A Grueling Waiting Game for Addicts Seeking Help

For thousands of weary addicts, sobriety has become a grueling waiting game. No one knows this better than Gilbert Saldate, a social worker for Homeless Health Care Los Angeles.

Twice a week, clipboard in hand, Saldate is down on skid row trying to coax a never-ending supply of crack heads and junkies into drug rehabilitation. Eight to 10 people sign up on each outing, yet only one or two will get help--largely because there aren’t enough treatment programs to meet the enormous demand.

“Society wants addicts to change,” says Saldate, himself a former heroin addict. “But I have to ask myself whether society really wants to help them make that change.”

Drug treatment advocates wonder the same thing. While national studies show that drug abuse among teenagers and heavy users is rising, government-subsidized rehabilitation for indigent addicts remains hamstrung by unstable funding, concerns about quality of care, and a skeptical public that believes police and prisons are the answer to the nation’s drug crisis.

In urban centers such as Los Angeles County, large numbers of hard-core addicts--those who spread the most crime, disease and turmoil--never make it into a program because the wait can take up to six months, a potentially expensive delay for society.

Studies show that an untreated addict can cost taxpayers as much as $90,000 a year in welfare, medical care, law enforcement and losses resulting from crime, eclipsing the $21,000 annual cost for long-term residential treatment.

“I just kept stealing, shooting heroin and running the risk of getting AIDS,” says Heather, a 21-year-old addict who spent almost three months on the street while trying to get into Impact House in Pasadena.

Barely five feet tall with wavy brown hair and dark-rimmed glasses, Heather looks like a schoolgirl in a class photograph. But the innocence stops there. Homeless since age 12, she has spent almost half her life hooked on heroin and cocaine.

Like many addicts on waiting lists, Heather almost didn’t make it into treatment. The day before her admission date, she was arrested for theft. Instead of sending her to prison, the judge gave her 30 days in jail and the chance to enter Impact House, where she completed a six-month course of treatment.

“The wait was horrible,” says Heather, who used to live in a battered Toyota Tercel. “My whole life had become heroin. I wanted to feel different from what I was feeling.”

The same was true for Richard, 28. He waited almost two months before getting into Pacifica House, a residential treatment center in Hawthorne, in September. About a week before a slot opened for him, Richard stopped taking his medication for depression and ended up in Glendale Memorial Hospital after becoming suicidal.

“I doubted I would stay alive long enough to get into a program,” he says. “You make this big decision in your life to get help, then it just isn’t available.”

In recent years, numerous researchers have concluded that substance abuse treatment is one of the most powerful--and cost-effective--weapons in the nation’s war on drugs.

A 1994 Rand Corp. study, for example, found that drug rehabilitation is far more efficient in reducing cocaine consumption than anything law enforcement has thrown at the problem. Other researchers, meanwhile, have reported that after addicts undergo treatment, violent behavior drops dramatically, along with arrests.

The California Department of Alcohol and Drug Programs concluded in 1994 that for every $1 invested in treatment services, taxpayers saved $7 in law enforcement, welfare, public health and crime costs. The same conclusions have been reached in other states.

Yet despite such promising findings, government spending for rehabilitation amounts to a fraction of the $290 billion spent since 1980 on drug enforcement by local, state and federal agencies.

“Drug treatment has been and still remains a very hard sell,” said David Mactas, director of the federal Center for Substance Abuse Treatment, which administers grants to state rehabilitation programs. “Addicts are a highly stigmatized population. People would rather lock them up than give them a chance for recovery.”

Indeed, a recent Gallup poll found that a majority of Americans think treatment is less effective than education, traditional law enforcement efforts and the interception of foreign narcotics shipments.

San Francisco County stands alone in California as the only place that seems willing to challenge convention and gamble millions of dollars on expanding drug treatment. In an unprecedented move, officials there plan to raise enough money to provide treatment on demand for indigent addicts. The goal: Reduce the average wait from three months to 48 hours.

