surprisingly, given the intensity of the regimen. At Phoenix House, 30 percent of residents drop out within the first six weeks, about half make it through the first year, and only one in four or five finishes. This is much higher than the 10 percent completion rate that is average for therapeutic communities.
The challenge, clearly, is to improve the likelihood that patients will stay with the program. Doing so requires recognizing a fact as simple as it is surprising: treatment is more likely to succeed if it isn't voluntary. An addict who is court-ordered to treatment is much more likely to graduate than an addict who signs himself in, though no particular psychological profile can forecast who will leave treatment early. More striking, once back in the community, court-ordered addicts also do as well as graduates who voluntarily enroll.
"It's a myth that an addict has to want to change in order for treatment to have an impact," says Dr. Langenbucher of Rutgers. Adds Mitchell Rosenthal: "A lot of our most successful residents come in here kicking and screaming, but over time they acquire a desire to change." Along with the 700 patients in its New York State prison-based programs, some 10 percent of Phoenix House's 2,000 residential patients are involuntarily enrolled.
Criminal courts, ideally suited to identify drug users and enforce long-term treatment, are a key point of entry to residential programs. With the criminal justice system picking up the tab—$17,000 a year in New York City—an addict can't be refused a bed for lack of funds, as often happens to Medicaid recipients, whose coverage does not include residential treatment. "I wish the cops could bust addicts for jaywalking or littering," says a clinic director, only half-jokingly. "At least they could get a treatment bed, and, even better, the court would make sure that they complete the program.'
Courts also have the capacity to track addicts and require urine tests as a condition of parole long after treatment is over, pressuring them to remain drug-free. Though today such tracking isn't routine, many treatment experts would like it to be.
To improve the overall efficiency of the nation's drug-treatment effort, experts also want criminal justice agencies to hold programs accountable for their results. When a judge sends an offender to a facility like Phoenix House, he can be sure that the quality of care is high. But drug courts typically send offenders to less expensive outpatient programs, where outcomes can vary dramatically. Miami's drug court program, for example, is notorious for its reported ultra-short stays in treatment, incompetent staff, and drug use and prostitution at its treatment centers. According to a 1994 Miami Herald report, felons were thrilled to be sent to "treatment," which allows them to live on the outside, visiting a clinic several times a week for a few months instead of spending years in prison.
Washington, D.C., by contrast, gets good reviews for its drug court experiment. Even though virtually all participants receive outpatient therapy, the compliance rate is high, according to program director Jay Carver, because the court subjects participants to tight surveillance, including daily urine testing, with immediate jail time for positive results. Urban Institute researchers plan to analyze the success of the treatment itself once enough participants have completed it.
If done right, compulsory treatment through the criminal justice system is also a promising strategy for reducing crime. Studies show that methadone patients are five times as likely to commit crimes when they are using heroin as when they are not. Patients in therapeutic communities, of course, are off the streets entirely and therefore commit virtually no crimes.
But it shouldn't take a felony charge to make an addict eligible for mandated long-term treatment. Most states allow the seriously mentally ill to be committed to an institution if their illness leads to profound self-neglect, a condition called "grave disability." (See "Treating Insanity Reasonably," City Journal, Winter 1995.) Although addicts are not covered by the same laws, heavy drug use can be gravely disabling as well. Hard-core users are often malnourished, exposed to the elements, sick, and physically traumatized. They can be paranoid and aggressive when using cocaine, then suicidal when it wears off. They are as impervious to reason as any deluded schizophrenic. Though not clinically psychotic, they have lost the ability to make free choices, subjugating all needs, desires, and responsibilities to the drug.
Many states have laws on the books permitting commitment of addicts when doctors, friends, or family members petition the court with evidence that the user is out of control and spiraling downward. But these laws have not been widely used for the past 20 or 30 years.
New York's law was repealed in response to the failure of the Narcotics Addiction Control Commission. Established in 1966, the commission had the power to compel non-offender addicts into long-term residential treatment for up to three years. The state spent about $1 billion and created 4,000 new treatment beds. The program failed because it took a punitive rather than therapeutic approach: treatment facilities resembled prisons and were run by corrections officers, not clinicians. When Governor Rockefeller began dismantling the program in 1973, he mistakenly concluded that compulsory care was a hopeless enterprise.
