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Old Habits

Medicalization is the hot new thing in drug treatment. Just like in 1970.

Dr. Robert Dupont
Joseph Kohl
Kurt Schmoke

By Edward Ericson Jr. | Posted 7/28/2010

Second of a four-part series.

Read part 1, part 3, and part 4.

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The optimistic spirit of the '70s faded in the 1980s as outcome measures morphed into marketing hype amid a new drug crisis. The new epidemic of crack left drug policy experts gasping. Wide-spread addiction and frightening crime rates returned to Washington, D.C., with 60 percent of arrested Washingtonians testing positive for cocaine in December 1987, up from 15 percent in March 1984.

"At the moment the conventional wisdom is [that] nothing works," University of Maryland and RAND Corporation researcher Peter Reuter told a Los Angeles Times reporter in 1989. "It's a view that comes out of despair."

Reuter published several papers in the late '80s that questioned the efficacy of both drug interdiction efforts and the prevailing drug treatment regimes that had grown up based on the 1970s models. Treatment programs had become big business by the mid-'80s. But for most people, the programs didn't work.

"The largest nationwide study of drug treatment outcomes (the Treatment Outcomes Prospective Study, or TOPS) showed that the majority of those treated for heroin or heavy cocaine use were again using drugs on at least a weekly basis within a year of their discharge," Reuter wrote in one of his RAND studies. "Recovery from drug dependency is a long process," he wrote, citing statistics from the Maryland Department of Health and Mental Hygiene showing that only 20 percent of those treated for heroin addiction in Montgomery and Prince George's Counties were drug-free when discharged.

Simplistic promises to eradicate drug abuse gave way to cost-benefit analyses touting the savings to society from fewer days of drug use, and fewer crimes committed by addicts while in treatment. This change, mostly unnoticed outside the drug treatment industry, led to sunnier interpretations of the data. The TOPS results are today cited to claim that "Treatment was found to be effective in reducing daily opiate use and other illicit drug use during and after treatment," as the study's NIDA-funded authors claim.

DuPont, now president of the Institute for Behavior and Health in Rockville, says that shift was toxic. "That's what's called harm reduction," he says. "It has become a dominant view in the treatment field, a view that I think is totally wrong. What it does is justify failure."

The crisis of the 1980s led to a renewed interest in novel and even radical solutions. By 1988 Baltimore Mayor Kurt Schmoke was calling for a debate on drug legalization, saying the concept should be discussed openly and seriously.

"I propose that we make a dramatic change," Schmoke told a gathering of correctional officers in Baltimore in 1989, "that we have the war on drugs considered primarily a public health rather than a criminal justice war, that the war on drugs should be led not by police and prosecutors, but by the Surgeon General."

Although Schmoke's ideas are still considered ahead of their time, the language of medicalization was already en vogue. "We're trying to get them to deal with addicts as patients," then Baltimore Health Commissioner Maxie Collier told The Washington Post, explaining the Schmoke administration's efforts to coordinate drug treatment programs with the city's private medical community. "Addiction has to be viewed as a primary care problem . . . like hypertension or diabetes."

With that goal in mind, Schmoke obtained a federal grant in 1990 to establish the Baltimore Substance Abuse System within the city's Health Department. The model was not unlike Jaffe's old White House Special Action Office for Drug Abuse Prevention, which was phased out by 1975. "BSAS was supposed to put itself out of business in five years," bSAS Chief Financial Officer Arnold Ross says.

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