Stanton reviews and critiques Michael Massing's popular fantasy, The Fix, along with the parallel work of drug policy maven Mark Kleiman. Both authors believe that, if we would only divert from (or add to) massive sums being spent on interdiction, policing, and punishment so as to vastly increase our spending on drug abuse treatment, we could lick our substance use problems. Stanton shows that this tempting but wrongheaded idea leads nowhere.
Prepublication version of article appearing in the International Journal of Drug Policy, 10:9-16, 1999.
© Copyright 1999 Stanton Peele. All rights reserved.
The Fix Is In
A Commentary on "The Fix" (Massing, 1998) and "An Informed Approach to Substance Abuse" (Kleiman, 1998)
Stanton Peele
Fellow, The Lindesmith Center
New York City
Other than current and former drug czars, it is hard to find someone to praise American drug policy. While pointing to the overall decline in illicit drug use in the U.S. since 1980, those inclined to defend this policy must also acknowledge constant levels of addiction and intensive usage, periodic rises in adolescent drug use, the readily available and inexpensive illegal supplies of cocaine, heroin, and marijuana, historically high prison populations, continued drug-related social problems (most notably AIDS and hepatitis), along with the tremendous economic, social, and emotional costs of an ever-escalating war on drugs.
At one point, the focus of critics of drug policy was legalization—primarily of marijuana—and was associated mainly with community researchers who studied drug users in the field and who were joined by a vocal group of drug enthusiasts. Although some preliminary steps were taken in this direction at the state level and by national commissions (notably one under Jimmy Carter) in the 1970s, this stance was largely polemic and quixotic, and has continued to be so in the U.S. At the same time, there has always been a category of public health critics (which is not well-recognized by the authors discussed in this article) who decried the lack of focus on treatment of addiction (current treatment advocates should familiarize themselves with the history of the U.S. Public Health Hospital at Lexington and the career of Lawrence Kolb; see Kolb, 1962.)
However, beginning in the late 1980s, drug policy reformers started to find legitimate national voices in Europe and, to a lesser extent, in the United States. This loosely organized group of policy critics began to focus on decriminilization of all drugs or just "soft" drugs such as marijuana, as was tried in several states in the U.S. in the 1970s. Typically, decriminalization means not permitting legal sales of drugs, but dealing with users by other than criminal sanctions. As we approach the 21st century, this position has taken a number of new directions. In the U.S. widespread support for medical use of marijuana has been expressed in electoral initiatives. The term "harm reduction" is now commonly used to describe policies that recognize and accept the continued use of drugs by many people and to prevent harms from this use, particularly the spread of AIDS. Needle exchange programs, as well as reducing HIV infection, keep addicts healthier in general and offer them positive connections to society.
In much of Europe and the English-speaking world, harm reduction has been adopted by many elected officials, and it has been made national policy in a number of these countries. This means that, unlike the U.S., these nations endorse and fund the provision of clean needles for injecting drug users, as well as experimenting with innovative approaches such as the de facto decriminalization of the sale of marijuana in the Netherlands and provision of heroin for addicts in clinical or controlled settings, a practice begun in Switzerland and which is being considered or tried in countries such as Germany, the Netherlands, and Australia. Harm reduction has thus had a liberating impact by suggesting an entirely different relationship to drugs. It means recognizing that drug use will be a continuing feature of civilized life and that reasonable provisions must be made for the range of people who use drugs—from young people who primarily experiment with drugs, to a small group of people who continue to use drugs either occasionally or regularly in adulthood, and finally to a still smaller group of people whose drug use is problematic in ways beyond the danger of running afoul of the law.
The United States as a society has not been able to make this leap to a new conception of drug use in relation to society. It is the only western nation that refuses to support needle exchange programs (in most communities and states it is actually illegal). The reason for opposing such programs (which are nearly universally endorsed by American public health and AIDS organizations) is that "they send the wrong message about drugs"—that is, they recognize and accept continuing drug use. But the opposing position, that drug use is bad and must be eliminated, is one that does not lead to a viable public policy.
