Addiction ‘Cures’ Elusive : Does the War on Drugs Underestimate an Enemy?
Joe Ferguson’s severance pay from his last job arrived like a bad omen. There it sat, in his savings account, driving him nuts. Just thinking about it during those early days back in drug treatment made his head spin and his eyes water. Finally, he couldn’t resist.
Ferguson walked out of the treatment program. He went to the bank, withdrew the money, bought some rock cocaine and prayed. In just four days, he blew the entire $700 on women, motel rooms and drugs. He ended up disgusted with himself; it wasn’t even fun.
“I kept saying, ‘Am I that trifling that I don’t care?’ ” recalled Ferguson, a 40-year-old addict who has been trying for the last five years to get and stay clean. “Or, does this thing really have that kind of control over me?”
Ferguson’s story continues--a characteristic of the genre.
He made his way back to the neighborhood of the drug treatment program. He took up residence in a park near a hall where a recovering addicts’ support group met. He lived on doughnuts, went to meetings and, last month, earned readmission to the program he had left.
“It’s like I’m crazy. But I know I’m not crazy,” Ferguson mused last week in a small, bare room at the Cri-Help program in North Hollywood. “Sometimes a person has got to hurt enough out there until the head gets softened, because I’m a hard-headed fellow.”
In Ferguson’s tale are lessons about drug addiction and recovery that experts and former addicts say must be understood in the war on drugs: Addiction is chronic, recovery is protracted, and just because a man stumbles does not mean he will never walk.
Earlier this month, President Bush proposed increasing by 50% federal spending on publicly subsidized drug treatment programs, a nationwide network of thousands of outpatient and residential programs serving hundreds of thousands of Americans a year.
Specialists in drug addiction have welcomed the proposal as a first step but suggest that a doubling or tripling of the $600-million budget is needed. Some of them trace the Administration’s parsimonious attitude to an underestimation of the treatment process.
Does it work? On the surface, the statistics are discouraging. Only a small fraction of users who enter residential programs complete the process. But of those who make it, research indicates that many cut back or stay clean, at least for a while.
A massive federal study to be published this month has found that the most effective treatments reduced drug use by an average of 75% in the first year after a user enters. While its effects on addicts’ productivity were unclear, treatment also helped cut down on crime.
Experts and former addicts say the question should be not whether treatment cures addiction. Success should be judged by other standards: Can treatment help addicts stop using or cut down? Can it help reduce drug-related crime?
True recovery is a long time coming. The story of most former addicts includes repeated failed attempts. Months in treatment, months of sobriety, then a plunge back into using, followed by more treatment, more relapses and, over time, perhaps, success.
“People say to us, ‘What’s your cure rate?’ ” said Rene Topalian, assistant director of the Los Angeles County drug abuse program office. “Give me a break. We’re dealing with addiction, which is a physiological and psychological disease process that has a very heavy demand on a person--and a very heavy relapse effect as a result.”
M. Douglas Anglin, a drug-abuse researcher at UCLA, draws a non-user’s parallel:
“We allow well-socialized people with lots of skills and good backgrounds to fluctuate 20 pounds in their weight, or smoke five cigarettes a day instead of 2 1/2 packs,” said Anglin, a social psychologist.
“All of those things are quite acceptable for the best of us,” he said. “So to impose a rigid expectation of instantaneous or near-instantaneous behavioral change with drug-dependent individuals is, to me, morally repugnant.”
As Joe Ferguson tells it, he never knew his father. But his mother used to describe him this way: “He was no good. Like you.” Her son’s African features didn’t please her either, Ferguson recalls. She would tell him, “Pinch your nose. Suck in your lips.”
She was a maid, and hard-working, often gone from their South Bronx home. At age 5, Ferguson found himself frequently alone. He began sampling the bottles of Thunderbird left around by his mother’s new friend; after all, the man was funny when he was drunk.
Ferguson developed a repertoire of suicidal games--"playing matador” with passing cars and jumping from roof to roof. One game, called pony, entailed leaping from a flying swing to straddle a 12-foot fence without careening over the top onto a heap of rubble.
For his wildness, his mother would take him into the bathroom with a belt. Ferguson simply graduated to fighting, then drugs: “I resented my mother. I loved her, and I never got a hug from her. I thought she was beautiful, and she was telling me to pinch my nose.”
One night, en route to a James Brown concert, a gang tiff escalated. Ferguson, 14, saw his best friend shot dead between the eyes. He remembers a newspaper account of the incident: A 14-year-old sat over the body, weeping.
Years later, he was with his mother when she learned that she had terminal cancer.
“That was the first time she ever hugged me,” said Ferguson, who says that even now, at 40, he hungers to be embraced. “She cried in my arms. Like I was her father and she was my daughter.”
Cri-Help is one of about 25 to 30 residential programs in Los Angeles County that receive some public funding, drawing on a pot of federal, state and local money that has grown increasingly tight in recent years as demand for treatment has escalated.
