A Battle Plan for the Drug War

The Wall Street Journal, October 12, 1998

By Sally Satel

New York Mayor Rudolph Giuliani hopes to eliminate methadone treatment in city-run clinics, saying it simply replaces one addiction with another. Meanwhile, the nation’s drug czar, Gen. Barry R. McCaffrey, praises methadone as one of the best ways of helping hard-core heroin addicts; he wants to expand its availability. The methadone battles have begun. Again.

The history of this and other skirmishes in the war on drugs is recounted in “The Fix” (Simon & Schuster, 335 pages, $25), Michael Massing’s tour of the modern era of domestic drug policy. He starts with the 1960s heroin epidemic, takes us through the creation of a national treatment network under Nixon, harsh drug laws in New York state under Rockefeller, softness on marijuana under Carter, “Just Say No” and the crack explosion under Reagan, and ends with the bounce in adolescent use under Clinton. Well-written and lively, “The Fix” features an amazingly long subtitle that says it all: “Under the Nixon Administration, America Had an Effective Drug Policy. We Should Restore It.”

That policy was a drug treatment system for hard-core addicts, a network of methadone clinics, and other drug treatment facilities featuring detox centers, outpatient clinics, counseling and residential supervision — all connected by an efficient referral system. Key to the project’s success, Mr. Massing says, was the steadfast commitment of Nixon aides to clinical principles over politics. The threat of thousands of soldiers returning from duty with habits they acquired in Vietnam made this policy especially urgent. There is little doubt that treatment had a large role in curtailing inner-city heroin epidemics of the late 1960s and 1970s.

“The Fix” is part ethnography, part policy. Animating the book are the interwoven tales of Mr. Massing’s two heroes: psychiatrist Jerome Jaffe, the careful and creative architect of Nixon’s treatment system, and Raphael Flores, a tireless worker in today’s Spanish Harlem who practically carries his strung-out clients from clinic to clinic until he finds them help. Mr. Massing followed Mr. Flores on his rounds and captures to perfection the grittiness, desperation and squalor of addict life. He documents the maddeningly byzantine process of trying to get enrolled in a detox program or to find a treatment bed. Interspersed are data on the effects and limits of drug treatment. Regarding Mr. Giuliani’s plan, the reader can’t help predicting disaster — a return to crime and heroin use, and a higher risk of AIDS, for methadone patients who are jettisoned from the clinic rolls.

In contrast to many recent books and articles raging against the drug war, “The Fix” is balanced. Significantly, Mr. Massing takes a sober look at harm reduction — the policy of making addictive behavior safer rather than curtailing it. “Unfortunately, the harm reductionists . . . [refuse] to acknowledge the perils inherent in drug addiction itself,” he writes. “Harm reduction, with its learn-to-live-with-drugs approach, does not offer much guidance as to how to bring down the appallingly high levels of addiction in this country.” In his final chapter, the author offers some pointed recommendations. Among them: scrapping the drug czar’s office, decriminalizing marijuana possession, ending prison construction, smoking out foreign drug lords and spending more on the demand side of the drug problem. Whether or not you agree, Mr. Massing has done a good job of laying the groundwork for most of his arguments.

The author has one annoying habit, however: He tends to sentimentalize addicts. He puts little emphasis on user accountability, plays down the effect of law enforcement and falls into the trap of discussing addiction as a medical rather than a moral problem, when it is clearly both. “It just might become possible to usher in a new, more enlightened era of drug policy, one in which the nation’s drug addicts are treated with the care and compassion they deserve,” he writes. Ironically, the chaos and meanness of addict life, which Mr. Massing portrays so well, is the very reason why his recommendation of ever-available treatment, outreach workers and case managers is good but not enough.

True, almost all addicts will use fewer drugs and commit less crime during even the briefest exposure to treatment. Yet many don’t want help, and even those who seek it routinely drop out of whatever program they are in. Thus, if treatment is to fulfill its promise — and it does seem to work when done properly — addicts must not only enter treatment but “graduate.” Coercion can help — exercised either through the criminal justice system or as a condition of public support. Without such leverage, though, a prescription for more treatment is incomplete, even naive.

Still, Mr. Massing is right about the importance of treatment, and it is not naive to think that we can do better than we are doing now in the fight against drugs.