For Addicts, Force Is the Best Medicine

The Wall Street Journal, January 6, 1998

By Sally Satel

Autopsy reports confirmed last week that actor and comedian Chris Farley died Dec. 18 of an overdose of cocaine and morphine. Farley was 33, the same age at which his idol, John Belushi, fatally overdosed on cocaine and heroin in 1982.

Two weeks before Farley’s death, another actor, Robert Downey Jr., came before a Los Angeles County municipal judge in a Malibu courtroom on a drug-related charge. The judge, Lawrence Mira, jailed him for six months, having gone easy on him after several earlier convictions. “I’m going to incarcerate you in a way you won’t like,” Judge Mira told Downey, “but it may save your life.”

Indeed it may. And if Farley had had the good fortune to be arrested and come before a tough judge, he might well be alive today. As a psychiatrist who treats drug addicts, I have learned that legal sanctions — either imposed or threatened — may provide the leverage needed to keep them alive by keeping them in treatment. Voluntary help is often not enough. After all, Downey and Farley had already been to some of the nation’s finest rehabilitation centers, but their stays were far too brief. “Chris kept trying, and he would go into rehab and he would come out, and sometimes he’d be really healthy,” Al Franken, who worked with Farley on “Saturday Night Live,” told a reporter after his death.

It’s an all-too-typical story: Addicts avoid treatment for years or take it in small doses, enough to refresh themselves before starting out on another binge. According to the federally funded Drug Abuse Treatment Outcome Study, patients report being addicted for 10 to 15 years on average before first entering treatment. When they do enroll, only one in seven completes a program. Downey, for example, once bailed out after a few days.

At the root of the problem are the misguided though well-meaning attitudes of many drug-treatment professionals. They believe in waiting until a drug user is “motivated” to get help, allowing him to reject help until he is no longer “in denial,” and telling addicts that treatment won’t work until they “want to do it for themselves.”

At the same time, the prevailing view holds that an addict is someone suffering from a chronic illness, rather than someone whose behavior can be influenced by meaningful consequences. The National Institute on Drug Abuse, part of the National Institutes of Health, even goes so far as to call addiction a “brain disease.”

In truth, drugs do affect the brain, but even many of my patients know that stopping is a matter of personal responsibility. In encouraging users to take that responsibility, coercion can be the clinician’s best friend. Without it, our work is often in vain.

In the methadone clinic where I work, many patients continue to use cocaine and heroin while receiving counseling and group therapy. Short of ejecting them from the clinic, there is little we doctors can do about this. But sometimes a patient will get a lucky break: He’ll get arrested and put on probation with the requirement that he take frequent urine tests and the stipulation that he goes to jail if he fails. With this threat hanging over their heads, patients often test clean — no great surprise to anyone not steeped in therapeutic ideology.

Some addicts themselves recognize the benefits of coercion. One patient told me he planned to get a job as a truck driver. “At least they’ll test my urine, and I’ll know someone’s watching,” he said. This patient put his finger on the crying need for built-in controls and individual accountability. When they’re there, imposed by a judge or an employer, I can do my job better. The patient and I don’t waste time bargaining over how many drug tests he can fail — “C’mon, doc, next week I’ll be clean.” I don’t have to risk straining the treatment relationship by threatening the patient with discharge from the clinic.

Instead, with externally imposed limits and expectations, I am clearly the patient’s ally. We are working together toward his recovery, developing strategies to resist temptation and ultimately discovering larger reasons to stay clean, because we both know that there are serious consequences for failing. And it’s a myth that addicts have to want treatment. Ample evidence from large-scale studies shows that when they are compelled to treatment by judges or mandated by their employers, these coerced addicts do at least as well as their counterparts who voluntarily enter and complete the program.

It is also well documented that the longer a patient stays in treatment, the more likely he is to avoid future criminal activity and drug use. For example, any patient — whether treated voluntarily or under court order — staying 18 to 24 months in Phoenix House, a residential community program, has a 90% chance of being employed and out of legal trouble and a 70% chance of being completely drug-free five to seven years after discharge. The Brooklyn, N.Y., district attorney, who routinely sends nonviolent drug felons to mandatory residential treatment programs instead of prison, finds they remain in treatment two to four times longer than their noncoerced counterparts. They also fare better than their imprisoned counterparts, whose rearrest rate one year after release is more than twice the rate of those who have completed treatment. Treatment is one-third cheaper than incarceration, to boot.

The idea of “harm reduction” — decriminalization, along with medically supervised heroin distribution, needle exchanges and other such measures — has been gaining currency in the drug debate of late. But addicts would be better off if more of them were arrested and forced to enroll in treatment programs. “I wish the cops could bust an addict for jaywalking or littering,” a colleague of mine says, only half-jokingly. “At least then he would get placed in a treatment program where the court would make sure he’d stay.” Civil judges can, without arrest, commit some addicts to treatment for their own protection if they are clearly out of control — as Farley appears to have been. More than half the states have statutes, seldom used, that allow civil commitment for alcoholics and drug addicts on the basis of grave disability or a threat to oneself or others.

To be sure, being forced into a program and losing autonomy — either in a residential, a jail-based or a probationary treatment program — can seem harsh. But the payoff is immense: an opportunity to develop the social competence, trust in others and optimism about the future that are the prerequisites for a life without drugs.

The payoffs for society are substantial, too. Numerous large-scale cost-benefit analyses reveal that every dollar spent on drug treatment saves between $2 and $7 on law enforcement, corrections, health care, lost productivity and welfare.

To my dismay, some of my treatment colleagues oppose coercion as “punitive.” I suppose it may seem that way if one thinks addicts are helpless victims of a brain disease. But addiction is a moral condition as well as a medical one. If we view it in this light, then predictable consequences for failure and rewards for success are the essence of humane therapy.