COLUMN ONE : Neglected Weapon in Drug War : Can cocaine addiction ever be cured? Yes, argue researchers who say treatment programs could reduce prison costs and the demand for narcotics.

They started straggling into the fifth-floor meeting room of the Madison Avenue Presbyterian Church just before dinner time, taking seats on windowsills or on the brown bridge chairs.

“My first experience was pot and I loved it,” the evening’s speaker told the group of 25 men and women, including a couple with a toddler. “I went through the PDR (Physicians’ Desk Reference). I took anything that made me high. It was better living through chemistry.”

An edge of desperation suddenly sharpened his voice. “My bottom came on Christmas Day. Instead of going into the future or looking back into the past, I freaked out. I thought I had an invisible shroud around me. That evening I wanted out; I thought about suicide.”

The speaker, a schoolteacher in his early 40s, said he had given up drugs since that grim Christmas season, five years ago.

“It’s a day at a time; if you can’t do it, a minute at a time,” he exhorted the members of the national self-help group Cocaine Anonymous. “I will do anything I can to stay straight . . . . I am not unique. The common denominator we share is pain.”

Despite the hope and determination exhibited, groups like Cocaine Anonymous were relegated, until recently, to the rear lines of the U.S. war on drugs, which stresses interdiction, enforcement and education.

During the past decade, the myth that cocaine was a romanticized, relatively harmless drug was replaced by another: that cocaine addiction--particularly crack addiction--could not be treated.

Faced with the profound social disorientation produced by crack, its potential for rapid addiction and its ready availability, many people concluded that the situation was close to hopeless.

As a result, treatment became the poor cousin of the drug war. In the 1990 federal budget, $7.028 billion was appropriated for enforcement versus $1.337 billion for treatment. The Bush Administration has requested increased funds for both categories, but in roughly the same proportion, for fiscal 1991.

But treatment advocates--who include experienced researchers and clinicians--now are forcefully arguing that cocaine addiction (which almost always is mixed with abuse of alcohol or other drugs) can be cured in significant numbers. They say that new treatment programs not only can attack addiction, but also can save millions of dollars in prison costs and in the long run reduce illicit drug demand.

Physicians contend that even some of the hardest-core crack cases can be helped, particularly through long-term outpatient care or in residential therapeutic communities. Reversing addiction is also being aided by new understanding of cocaine’s effects on brain physiology and chemistry and by several promising drugs designed to block or ameliorate cocaine’s intense craving.

“I think there is a gradual recognition of the need for increasing the resources for treatment,” said Dr. Charles R. Schuster, director of the National Institute on Drug Abuse. “ . . . Treatment can work and we have to get the message out.”

Growing Evidence

He and others point to a growing body of anecdotal evidence:

--Debbie, now 20, was a frightened 16-year-old who had been arrested four times for using and selling crack when a judge gave her a choice. She could go to jail or to Phoenix House, a New York therapeutic residence for addicts with branches in Los Angeles and London that stresses a disciplined life, intensive therapy and peer pressure.

At Phoenix House, Debbie received her high school diploma, graduating with honors. She now works as a secretary in a law firm, has her own apartment, which she shares with a Labrador retriever, and is engaged to be married. “I grew up in Phoenix House,” Debbie said.

--Virginia, a successful artist, started experimenting with drugs while in college. Her drug taking intensified after she gave birth to a highly retarded child. After psychotherapy and a 28-day stay in an expensive private psychiatric hospital, Virginia managed to drop cocaine but found that she was an alcoholic.

She is now a member of Alcoholics Anonymous, and she has been drug-free for 5 1/2 years and abstains from alcohol. She is remarried and expecting another child. “The only way an addict stops is if he thinks he is looking at death right in the face,” she said.

--Robert, 34, started drinking at the age of 13 and later began experimenting with drugs, including cocaine. He was hospitalized, entered an outpatient cocaine program and joined Alcoholics Anonymous. He has been drug-free for a year and credits his move to a new apartment so he could escape his former drug-using companions.

“Moving to a new neighborhood was key,” he said. “I wasn’t seeing the same people every day who I used to party with and who knew me when I was high.”

But many success stories can be matched by grim sagas of failure.

Dawn, 23, who is undergoing treatment at Phoenix House, was constantly rebuffed when she tried to befriend another resident. “She didn’t want to talk about nothing,” Dawn said. One day, Dawn found the woman wearing a thin jacket standing with her suitcase near the front door, leaving. “It’s freezing out . . . . Damn, why didn’t she give herself a chance?” she asked.

Despite the fact that such scenes are repeated almost daily at drug treatment programs across the country, treatment advocates say the anecdotal tide is turning in their favor.

They contend that therapies are improving, and promising new research into cocaine’s effects on the brain is leading to development of drugs that attack cocaine’s addictive hold.

So far they lack statistical proof. The arguments for and against greater funding for treatment often center on anecdotes because statistics on the effects of treatment often are fragmentary or contradictory.