The U.S. is thus the most polarized western nation about drugs. Moderate politicians elsewhere can openly consider a heroin maintenance program, for instance. In the U.S., socially liberal Republicans (like New Jersey Governor Christine Whitman) and Democrats (President Bill Clinton) feel they must reject their own commissions' or cabinet members' support of needle exchange, and virtually no Congressperson (except perhaps one or two from the very most liberal sections of the country) and virtually no United States Senator or state governor can come out for liberalized drug policies (one recent exception has been the governor of Hawaii). These politicians reckon they cannot be seen to accept drug use in any form. Perhaps they are wrong, or will become wrong. However, more likely their reticence is appropriate, given the anti-drug bias and campaigning in the U.S.
There is thus a large opening available in the U.S. for a middle ground in drug policy. For many, this middle ground comprises the view that it is counterproductive to spend drug war funds on eradicating drug crops in the U.S. and overseas and interdicting drug supply lines in combination with heavy police efforts and the imprisonment of drug users. Instead, this position maintains, the bulk of our effort should be spent on prevention of drug use, drug treatment, and research to discover the sources of the impulse to use drugs—the so-called demand-reduction rather than supply-reduction approach.
Several groups and individuals claim the middle ground between the punitive approach and that of decriminalization per se—notably the College on the Problems of Drug Dependency, a group of drug abuse researchers, and the Physician Leadership on National Drug Policy. But this middle position actually shares a primary assumption with current policy—it regards drug use in exclusively negative terms as something wrong and harmful that must be avoided, treated away, and medically cured (Peele, 1996). This position appeals to an influential, largely federally-funded scientific lobby and to medical groups which feel that illicit drug use leads to medical harm and has no benefits.
A middle-of-the-road drug policy also appeals to the moderate but moralist tradition in American policy which justifies itself by pointing to "extremists" on either side. This centrist tendency has worked well to preserve political stability in the U.S., but is not necessarily the best avenue for solving complex social problems. Two thinkers who have nonetheless garnered praise for their claims to bypass the polarization of "drug warriors" and "legalizers" are Mark Kleiman, a professor of policy studies at U.C.L.A., and journalist Michael Massing, former editor of the Columbia Journalism Review. Kleiman, who has achieved currency among policy analysts inside the government and out, and who previously wrote Against Excess: Drug Policy for Results (Kleiman, 1992), expressed his views in a recent article in the journal Issues in Science and Technology (Kleiman, 1998). Michael Massing (1998c) has written The Fix, a book that has received wide attention.
Both men obviously delight in being able to point out extremists on either side of them. Both clearly recognize that current American drug policy is wrongheaded, and the clearest sign of this for them is that the majority of funds earmarked for drugs are for policing and interdiction, rather than for prevention and treatment. Both have at the center of their reform goals the reprioritizing of this spending. Of the two, Kleiman is by far the better informed and more sophisticated about drugs and drug users. But the two men both display the strong and weak points of the "treatment uber alles" position.
To begin with, both men recognize the distinction between drug abuse and addiction, on the one hand, and casual or experimental use (although they do not explicitly come to grips with regular, controlled use). Kleiman correctly rejects the causal importance of the gateway hypothesis, since the overwhelming majority of marijuana users do not go on to use other drugs. Instead, he emphasizes compulsive marijuana use per se, although he clearly indicates that it occurs with only a small minority of pot smokers. Massing, who has little time for epidemiological data and concepts, embodies his analysis in journalistic vignettes. For Massing, parent anti-drug groups like the National Federation of Drug-Free Youth and benighted drug policy figures like Carlton Turner, Ronald Reagan's White House drug advisor, eradicated the distinction between serious and casual drug use and simultaneously misdirected American attention away from drug treatment.