“We are not just talking the talk, but trying to allocate funding to solve the problem,” said Larry Meredith, director of Community Substance Abuse Services in San Francisco. “You just can’t have a front door that empties onto a vacant lot.”

For Some, a Way Out

For more than 20 years, Josie Gann was a heroin and cocaine addict. Today, at 43, she is living proof that, in her words, “treatment works.”

Gann started smoking pot and sniffing glue at age 12. She hit bottom three years ago in Anaheim. Unable to stay awake at work because of her nightly drug binges, she lost her job as a stock clerk for a computer company and moved into a cheap motel room in the shadow of Disneyland.

To make ends meet, Gann sold heroin and shoplifted until she was arrested in 1993 for commercial burglary. Because of her lengthy police record, she faced a minimum prison term of 18 months. Instead, an Orange County judge ordered her into Prototypes, a residential treatment program for women in Pomona.

“At first I didn’t want to go,” Gann says, “but then I saw people there with shiny hair, clean clothes and a twinkle in their eyes. I wanted that.”

Her path to sobriety included a strict routine of work and counseling designed to develop self-confidence, job skills and solutions to some of the personal problems that contributed to her addiction.

“Until I got there, I did not know how to live a day without doing drugs,” Gann says. “Treatment teaches you a new way of life. It’s about responsibility and accountability. By learning to discipline yourself, you can do things you never thought you could do before.”

Like holding down a job.

After working in the Prototypes kitchen under the tutelage of a chef, Gann became so adept at baking cakes and pastries that she developed a catering business on the side. Sober for three years, she now works as a drug and alcohol counselor in Dana Point and picks up a few extra dollars baking cakes for friends.

“I’m doing . . . better than ever,” she says. “I know now that I don’t have to live like I used to.”

Because treatment slots are limited, many of those who enter programs do so only after hurdling obstacles designed to deter the least disciplined. Many centers winnow out applicants, about a quarter of whom are alcoholics, by requiring them to call in regularly and attend weekly meetings--or lose their place in line.

For those in the late stages of addiction who may be homeless or in trouble with the law, the process is like climbing Mt. Everest. When someone’s life is a mess, it’s easy to miss a call. And the longer the wait, the more ambivalent people get about treatment.

“Many addicts have second thoughts as the process drags on,” says William Edelman, the director of drug and alcohol services for Orange County. “If they show some interest, we should be able to get them into treatment right away. It would save taxpayers money in the long run, and families a lot of misery.”

Unstable Funding

It is difficult to say how much money is needed to close the “treatment gap.” An exhaustive study published in 1990 by the National Academy of Sciences’ Institute of Medicine recommended that the federal contribution to rehabilitation services be increased by up to $3 billion a year to be effective.

That kind of money has been hard to come by. Part of the problem is that federal funding, which provides most of the money for drug treatment, has fluctuated with the philosophies of those in power.

The Reagan administration, which emphasized a get-tough approach to drugs, pared millions of dollars from rehab budgets during the 1980s. The Bush administration reversed Reagan’s policies and more than doubled spending for treatment.

President Clinton raised funding for drug rehabilitation by almost $100 million in 1994, but Congress erased those gains in 1995 with a $250-million cut. Last year, the funds were restored with a slight increase, and Clinton has asked Congress for an additional $194 million for treatment next year.

While directors of county drug programs welcome the additional funding, they complain that it has not kept pace with inflation or the rising costs of care because of increasing professionalization of the field and a client population that is harder to treat.

Today, treatment centers are dealing with more pregnant addicts, addicts with small children, and drug abusers who are mentally ill. More clients are infected with the AIDS virus or other communicable diseases such as hepatitis and tuberculosis.

“Annual increases of $500,000 or a million dollars a year for a county program are really pointless,” said Robert Garner, director of drug and alcohol services for Santa Clara County. “We should either double the investment in drug treatment or stop talking about it.”