By contrast, California has had a civil commitment program since 1962. During its most active years, until the early seventies, the program was impressively successful. It required addicts to be treated in a residential setting for two years and then closely supervised by specially trained parole officers for another five years. These officers had small caseloads, performed weekly urine tests, and had the authority to return individuals to forced treatment if they resumed drug use.
This success came after a difficult start. During the program's first 18 months, many California judges, unfamiliar with the new procedures, released patients on a writ of habeas corpus almost immediately after they'd been committed. This judicial blundering, however, proved a boon to UCLA social scientists, who were able to conduct an extensive evaluation of nearly 1,000 addicts, comparing those who received compulsory treatment with those who were mistakenly freed. The two groups were otherwise comparable with respect to drug use and demographics. The researchers found that addicts who were committed fared significantly better: although 22 percent of them reverted to heroin use and a like proportion to crime, this was less than half the rate for the prematurely released group.
California's civil commitment program has become moribund, though the law is still on the books. In New York State, where civil libertarians wield great political clout, legal provisions for commitment are virtually useless. In 1994 the State Legislature passed a law allowing emergency treatment for patients who are incapacitated by alcohol or drugs. Under the new law, hospitals may retain such individuals for up to 48 hours against their will. Such an immediate response may well be lifesaving, but it does nothing to reduce drug abuse. Emergency care is expensive, and the law puts addicts who require sustained treatment back on the street, where they resume their self-destructive behavior—sometimes within hours, returning to the emergency room before the shift is over.
The idea of compulsory treatment for gravely disabled addicts draws misguided opposition not only from civil libertarians, who believe 52 that unless someone poses an acute, imminent danger any restriction on personal liberty is unacceptable, but also from some conservatives, who regard treatment as coddling. Addicts in a therapeutic community, however, do not feel coddled: a residential program with constricted freedom, rigorous rules, and enforced separation from drugs is the last place most addicts want to find themselves, at least initially. This helps explain why so many addicts drop out and why some prefer prison over treatment when offered the choice in drug court.
Long-term residential treatment beds are in extremely short supply. Nationwide there are 12,000 beds (15 percent of them operated by Phoenix House) and 2.7 million hard-core drug users, according to the Office of National Drug Control Policy. The figures for New York State, according to its Office of Substance Abuse Services, are 6,982 beds and 623,800 "regular and heavy" drug users.
Even so, waiting lists for the few existing long-term residential beds in New York State are short, in part because Medicaid does not cover residential treatment, but also because most addicts find such programs an unattractive alternative. Not only is life in a therapeutic community hard at first, but government welfare programs make life on drugs far easier, "enabling" addicts by supporting them in a destructive life-style.
The federal government provides cash subsidies to addicts through the Supplemental Security Income disability program. (See "Welfare's Next Vietnam," City Journal, Winter 1995.) Although addicts who receive SSI are supposed to enroll in treatment, this requirement has rarely been enforced. Little wonder that only 1 percent of the 20,000 enrolled in SSI for addiction in 1990 had recovered and left the rolls four years later. Congress is currently considering making addicts ineligible for cash benefits under SSI. Some residential treatment programs arrange with their patients to receive their monthly SSI payment, as well as other welfare benefits, to defray the cost of treatment. This useful practice should not be at the patient's option: the Social Security Administration should put teeth in SSI's treatment requirement by disbursing SSI only to treatment programs rather than to addicts themselves.
The federal Fair Housing Act defines addiction as a protected disability, prohibiting local housing authorities from directly inquiring into drug activity of applicants for public housing or Section 8 rent vouchers. In 1994, however, the New York City Housing Authority began working around this perverse constrains by initiating aggressive new screening procedures, including criminal background checks, visits to an applicant's current residence, and interviews with his neighbors and landlord. The authority rejected one in four public housing applicants in 1994, including active drug addicts who would have easily received apartments under the much more permissive Dinkins administration. Congress should amend the Fair Housing Act to exclude addicts from its protection.
Every missed opportunity to treat a hard-core drug addict means more street crime, HIV transmission, welfare dependency, and misery for addicts and their families. Cost-benefit analyses show that treatment is most assuredly worth it for society. But in order to help addicts themselves, we must kick government props like welfare and subsidized housing out from under drug abusers and provide long-term residential treatment—against their will if necessary—to give them a real hope of recovery. Over time, such actions could help reclaim—for society and for themselves—the thousands now lost to drug addiction.