Interview of Dr. Alan I. Leshner  provided by PBSWhat is drug treatment?

People tend to think of drug treatment as a simple unitary thing. That's not true. Just like you don't have a single treatment for hypertension or a single treatment for diabetes, you don't have a single drug treatment. Drug treatment is composed of a series of elements and components. Some of it is biological, like medication. Some of it is counseling. Some of it might be mental health services. Some of it might be housing services.

Treatment is the constellation of the entire set of events that helps the individual to: A, stop using drugs; B, to return to society; C, to deal with all of the cues that surround drug use and might trigger a relapse. We have to help the individual resist the inevitable craving to go back to using drugs. The ultimate goal of drug treatment is not only to get an individual to stop using drugs, but to restore them to being a functioning individual--in their home, and in the workplace, because if they're not functional, they'll go back to using drugs. And then the cycle starts again.

What are the major treatment problems that you encounter?

The biggest problem in drug treatment is actually keeping people through the initial period of abstinence and detoxification--getting people to stay in treatment long enough for it to have an effect. Many, many people enter a treatment program, discover this isn't going to be a bundle of fun, and take off virtually immediately. And over time, treatment needs boosters. You need ways to keep an addict in abstinence, to prevent relapses. Luckily, now we have techniques for that. What seems to be most difficult is getting the patients matched up with the treatment programs.

Is there a big difference between the effectiveness of voluntary treatment and coerced treatment?

Very few people enter treatment truly voluntarily. There's an old saying that all people are in treatment either because they're court-mandated or "mommy mandated"--someone in their family has insisted on it. There's a myth out there that you have to want drug treatment in order for it to work. That's not true.

Studies have showed that "coerced treatment," that is, mandated treatment, leads to longer treatment retention times--people stay in treatment longer. And the best predictor of success is the length of time that you're in treatment. Voluntary treatment is good. But if you have someone under the control of the criminal justice system, two things are true. One, you can use that control to get a person into treatment, and they'll likely have a good outcome. And the obverse is also true: it's foolish not to force an addict into treatment while you have them under your control.

When crack addiction first appeared, did you think it was treatable?

We didn't know anything about crack. We knew about addiction, and we did have an array of effective treatments in the clinical toolbox. But crack showed us that there really is no single thing known as "drug treatment." The most important clinical lesson is that even if all crack addicts look the same, you can't treat them all the same. What we learned from the crack addicts is that we have to match the array of services to the individual, to the severity of his or her addiction, and then to the environment they'll return to.

When crack cocaine came onto the scene in the 1980s, what was the treatment situation like?

I wish it didn't take us so long to figure out that crack addiction is truly a bio-behavioral disorder. We have to attend not only to the behavioral symptoms, but also to the fact that a crack addict is in a different brain state. If we'd known that in the 1980s, we might have had the sense to make a far more systematic and substantial investment in treating those people. We wouldn't ask for a simple solution to another brain disease; we invest in long-term rehabilitation for stroke victims and schizophrenia.

Is treatment more effective today?

The quality of drug treatment in the late 1980s was good. But now drug treatment is very good. We've seen the advent of a much more formalized treatment process, or set of processes. Different programs use different approaches, but they've become much more systematic. Let me give you one example. In the last two years, we, the National Institute on Drug Abuse, put out four manuals, laying out step by step exactly how you do cognitive behavioral therapy for cocaine addicts. We didn't have that ten years ago. We didn't have a prescription, or protocols of how you go through a treatment process. It was much more day by day, "Figure it out as you go, use your own personal experience," as the backdrop. It worked, but not nearly as well as our current techniques.

What was the attitude of policymakers when the treatment world was learning how to deal with crack?

We've lived for decades under a sort of philosophical polarity. There were people who saw drug abuse and addiction as a moral failure and a weakness, which we needed to approach solely from a punitive approach. Deep in their hearts, many people believe that drug addicts did it to themselves, therefore they're bad, and the only way to deal with them is to tough it out.

And at the other end there were people who were compassionate for the drug addicts, and worried about the reasons they got into addiction. Of course, it's a combination of the two. Drug use is a voluntary behavior. You do make the initial choice to use the drug. The problem is that, over time, the drug use changes your brain in fundamental and long-lasting ways, and you develop, in effect, another brain state. The person you're dealing with isn't the same person who started using drugs voluntarily. They can't exert the same level of control.