The budget for the California Department of Alcohol and Drug Programs, which disburses state and federal dollars to the counties, rose from $312 million in 1991 to $354 million in 1996. In Los Angeles County, funding has remained relatively unchanged, rising from $68 million in 1991 to $69 million in 1996.

Most of the government money that flows to treatment centers pays for detoxification, methadone maintenance for heroin addicts, outpatient counseling, hospital-based programs and residence for up to a year in drug-free settings known as “therapeutic communities.”

At the heart of the treatment is the 12-step method developed by Alcoholics Anonymous in the late 1930s. The approach helps substance abusers confront their problems and change their lifestyles under the guidance of former addicts.

Honesty, discipline, accountability, instilling a desire to help others and a reliance on a spiritual force to overcome addiction are all hallmarks of the 12-step philosophy.

“At first it’s difficult,” says Gerald Boyd, 26, a methamphetamine addict who is now in Pacifica House. “They get on you for every little house rule you break. . . . Then you realize everything you do has consequences, that you should do the right thing, no matter how little the task. What you learn is self-control and discipline.”

Boyd was fortunate. Determined to clean up his life, he got into Pacifica in less than a month largely by attending every orientation meeting and calling the center more often than required.

Although Boyd’s wait was relatively short, he says, it was long enough to give him pause about pressing ahead with treatment, especially since he had the possibility of getting a job at around the same time.

“I had a drug problem I couldn’t control and my life was totally unmanageable,” he says. “Yet here I was having second thoughts that things would turn out better. Had I not kept calling I don’t know what would have happened.”

In California, as many as 8,000 addicts and alcoholics are on waiting lists for a chance at one of the 54,500 publicly funded treatment slots--nearly half of which are in Los Angeles County.

Researchers say that those people represent a fraction of those who want treatment but have been scared off by the wait or have dropped off the lists for a variety of reasons. Studies conducted by UCLA’s Drug Abuse Research Center have found that the demand for government-funded treatment in Los Angeles County might be three to four times the 21,000 available slots.

The waits are particularly long for mentally ill drug abusers, who require the most intensive kind of care. The same is true for juvenile addicts.

Further hindering the delivery of drug treatment in California, a federal judge ruled in 1994 that some counties were illegally denying Medi-Cal benefits to addicts in methadone maintenance programs. Medi-Cal is California’s health insurance plan for the poor.

The decision prompted the state to shift tens of millions of dollars away from some county drug programs to extend Medi-Cal services not only to more methadone users, but also to pregnant addicts, addicts with infants, and those infected with the AIDS virus.

Directors of county drug and alcohol services say the shift “robbed Peter to pay Paul” as money was taken out of services for indigent addicts who could not qualify for Medi-Cal.

They contend that the state could have avoided the fiscal calamity by seeking more money for treatment and restricting the use of Medi-Cal to methadone users, the only group to which the court ruling applied.

Andrew M. Mecca, the director of the California Department of Alcohol and Drug Programs, said state budget deficits at the time precluded getting more money to compensate for the impact of the court decision. Shifting resources to the Medi-Cal program, he said, enabled the state to get matching federal funds, which increased the pool of money available for rehab services.

“Historically, treatment has been grossly underfunded,” Mecca said. “But California has provided the most demonstrative leadership in the field. There is no government or state that has come close to our level of investment.”

Answers Remain Elusive

While support for rehabilitation has been on the rise, some researchers warn that treatment is no cure-all.

In 1993, for example, the federal Treatment Outcome Prospectives Study showed that for every 10 cocaine addicts admitted to treatment, eight relapsed into heavy use within three to five years after their rehab.

In addition, critics say that there has never been a study comparing treated and untreated addicts to determine whether rehabilitation programs really make a difference.