Physicians say recovery rates in some treatment programs can run as high as 70% with stable working-class blue-collar drug users versus less than 30% for youngsters in crack-infested ghetto neighborhoods. At Phoenix House, where 50,000 drug users have been treated, 70% of those who stay with the program for a year are still drug-free five years later. But 60% of all participants drop out before getting to the one-year mark.

Critics, particularly advocates of greater spending on enforcement and interdiction efforts, seize on such numbers as evidence that treatment cannot truly be a front-line defense in the war on drugs. Some contend that treatment programs may actually encourage those who seek to legalize drugs.

“More treatment will not win” the war on drugs, said Stanton Peele, a psychologist and author of “Diseasing of America: Addiction Treatment Out of Control.” “It will only distract our attention from the real issues of addiction,” including unemployment and urban decay, he said.

Few doubt that examples exist of therapies that have saved crack addicts from ghetto neighborhoods. But can comprehensive treatment save thousands of addicts at a cost society can afford?

“We absolutely believe that treatment can be effective if you can give poor addicts something else,” said Dr. Robert B. Millman, professor of psychiatry and public health at Cornell University Medical College, who reports significant success in treating blue-collar drug abusers.

“Here’s the problem: Poor people come into treatment. They have been on welfare. They are drinking a lot and using some heroin and using some coke and their life is this: They come into the program and then they go to the welfare office. And then they go to the liquor store and then they may go to their dealer. We do not have enough chance to interrupt that very destructive pattern. We’ve got to break that up.”

Combining Therapies

The key, say drug counselors, is the development of so-called comprehensive strategies which bring together all the treatment efforts in a community into a “cafeteria” of therapies. Ideally, such treatments would include a variety of approaches tailored for different problems, coupled with job training, comprehensive medical care and drug-free housing for low-income recovering addicts.

Equally important in the future, counselors say, are the use of drugs, now undergoing tests, designed to block cocaine’s intense high and prevent long-term craving. If promising clinical trials based on new understanding of cocaine’s effects on brain physiology and chemistry are successful, the result could be major weapons in the therapeutic arsenal.

“We are very excited because we have very promising ideas at the moment,” Dr. Schuster said. “The more we are learning about the basic chemistry of the brain and how drugs interact there, we are better able to tailor-make new medications for the treatment of addictive disorders.

“But you will need other forms of treatment. There is no magic bullet. All the drugs are doing is providing us with a window of opportunity for other kinds of behavior therapies.”

Physicians and drug counselors say sexual problems, underlying depression, family stability and such issues as AIDS, child abuse, incest and abandonment often are intertwined with drug abuse.

In recent months, some of the nation’s leading foundations have committed funds toward drug treatment strategies with strong community roots.

“All the activities going on out there in the community were going on in isolation from each other,” said Paul Jellinek of the Robert Wood Johnson Foundation in Princeton, N.J., the nation’s largest health care philanthropy. “It’s like having an army of people where everybody stands behind a tree and fires away. You need a general so they are shooting at the enemy.”

“Each city and community should have a centralized referral program,” Schuster said. “One of the things we really stress is the importance of having appropriate centralized patient evaluation,” said Dr. Herbert Kleber, deputy director of the Office of National Drug Control Policy. “Right now the treatment you get into is an accident of the door you knock on.”

What could serve as a national model has existed in New Haven since 1968 as a joint venture of Yale University and the state of Connecticut.

Patients are seen in a central screening and brief treatment unit where physicians have a variety of options. Drug users can be briefly hospitalized, sent to a methadone program for heroin addiction, an outpatient cocaine program or a clinic treating alcohol abuse. Other options include 12- to 18-month residential therapeutic communities for adolescents and adults and a vocational unit for recovering addicts with poor job skills.

Screening physicians ask themselves some basic questions: Does the patient need to be hospitalized because of psychosis or potential suicide? Is the drug user on a cocaine binge that can’t be stopped? Can the patient remain drug-free in a non-controlled environment? What are the main drugs being abused and is detoxification required?

“The people who need to go to a 12- to 18-month facility, who need habilitation are those whose life is centered around drug abuse,” said Dr. Richard Schottenfeld, acting co-director of the substance abuse treatment unit at the Connecticut Mental Health Center at Yale.

Often, “these are people who have no job skills, who don’t have a place to live that is drug-free. In a controlled drug-free environment, their craving improves, frequently after a long period of time of being addicted,” he said.

Better Success Rate

Studies show that about 65% of those entering the New Haven programs are drug-free after five years. Many of the clients served by the central screening system are blue-collar workers and the inner-city poor. The success rate is considerably higher than many other clinics have reported.

Controlling craving for cocaine, which can be triggered by any reminder of drug use, is essential.

“With a crack smoker, it goes from the stimulus to a full-blown craving in a matter of seconds,” said Richard A. Rawson, executive director of the Matrix Institute on Addictions in Los Angeles, a treatment facility. “They don’t know what hits them. A crack addict can have the best of intentions and run into a person or place and get a full-blown craving response.

Many former users initially believe they have beaten their habit. But this “honeymoon” period is followed by profound depression. Researchers at Matrix Institute have named the depressive phase, when potential for relapse greatly increases, “The Wall”--after the grueling stretch marathon runners experience.