The problem historically--and I'm sorry to say it hasn't changed that much--is that there wasn't a lot of public confidence in the ability of drug treatment to help deal with the problem. There was a lot of disbelief about the effectiveness of treatment. I also don't think our treatments were as sophisticated as they are now, a decade later. Science has given us a lot of techniques used to help in the recovery process and in the treatment process.

Since the 1980s, have attitudes changed?

The biggest proponents for drug addiction treatment today are people in the criminal justice system. That's a significant change from what you saw 15 years ago, when the attitude was, "Lock them up, get them out of my face, warehouse them if you have to." Today, the criminal justice system advocates treatment, either as an alternative to incarceration, or during incarceration, if people have committed crimes. What we've learned now is that you can't warehouse that many people. And if you send them out on the street again without treatment, they'll be back--back committing crimes, and back using drugs.

Do you see a visible success rate with treatment today?

There's no question that drug addiction treatment is effective. The success rates for drug addiction treatment--50 or 70 percent, depending on exactly what you count--is absolutely comparable for that of any other chronic relapsing illness, whether it's the control of hypertension, diabetes, or asthma. But the problem we have with drug treatment is the same problem that we have with other chronic illnesses: people don't adhere to the treatment regimen. If you don't take the whole course of antibiotics, you're not going to get better. If you don't take the full course of drug treatment, you're not going to get better.

There's a tremendous database that shows, depending on the study, that for every dollar you invest in treatment, you get between four and seven dollars back in savings in "societal benefit." And all of the analyses have shown that 50 to 60 percent of those people who complete a treatment go back to full work productivity in a relatively short period of time. If you think about the price of a drug addict, you have to think about not only their drug use, but also the crimes they commit, what's happened to their family, and the healthcare costs that we incur because of it. So drug treatment is tremendously cost-effective. There's this sort of myth out there that drug addiction treatment doesn't work very well--but look at the data.

Do policymakers recognize the value of treatment?

I think it's only in the last few years that we really are seeing people both in the general public and in the treatment community who understand addiction to be the illness that it is--a brain disease. And I think what we've learned now is that we have to have systematic protocols that you follow that are similar to the treatment protocols you'd use for any other kind of illness. But there's a terrible treatment gap, and that gap has to be filled.

I think that the misunderstanding about the nature of drug abuse and addiction is at the core of much of the problems we've had over the past couple of decades. If you see drug addiction only as a failure of will, as a moral weakness, then your corrective approaches are going to be that simplistic. And they're not going to work.

We still have about four million hardcore drug users in this country, and only about half of whom have ever had any treatment experience at all.

How do heroin and crack addiction differ?

Crack is a very different substance from heroin. Heroin sort of mellows people, whereas crack is a stimulating substance--addicts are hyperactive. Crack cocaine withdrawal is very different from heroin withdrawal. People on crack would go into these phenomenal depressions without having physical withdrawal symptoms.

Do you think crack use has significantly declined since the 1980s?

I don't think so. Drug use has always been cyclic. There have always been rises and falls, which I think are tied pretty much to the perception of harm. After the late 1980s, the general population did become a bit more sophisticated, more knowledgeable, about what crack could do--how it could take over your life, hijack your brain and hijack your life.

But we go through these cycles where we have mass hysteria about the drug problem, then we make a little bit of progress and we say, "Okay, now things are terrific."

There's a mistaken relaxation of concern around crack. Too many people think there is no longer a crack problem, because the numbers aren't going up anymore. Well, that's wrong. Things aren't terrific. We still have terrible drug problems in virtually every community in this country. In fact, studies just released show that drug use amongst young people in rural environments is actually higher than it is in urban environments. The truth is that crack cocaine is not over. We still have millions of people who are addicted.

There seems to be a lot of focus on whittling down the number of casual users. Does this mean that what's left is a hard-core, perpetually addicted population?

