Los Angeles Times, Wednesday, March 14, 1990
Cures depend on attitudes, not programs
About one-third of the $10 billion-plus that President Bush has requested for waging war on drugs is targeted to pay for treatment and prevention programs. That's double what it was as recently as two years ago.
The national debate over how much more to spend on drug-abuse treatment involves private as well as public funds. The fastest-growing sector of private-hospital care in the United States is for "chemical dependency" (including alcohol). If Bush's request is approved by Congress, about $10 billion will be spent for the public and private treatment of alcoholism and drug abuse this year, roughly a tenfold increase from the mid-1970s.
Between 1982 and 1987, the National Institute on Drug Abuse reports the number of drug-treatment centers jumped from 3,000 to nearly 5,500, an 80% increase. The proliferation of private centers that treat alcoholism has been meteoric since the mid-'70s. Between 1978 and 1984, the number of such centers more than quadrupled (from fewer than 900 to more than 4,000); private hospital beds occupied by alcoholics quintupled. Most of these facilities now offer treatment for drug abuse. Virtually all substance-abuse treatment in the United States is rooted in the assumption that drug addiction and alcoholism are diseases. Yet treatment largely embraces the "spiritual" 12-step Alcoholics Anonymous program. Its primary technique is the group-confrontation session in which addicts are prodded to acknowledge the error of their ways. Nearly all this mea culpa treatment is supervised by former addicts or alcoholics.
Research designed to assess these programs' effectiveness in controlling alcoholism and drug addiction has not been reassuring. Psychiatrist George Vaillant, after an eight-year study at Cambridge Hospital in Massachusetts, reported that treated alcoholics achieved remission no more often than those who received no treatment whatsoever. A study by Dr. John Helzer and his colleagues at Washington University found that only 7% of patients treated in an inner-city hospital alcoholism ward were still alive and sober when assessed five to seven years later.
The performance of publicly funded drug-treatment programs is no better. (Private programs seldom permit outside evaluation.) In 1982, for example, Joseph A. Califano Jr., former secretary of Health and Human Services, evaluated New York state's drug-abuse programs. Of those treated for heroin addiction, less that 10% broke the habit. Today, government officials report that the success rate in treating inner-city crack addicts is no better.
Although private treatment centers often report better results than those in public hospital wards, research consistently demonstrates that hospital treatment of any kind does not produce superior results to outpatient counseling programs for alcoholism and drug abuse. That hospital treatment for alcoholism and drug abuse is not cost-effective has been obscured in the United States by a powerful treatment industry, by the American Medical Assn. and the American Hospital Assn. and by organizations such as the National Council on Alcoholism and Drug Dependence. They argue that since alcoholism and drug addiction are diseases, they should be treated in medical settings.
One of the best-kept secrets in the addiction field is that people often quit drugs or alcohol without entering treatment or support groups like AA. The treatment industry repeatedly and erroneously claims that no such self-curers exist.
These self-curers are not a highly visible group. While we regularly see testimonials on television for one treatment program or another, we never hear from those who fail treatment or who solve their own problems. Yet researchers like Vaillant have found in untreated populations that most alcohol- and drug-dependent individuals evolve out of their addictions. Vaillant also found that of those who either quit or cut back drinking, 75% did so without benefit of treatment or AA. An even larger percentage (90%) of the 45 million Americans who have quit smoking have done so without any assistance despite the potency of nicotine addiction. Indeed, in several surveys, alcoholics and drug addicts have reported that they found it harder to quit cigarettes than alcohol or crack.
Whether people succeed through treatment or on their own, they generally do so for similar reasons. Research has shown that certain characteristics of the patient, not the treatment, are crucial to the outcome of alcoholism and addiction treatment. Patients with stable family and work lives succeed far more often (this is why private treatment centers can claim better remission rates than public hospitals). "The best predictor of success is whether the addict has a job," says Dr. Charles Schuster director of the National Institute on Drug Abuse. Dr. Herbert Kleber, the official in charge of demand reduction in the Bush Administration's war on drugs, indicates that successful treatment for inner-city crack addicts, who lack social and economic resources, entails "habilitation more than rehabilitation."
Perhaps the most successful method for treating inner-city drug addicts is a non-medical residential program. Therapeutic communities, as these programs are known, teach addicts basic functional skills like personal hygiene and punctuality and usually include some job training. The key to this type of program's success is that addicts voluntarily surrender total control over their lives for up to two years. Since few people are willing to sacrifice this much freedom, drop-out rates in these programs are high. Long-term residential treatment and training is also extremely expensive, limiting the number of addicts who can be maintained in such programs.
But there is a more fundamental question that the therapeutic-community concept raises. If the ability to function free of drugs depends on job training, social skills and pro-social attitudes, why do so many Americans fail to acquire these in the first place? For every person who can possibly be cured in therapy, many more young addicts are appearing in cities. What the therapeutic-community process actually argues for is not more or better therapy, but programs to strengthen families, communities, education and job training.
Advocates of legalization invariably call for shifting resources from enforcement and interdiction to traditional methods of treatment. But relying on treatments that are, at best, only modestly effective is no way to head off potential problems resulting from legally available drugs.
Addiction is a way of coping with life, of artificially attaining feelings and rewards people feel they cannot achieve in any other way. As such, it is no more a treatable medical problem than is unemployment, lack of coping skills, or degraded communities and despairing lives. The only remedy for addiction is for more people to have the resources, values and environments necessary for living productive lives. More treatment will not win our badly misguided war on drugs. It will only distract our attention from the real issues of addiction.