Amid such questions, some drug policy analysts doubt that major infusions of government dollars could significantly reduce addiction. They point to federal statistics showing that past increases in drug-treatment funding did not lead to significantly more admissions to rehabilitation programs and did not curb drug use among heavy abusers.

“Some very fine drug treatment programs have proven their usefulness, but the government treatment bureaucracy is manifestly ineffective,” said John P. Walters, a high-ranking drug policy official during the Bush administration.

Rehabilitation advocates counter that most of the increase in federal funding has had to pay not for new treatment slots but for improving the quality of patient care, which suffered from the deep cuts of the Reagan years.

“I think there are very few examples of greater efficiency or better investment of federal dollars,” said Mactas of the Center for Substance Abuse Treatment. “Look at the California study. For every $1 invested, you save $7. You don’t get that kind of return on Wall Street.”

Even so, questions have been raised about whether the payoff could be bigger if financial oversight and controls of treatment programs were strengthened.

Consider the experience of Santa Clara County, where up to 4,000 indigent substance abusers are treated each year.

In November, officials there began scrutinizing the county’s drug treatment programs. Since then, they have discovered people receiving unneeded care or participating in expensive programs when cheaper alternatives were more appropriate. In the future, the county hopes to award contracts to treatment providers based on their success rates and prices.

Advocates of government-funded treatment acknowledge that, given the fiscal pressures on government, rehabilitation expenses must be kept down. But they worry that too much attention to the bottom line could leave patients shortchanged.

Already, they say, some county programs have begun reducing treatment times whenever possible, even though research shows that the longer people stay in counseling the better they do.

Cost-saving efforts also could prove especially self-defeating for hard-core addicts in need of full-time residential care who are being forced into cheaper out-patient facilities.

“Indigent clients are not the same as private-pay or insured clients. They are harder to deal with and more expensive to treat,” said Ellen M. Weber, a policy analyst for the Legal Action Center, a nonprofit agency in Washington, D.C., that specializes in drug treatment issues.

Many veterans of the substance-abuse field say one way to reduce costs without jeopardizing patients is to make a fundamental change in the treatment system. They contend that rehabilitation has turned into an industry at the expense of cheaper approaches. Today, the government is reluctant to provide funds to treatment programs unless they are accredited and have credentialed staffers.

“The white coats, the degrees and accreditation are really just frosting on the cake,” said Al Wright, an attorney and former director of alcohol programs for Los Angeles County.

Wright contends that treatment dollars could go much further by relying more extensively on smaller “social model” facilities.

These programs use recovering addicts and alcoholics as counselors, who may or may not have professional degrees. No trained psychologists or medical personnel are on staff.

For six months or longer, 20 or so clients live in a drug- and alcohol-free home. The social-model programs work closely with existing schools and social services in their communities to provide education, medical care, psychological counseling and job training for participants.

Public health researchers at UC Berkeley say this approach has grown increasingly out of favor because state and federal actions have professionalized substance abuse treatment.

Many drug treatment experts say that while they admire social model programs, they typically do not have the accreditation and the administrative staffs that are required to qualify for state and federal dollars.

“You must become a bona fide health care service to get government money today,” says Dr. Richard Rawson, who runs the Matrix Institute, a drug rehab center in West Los Angeles.

On the Streets, Battle Continues

Unless the philosophical debate is resolved soon or substantially more money gets pumped into the system, Gilbert Saldate’s work on skid row will remain what it has always been--a lesson in frustration.

Saldate, 36, knows what treatment can do. Seven years ago, he inventoried his life and all he saw were arrests, jail sentences, overdoses and the crimes he committed as a member of Frogtown, a street gang in northeast Los Angeles. He entered House of Stephanas, a church-based rehab program in Montebello, and stayed four months. He has been clean ever since.

“I talk to people all the time on the row,” Saldate says. “They get interested in treatment. Then you tell them there is a wait, that it could cost them $200 to get into detox and they start to walk. You can see the hopelessness in their faces.”