In addition to programs like Cri-Help--said to be one of the older and better-managed residential programs--the county funds dozens of outpatient and short-term detoxification programs. There is also an expanding network of private, for-profit treatment centers.
The Cri-Help program stands on Burbank Boulevard amid auto-body shops, liquor stores and a plumbing and rooter service. There’s an administration building, dormitories and a large, fenced yard with basketball nets and a track.
Sixty-five men and women live in the complex. Their drug habits have ranged from prescription pills and alcohol to crack cocaine. Most have been in treatment at least once before, and two-thirds have been sent to Cri-Help by the federal and state court systems.
About 15% of those who enter Cri-Help complete the nine-month program. Of those who leave, 10% to 15% are expelled for infractions. Others walk away; the door is open. To earn readmission, they must begin by attending 20 Narcotics Anonymous meetings.
Ex-Addicts Run Program
Former addicts, for the most part, run Cri-Help--many of them heroin users in the 1960s and early 1970s. Many of them recovered there themselves over the last 18 years--often after years of unsuccessful treatment in psychiatric wards.
For that reason, there is some skepticism of “the medical approach” to addiction, which includes traditional psychotherapy by professionals as well as the use of medications. Psychotherapists have been incorporated over time into Cri-Help, but its approach remains rooted in the experience of addicts seeing in former addicts the possibility of a new life.
Men and women working in and with the program serve as living examples.
“This is a program of attraction. What are we selling? We’re selling hope,” said Marcus Sola, the 45-year-old assistant director. “They see me: I have an education, I have a position here, I’m articulate. And most of all, I’ve been clean for 12 years.”
The treatment program entails several elements:
First, it interrupts the process of using drugs by providing an environment that is drug-free. For the first few months, residents have no contact with family and old friends. Only over time are they re-integrated into work and community life.
At the same time, the program attempts to begin changing users’ behavior through a battery of rules governing every aspect of daily life, and through incessant chores that both compel contemplation and carry messages about responsibility and community life.
Finally, residents are encouraged, through meetings with caseworkers and group therapy, to begin examining deeper psychological scars. The aim is eventually to come to terms with experiences like childhood abuse and abandonment, achieving some internal peace.
Stages of Development
Kent Harris, a 33-year-old former addict who went on to earn a master’s degree in psychology and now works as a caseworker at Cri-Help, describes the counseling process as one of guiding a person through stages of development that he or she missed in the fog of addiction.
For example, a caseworker might help a resident set goals like developing trust and creating a bond with others. A first step in that direction might be shaking a few hands at a Narcotics Anonymous meeting or being introduced by a sponsor.
Meanwhile, job assignments and interaction with other residents work toward building a sense of social obligation lacking in the self-centered world of an addict. For perhaps the first time, residents take on the challenges of life without the help of drugs.
“It’s a tremendously painful process, I’ve got to tell you,” said Harris. “Because the only way we knew to deal with our problems--we don’t have anymore. The feeling is usually terror, total fear. Some express it in anger, some by withdrawing.”
“You’re really angry,” the psychotherapist observed calmly. The young man was seething, his jacket yanked back over his shoulders in the stuffy room. When he answered, he looked away from the therapist at a wall, fidgeting with a ballpoint pen.
“You seem like you’re ready to explode,” she said quietly.
“Yeah. Gimme a bomb.”
The other men, slouched on a couch, leaned forward, listening.
“I’m sick of being here,” he snarled sadly. His birthday was approaching. He’d spent years in jail and had been in three programs. There was nothing to go to “out there,” he said. “But I would rather do that than sit in this house and deal with these people.”
“I don’t need to learn how to socialize,” he went on scornfully. “I know how to socialize. Man, I’ve run all over this town. I’ve done it stoned, I’ve done it sober. . . . I’d rather be working on my recovery than pushing a broom for hours a day.”
‘I Know How to Work’
Another resident in the group piped up softly: “Are you still not at the point where you accept that as part of recovery?”
“Pushing a broom has nothing to do with my recovery,” the man shot back. “I know how to work, I know how to pour concrete, build buildings. I’ve worked since I was a kid. . . . There’s times I wanna just take a mop and wrap it upside somebody’s head.”
The conversation curled off onto the subject of personal change--specifically, the difficulty of sloughing off perceived affronts. A woman cuts you off on the freeway, a guy elbows you in basketball. How could it be best to suppress your anger?
A slight, blond man with a Jack Nicholson voice recounted an experience.
“I was out with my sponsor. I said, ‘What is surrender?’ ” he recalled, using a word often heard in recovering-addict circles. “Turn it over,” the sponsor told him. Recognize that you are powerless over people, places, things.
“Acknowledge it, and let it go,” the blond man mused. “If you honestly turn it over and accept it, how can you have resentment?”
He turned to reassure the angry man. “You’re in the car. You and me. We’re in the car, till the wheels fall off.”