Massing's story-telling approach makes for appealing reading. His ideas have gotten broad exposure in the major liberal intellectual outlets—his book and views were virtually ubiquitous in prominent periodicals in the latter part of 1998, at least in New York City. The Fix was reviewed in the December 17 New York Review of Books (Gladwell, 1998), featured along with—but far more prominently than—Mike Gray's (1998) outspokenly anti-drug-prohibition book, Drug Crazy. Massing himself authored articles in the New York Times Sunday Magazine in September (Massing, 1998d) and the November/December issue of the Columbia Journalism Review (Massing, 1998b). That one cannot look at a major publication addressing thoughtful people without encountering Massing's work is an indication of the extent to which current American drug policy is being questioned (as well as of Massing's connections).
Massing critiques American drug policy while holding out the promise we need only modify our approach in a clear but modest way, one that does not require a fundamental reorientation towards drugs and drug use: the title of his New York Times Sunday Magazine article is, "Winning the drug war isn't so hard after all." Massing's secret solution is current drug treatment programs, only more of them. Massing lauds in The Fix grass roots inner-city treatment centers like those he encountered in Harlem and elsewhere. His Columbia Journalism Review article features a picture of a blindfolded man in the center of a group. The caption reads, "a 'trust exercise' at Walden House, a drug treatment center in San Francisco."
Kleiman's and Massing's rejection of the need to reform legal penalties for drug use is puzzling. For, after all, their recognition that most drug use is non-harmful seemingly suggests that drugs should be decriminalized. Kleiman rejects this position, maintaining that, if drugs were legalized, many more people would abuse them. Massing's response involves even more of a non sequitur. When his argument draws him towards legalization, he instead leapfrogs to the horror of lives which are dominated by drug use. Thus Massing alternates policy discussions with the case of Yvonne Hamilton, an inner-city African American cocaine addict.
Massing's reliance on Ms. Hamilton's story as evidence about drug policy epitomizes the problem with a journalistic approach to drug issues. The question is not whether some people suffer from drug use—the issue is whether we can reduce the frequency and severity of drug problems through changing our approach to them. While Kleiman and Massing indicate there will be more addicts like Yvonne Hamilton if drugs were legalized, her case does not support this view. To start with, Ms. Hamilton is an example of a person who became a drug addict under current, prohibitionist policies towards drugs. Moreover, the very first drugs she sampled and abused were tranquilizers prescribed for her mother. Ms. Hamilton developed a drinking problem—examples of which are many times as common as drug addiction, even in the inner city—before she became a cocaine addict. Her case suggests that illicit drug abusers come from a group of people who could just as easily abuse licit drugs and alcohol.
Nor does Ms. Hamilton prove that expanding the availability of drug treatment will work to rescue many more urban African Americans and others who abuse drugs. Rather, Ms. Hamilton's difficult trip through treatment is really an illustration of how people's drug use is not so much amenable to treatment as it is a response to larger issues in their lives. Ms. Hamilton followed the typical serendipitous course through addiction and recovery, a pathway that seems most indebted to gradual but large changes in internal and external experience than to specific treatment episodes. As Massing (1998a) notes, "Most addicts require two, three, or more exposures to treatment before the process takes hold." Treatment was not a realistic issue for the young Yvonne who used drugs and drank for thrills and psychological relief.
It is hard to escape the conclusion that Kleiman and Massing ignore legal remedies for our current drug policy mess because they wish to avoid offending their audiences rather than due to their straightforward evaluation of the current drug scene. They support an anti-drug stance because it is essential for legitimacy in popular, scientific, and political circles in the U.S. Neither Massing nor Kleiman seems to feel free to explore the experiences of the vast majority of drug users, who enjoy and successfully integrate drug use into their lives. Likewise, both are completely tone deaf to fundamental constitutional or personal-freedom concerns about why the state is so concerned about even non-harmful drug use that police, employers, and schools routinely intrude into people's most private functions and places.
While avoiding direct policy recommendations that would affect these users, they instead deride decriminalizers as closet legalizers. Yet, they surely don't believe that casual drug users should be jailed. Thus, the cost of soft peddling their finding that limited or controlled drug use—even among those who use crack and heroin—is the norm is that Massing and Kleiman ignore a large group of otherwise normal and happy American drug users who are currently criminalized. If this group is not addressed, how then are we really reorienting American drug policy?