What most people don't realize is that the majority of long-term, hard-core drug addicts are dying in their 40s and 50s. The latest studies show that the life expectancy of a drug addict is 15 to 20 years after they start being a drug addict. So what we see is a replenishment of the population, a new crop of addicts. There are no 90-year-old heroin addicts. Most of those we were recording 20 years ago have died. The numbers are relatively stable, but they're constantly being replenished.

Who are the hard-core addicts?

When we talk about hard-core addicts, we mean very, very heavy drug users--whether it's heroin, crack cocaine, powdered cocaine, or the methamphetamine we now see in the West and the Midwest. When we say "hard-core addicts," we're talking about people who use large quantities of drugs, and who are addicted to the point that their drug use interferes with the rest of their lives. From a medical point of view, what matters in addiction is the compulsion to use drugs in the face of tremendous negative consequences.

Our best estimates are based on people using regularly, though this varies. Some people who are very heavily addicted are using multiple times a day. Heroin addicts typically inject three or more times a day. Crack cocaine addicts, when they are bingeing, are taking another hit every 20 to 30 minutes. But the exact number and the exact definition of "hard-core addict" is a very complicated issue, and very controversial. We don't really know exactly how many addicts there are.

How important are the hard-core addicts to the market of drugs, and the problems associated with them?

There's no question that the hard-core constitutes the largest percentage of the drug market. They are using tremendous quantities of drugs in a day, in a week. They drive much--but not all--of the market

What are the major problems with drug treatment policy today?

My own belief is that we need to get treatment going far earlier than we do. The historic approach has been to wait until somebody is a terrible mess. Then you've got them in jail, or their family has forced them into treatment, and you have to work tremendously hard to get them to stop using drugs. From a clinical point of view, I think everyone would agree that the earlier you can intervene, the greater the probability is that you can actually prevent the transition from occasional drug user to addict. Because once you've gone over that point--once the switch has flipped in your brain, and you're no longer under voluntary control--then you're a compulsive user. You're an addict. And treatment is far more difficult than it ever was before.

Is there an appropriate response for the casual drug user that's different to the response for a "hard-core user?"

There are lots of things that you can do with a voluntary drug user that you can't possibly do with someone whose drug use is frequently out of control, who is truly compulsive. We make distinctions, both from a prevention point of view and from a treatment point of view.

Why does public policy link crime to drug use?

The relationship between drugs and crime is not a simple one. Using, selling, and having drugs is illegal. However, many people who are drug addicts go out and commit other kinds of crimes in order to secure the resources to keep their drug habit going. So as General McCaffrey says, "If you hate crime, you'll love drug treatment." Drug treatment is the most effective way to reduce the criminality associated with drug use.

What would you say is the main story about drugs in the 1990s?

The biggest story about drugs in the 1990s is methamphetamine. Methamphetamine is a sad, but fascinating phenomenon. It has passed across this country from the Southwest through the West into the Midwest like a public health plague. It began as an isolated phenomenon in southern California, and then the Southwest, and then it moved up the West Coast. And now the largest methamphetamine problems are in the middle of the country. We don't know exactly why that happened, but the task is to keep it from spreading eastward.

Is methamphetamine the new crack?

There are people in certain parts of the country who refer to methamphetamine as the new crack, except that it seems to be attracting a somewhat different population. Methamphetamine users and addicts tend to be wealthier, and they tend to be people coming out of working communities rather than unemployed communities. So we don't know really whether it's methamphetamine substituting for crack, or methamphetamine as an addition to crack. But in cities like San Diego, San Francisco, and Los Angeles, methamphetamine is equal to crack cocaine as a drug problem.

What about the new wave of "designer drugs?"

Club drugs, like Ecstasy, GHB, and ketamine are an emerging drug plague, especially in the cities around the country. That is what all our early alert systems are telling us. The task is to get ahead of that plague, get in its path and prevent it from evolving. It's an emerging drug crisis--one that is not quite here today. The question is, can we stop it?

The lesson that we learned from the crack epidemic is that when we start to see a drug problem coming, we have to get in there immediately with a full-bore intervention. So the National Institute on Drug Abuse has mounted a major multimedia campaign geared towards young people and their potential use of these club drugs. We have a special site, clubdrugs.org, and we send out cards in bars, and record stores, telling people about the dangers of Ecstasy. We've started this multimedia approach to try to get in the path of the plague.