The man reached his big arms behind his head and stretched, seeming to fumble with an awkward, involuntary smile.
“I guess I’ll stay.”
Less than one-quarter of the residents at Cri-Help pay their way out of their pocket or through insurance. To cover the rest, the program relies on donations, fund-raising and public funding channeled through the county’s drug and alcohol program office.
But federal funding for drug treatment has faltered in the 1980s. The county’s $22.6-million addiction treatment budget in 1981-82 dropped to $20.4 million over the next two years. It returned to $22.4 million two years after that. It has since risen to $29.7 million.
That covers just 70% of what the county paid for in 1981-82, county officials say.
“We’re providing less service to the residents of Los Angeles County today than we were before crack, before AIDS and intravenous drug users, before perinatal (addiction) and before nobody-wants-a-program-in-their-backyard,” said Topalian of the county.
He said it remains unclear precisely how much help the Bush plan would provide.
The shrinking of the system has harmed treatment: Caseloads have grown, burnout has increased, counselors have defected to the private sector, experts say. To survive, programs have been forced to expend energy on fund raising, bingo and yard sales.
At the same time, the closing of publicly funded mental-health clinics has driven a new breed of user into drug-treatment programs--people whose primary problem is not addiction but severe mental disorder, people whom many programs are not equipped to handle.
“There is some kind of implicit expectation out there that the drug-abuse services system, which for years was everybody else’s stepchild, is now supposed to pick up everybody else’s burden,” Topalian said.
Marlene Nadel, the casework manager at Cri-Help, listed a few of the services the program would like to offer if it had more money: More educational opportunities, more group therapy, specialized treatment for the growing numbers of residents with eating disorders.
For those without a high school diploma, the program has been unable to find a volunteer teacher. Night school is out because of access to drugs. Without a medical team on the premises, it cannot take on addicts who require prescription medication, such as diabetics.
“We’ve had people sit in jail three to four months waiting for a bed,” Nadel said. “We’ve had people die waiting for a bed.”
This month, one of the largest studies ever done of treatment effectiveness is being published by a team of researchers who have followed more than 10,000 drug users in about 40 residential and outpatient treatment programs nationwide.
Their conclusions concur with the assertions of former addicts and others in the field: Treatment has been effective in reducing drug abuse up to five years after treatment, though it has been less successful in re-integrating former addicts into society.
A key factor influencing whether treatment works is the length of time a person remains in treatment, the federally funded research group found. They found no apparent benefit among men and women who were in treatment less than three months.
Differing Success Rates
Success rates differed by type of treatment and drug. Residential programs, like Cri-Help, caused the most dramatic reductions. Methadone maintenance cut heroin use by up to 75% but had less effect on other drugs. Outpatient drug-free programs generally came in third.
Within five years of treatment, “relapse was not uncommon,” according to the researchers at Research Triangle Park in North Carolina. But in any given year, fewer than 20% of former clients were regular users of any drug other than marijuana or alcohol.
It was unclear whether treatment improved users’ productivity. The researchers reported little increase in employment, even though criminal activity as well as depression and suicidal tendencies declined during and after treatment.
An 18-year-old girl in pearl earrings sat in an office at Cri-Help. She had thick reddish-blond hair and a cherub’s face. After six months in the program, she was standing on the cusp of Phase Two B: She would go out, find work and begin holding down a job.
Eighteen months ago, the girl was a student at a suburban Southern California high school--key club, honors society, high PSATs. The only child of two professional parents, she was headed for college. In the meantime, she had taken up with a boyfriend who ran drugs.
The girl started using a potent form of methamphetamine, commonly known as speed. When her mother asked her about it, she lied. Then one day last October, a detective approached her after Biology Honors 2. In the vice principal’s office, they found “an eight ball” of crystal in the girl’s organizer.
She was arrested and booked at police headquarters. She was in handcuffs when her mother arrived. For six days, she sat in Juvenile Hall. “This is not the Holiday Inn,” she recalls someone informing her when she asked if there were seat covers for the toilet.
The girl was sentenced to 60 days at a treatment program for girls in Idaho. The experience left little impression. She returned home to a Christmas tree and her mother’s restored trust--which made her feel all the worse when she went back to using.
Then one day she loaned her car to a guy to make a drug run, lied to her mother about it and was so loaded she forgot the lie. Her mother confiscated the car, the girl left home and began an ultimately terrifying slide into the world of cheap motel rooms and dealing.
In April, she turned back to her mother for help. She entered Cri-Help as the youngest resident. Sitting in an office talking last week, she said she had begun once again to “feel like the old me.” She spoke of humility, acceptance, new short-term goals.
“It’s been a rough road,” said the girl, looking like an intelligent child oddly out of place in the house. “In a week, I’ll be going on work-out, getting my car back and a lot of things will be facing me.
“I’m scared,” she confessed quietly.