The authors' shortchanging of moderate drug use is apparent in their concentration on the value of treatment (since controlled users do not seem to require treatment). Both writers emphasize the need to shift attention to treating hard core users or addicts. Both promise that more treatment will reduce drug use, drug crime, health costs, and the range of other drug-related maladies, as some recent research shows (Rydell and Everingham, 1994; SAMHSA, 1998). Both endorse the expansion of methadone maintenance programs, along with other treatments. Massing reports that it was only during a brief period under Richard Nixon that treatment was available to America's drug addicts "on demand," as it should be today.
This suggests that there are many addicts around the country clamoring for treatment who cannot find it. But the truth is that, to the contrary, most people undergoing substance abuse treatment in the U.S. had to be forced into it. I currently work as a pool attorney for the public defender in Morris County, New Jersey, where my indigent clients are invariably substance abusers. The State forces them to enter treatment as a way of minimizing criminal penalties or as a condition for regaining custody of their children. Treatment is in county- or state-supported or charitable programs or is paid for by Medicaid, and my clients parade through inpatient and outpatient programs not only in my county, but around New Jersey and even in other states. Meanwhile, they all have been in treatment previously.
Since our current drug treatment slots are already filled with unwilling (or at least involuntary) participants, opening many more treatment centers like the ones we have now will not affect drug use and addiction rates. Rather, to fill these treatment slots, coercion will have to become more systematic and pervasive. Kleiman's primary recommendations are that many more people be forced into treatment by the criminal justice system. He touts compulsory treatment of prisoners, probationers, and parolees monitored by drug testing, along with drug courts and other means for sentencing people to treatment. Although Kleiman endorses "coerced abstinence" plans, he points out that much benefit occurs from reduced drug use other than abstinence—an insight that expresses the harm-reduction viewpoint. Kleiman is also enamored of the idea that biological research can remedy people's urges to take drugs (cf. Goldstein, 1993), a view that completely dominates the agenda of the National Institute on Drug Abuse (NIDA).
Massing, with his journalistic cult of personality, harkens to a brief halcyon period he virtually alone has detected under Richard Nixon, when he claims pharmacologist Jerome Jaffe reoriented drug policy towards treatment of addicts. Most people will not recall Nixon's war on drugs as being so enlightened, particularly as it is described by Edward Jay Epstein (1977) in Agency of Fear, or in that administration's efforts to eradicate marijuana supplies which, while reducing middle-class marijuana use, ushered in a new period of narcotics use in inner cities. One classic of the drug policy literature is Gooberman's (1974) comprehensive investigation of the impact on New York City of Nixon's Operation Intercept. Although marijuana for a time did become more scarce and expensive due to government efforts to block importation of the drug from Mexico, Gooberman found that only casual users tended to desist drug use as a result. Those immersed in the drug culture continued to find supplies of marijuana, while other heavy users with fewer resources switched to hashish, amphetamines, barbiturates, and LSD, as well as (particularly for ghetto youths) heroin and cocaine.
This is not to belittle Jaffe's insights and accomplishments, or to say that he would not be a greatly preferable figure to head U.S. drug policy over General Barry McCaffrey. But he was far from the dominant force in Nixon's drug policy. Jaffe's greatest contribution to our knowledge of drug use was rather the seminal role he played in the study of Vietnam veteran heroin addicts under Nixon. Jaffe announced in the pop psychology magazine, Psychology Today, that a defense department task force had found that most returning veterans overcame heroin addiction when they returned home (Jaffe and Harris, 1974). The remarkable insights provided by the classic study (Robins et al., 1980) of these veterans included that their remission rate was not improved by receiving treatment and that remission persisted for the large majority of even those former addicts who used narcotics stateside.
Massing thus misses the key insight produced by Jaffe's stint under Nixon: treatment is secondary in comparison with the impact of a facilitative environment in accounting for drug users who resist or escape drug addiction. Massing instead highlights what he claims to be the immediate reduction in crime statistics that resulted in major cities due to Jaffe's treatment initiatives. Only a very, very optimistic—one might say "naive"—individual can believe that treating drug addicts leads to a large and appreciable decline in crime in a given city. Indeed, if one argues reflexively that whatever policy precedes a reduction in crime statistics is successful, one is forced to concede that Mayor Rudolph Giuliani and other drug warriors are on the right track, since the major categories of crime have dropped substantially in American cities since 1991 (which Massing is certainly reluctant to do—see Massing, 1998a).