Some researchers have found that administration of anti-depressants may markedly decrease cocaine craving by lessening the depression of withdrawal.

At Yale University Medical School, psychiatrists treated 72 cocaine addicts with the anti-depressent desipramine. Some patients also were given lithium, commonly prescribed for manic-depressive illness.

Physicians reported that 59% of those taking the desipramine were abstinent for at least three to four consecutive weeks during the six-week trial, contrasted with 17% who were given the placebo and 25% for lithium.

“Our findings indicate that desipramine is an effective general treatment for this first treatment stage in actively cocaine-dependent outpatients,” the researchers wrote in the “Archives of General Psychiatry.”

Some of the same Yale researchers, in another study, injected 10 crack smokers with the drug flupenthixol, which is generally not available in the United States. At low doses it is a potent anti-depressant; at high doses it is an anti-psychotic agent. Nine of the 10 subjects reported amelioration of cocaine craving within three days.

Dr. James Halikas, a professor of psychiatry and director of the chemical dependency treatment program at the University of Minnesota, gave carbamazepine, or Tegretol, a commonly prescribed anti-convulsant, to a group of 35 hard-core cocaine addicts, with a history of seven years of cocaine and crack use and 16 years of taking illegal drugs.

The results were dramatic from the first pill: Cocaine craving was reduced almost immediately.

“In our regular clinical practice, it is the routine drug we put people on with craving,” Halikas said.

The issue remains, however, will patients continue to take the medicine? Some patients who prefer living the high-risk cocaine lifestyle have stopped their pills.

“You still have to get to the bottom of why the patient turned to cocaine,” Halikas said. “If our treatment program fails to persuade them to live a sober life, it is not the medication’s fault. If you give someone penicillin for pneumonia and leave them out in the snow without an overcoat, don’t be surprised if they get it again.”

Treatment advocates argue that in the long run therapeutic communities can be cost-effective for hard-core addicts.

Sen. Joseph R. Biden Jr. (D-Del.) contends that $600 will buy three months of outpatient treatment that would in turn save taxpayers almost $3,000 in welfare, Medicaid and law enforcement costs. “Few other social programs can match that outcome,” he argues.

In New York City, where more than 75% of prisoners who enter the criminal justice system have a drug problem, it costs $52,195 a year to maintain an inmate in jail. Federal officials said the average cost of a residential treatment slot is about $15,000 a year, and an outpatient treatment slot costs only $5,000.

New York maintains the nation’s largest drug treatment program for jailed prisoners, with more than 700 beds, including 384 prisoners undergoing therapy on the Bibby Resolution, a prison barge anchored at a dock in lower Manhattan. The Department of Correction says prisoners undergoing treatment are less violent, commit fewer infractions, are more attentive and seem to show greater self-esteem. They require fewer correction officers acting as guards--a saving so far of $2.7 million a year.

Prisoners and staff aboard the Bibby Resolution are enthusiastic.

“This program has taught me there is another life out there,” said Nathaniel, a prisoner.

“A lot of us never got any kind of help,” said John, who also was doing time. “A lot of us get to see reality. It gives us a little push.”

But administrators report problems finding places in longer-term community-based drug treatment programs for inmates once they are released. “We are preparing thousands of inmates for treatment,” lamented Raymond Diaz, director of the Department of Correction’s Substance Abuse Division. “There are no slots for them to go to.”

Experts say drug treatment is made more complex by severe shortages of specially trained physicians and counselors.

“There are about 35 (drug abuse) programs affiliated with training hospitals, compared to hundreds in cardiology,” said Dr. Marc Galanter, professor of psychiatry at New York University’s School of Medicine and director of the Center for Medical Fellowships in Alcoholism and Drug Abuse.

Some physicians and hospitals complain that new health cost containment efforts among insurance companies and large corporation often create strong pressure to abbreviate treatment or to treat addicts as outpatients when they really require hospitalization or long-term care.

“Many employers have turned away from the traditional kind of health insurance they had,” said Michael Ford, president of the National Assn. of Addiction Treatment Providers. “You have managed care, prepaid systems, an alphabet soup of alternatives. Those have helped manage the costs. I am not sure they managed the care.

“Many people don’t respond to outpatient treatment. You have to let professionals, not bean counters, make decisions about what level of care people need . . . . We do not see the same kind of discrimination in other areas of chronic disease. We do not see it in cancer and heart disease. When people (have) these respectable chronic disorders, they get all the care they need.

“Can you imagine suggesting to someone with a heart attack: ‘Have you tried outpatient care first or tried heart attacks anonymous?”

Physicians and federal officials say the fragmentation of medical treatment causes additional difficulties. Many drug clinics are not equipped to deal with serious medical and psychiatric problems often accompanying drug abuse.

“If there is adequate psychiatric treatment, the outcome is better for both the drug problem and the psychiatric disorder,” Schuster said. “We have to be holistic about our approach and deal with the human being who comes in for treatment and not just his drug addiction problem.”

Researcher Lisa Romaine contributed to this story.