It is a reductive fallacy—akin to describing individual drug use or addiction as a biochemical function—to believe that treating individual drug abusers will result in large-scale policy benefits. Not enough users are addicted, not enough addicts can be reached to be treated, not enough reliably improve as a result of treatment, not enough can maintain non-drug-addicted lives following treatment, not enough new addicts can be prevented from surfacing to make a dent in our overall national drug problem. At points, both Kleiman and Massing recognize this. According to Kleiman, "Even if money were no obstacle, getting hard-core drug users into treatment and keeping them there would be a major problem."
For his part, Massing (1998d) notes that "drugs not only impart intense pleasure but also provide great comfort to people coping with various crises in their lives." But these are the individuals whose drug use both he and Kleiman want to correct. Massing recognizes that addiction is a function of poverty and deprivation, and that until poor schooling, employment opportunities, housing, community support of parenting, and the like are addressed, there is little chance of changing the inner-city environments that provide the most fertile soil for substance abuse of all sorts. Indeed, if he put two and two together, he would see that overselling treatment, like overselling criminal penalties, is simply another way to avoid contemplation of urban minority depredations that are the single largest failure of American society.
The programs that most often show the kind of benefits that Kleiman and Massing cite do not really represent the treatment available to these inner-city addicts, nor will such programs be the primary beneficiaries of new investment in treatment. The typical program instead is one staffed by undertrained personnel, that relies on religious 12-step bromides and group sessions in which expressions of contrition are the main aim, and that does not provide the broad range of supports needed to assist people out of addicted lifestyles. The "trust exercise" pictured in Massing's (1998b) Columbia Journalism Review article is not going to cure inner-city heroin addicts.
Massing incorrectly attributes problems like these to insufficient funding. Just as he opportunistically uses crime statistics to support the policies he dreams will succeed at remedying America's drug woes, Massing fails to appreciate the financial implications of his analysis. For while, as he notes, "only" $5.4 billion of the current $16 billion dollar federal drug budget goes for demand reduction, this figure can be compared with the $420 million total drug budget in 1973, the halcyon year when Jaffe's treatment approach supposedly reigned supreme under Nixon. In other words, all the drug problems Massing depicts with alarm have grown as the treatment budget has increased steadily, not to say exponentially.
Kleiman includes state and local government drug war expenditures along with federal ones, which he adds up to be $40 billion. This, in turn, means we are currently spending about $13 billion in government money on demand reduction. At the same time, Kleiman places "the total number of hard drug addicts at any one time at fewer than 4 million." Thus, government expenditures for demand reduction in the U.S. currently total more than $3,000 annually per addict. What, in Kleiman's and Massing's view, would be the ideal rate of expenditure to get each drug addict to stop using drugs—$5,000, $10,000, $25,000, or more? But the current $3,000 figure is already a substantial underestimate, since it ignores large private-sector expenditures on drug treatment through EAPs, facilities like Hazelden, the Betty Ford Center, and chains of "chemical dependence" hospitals around the country, among which there have been recurrent scandals concerning over-diagnosis, -utilization, -treatment, and -charging.
Is America's major problem in fighting the drug war really that we have been chary with our expenditures on drug treatment, as Kleiman and Massing and other liberal reformers assert? Or has American society already over-relied on drug treatment as a kind of all-purpose totem consistent with its belief that all social problems can be successfully treated as medical problems? We might consider the title of Massing's book in this regard. What is "the fix" meant to indicate (Massing supplies no subtitle)? Apparently, it is a play on words, meaning both the drug the addict is driven to pursue, and the elusive solution the U.S. pursues for its drug problems. But the treatment "fix" is just as imaginary a magic bullet as are the other illusions that drive both addictive drug use and drug policy.
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