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interview: dr. herbert kleber

 

photo of dr. herbert kleber

Kleber has been a pioneer in the research and treatment of narcotic and cocaine abuse for over 30 years, and was Deputy for Demand Reduction at ONDCP under Drug Czar William Bennett. Currently, he is Professor of Psychiatry, and Director of the Division on Substance Abuse at the College of Physicians and Surgeons of Columbia University, and the New York State Psychiatric Institute. This is the edited transcript of an interview conducted in 2000.
Take us back to the late 1980s. How was treatment viewed, specifically in terms of crack?

In the late 1980s, we basically had no effective treatment for crack. And that, of course, discouraged people from wanting to deal with the crack epidemic by simply increasing treatment. But even though we didn't have the number or the quality of treatment programs that we would have liked, there were certainly some that seemed to be more effective than others. For example, there were long-term, rigorous residential programs that seemed to do better than most. My concern when I came to ONDCP was that there was not adequate emphasis in developing medications for treating cocaine--that we weren't putting enough research dollars into it.

But remember, many of the people who were using crack did not need "rehabilitation." And the programs they were going into were basically rehabilitation programs. What these people needed was "habilitation." There was no "re" to go back to. They lacked the vocational skills, the interpersonal skills, and the educational skills to cope in modern society. So even if you got them to stop using drugs, they weren't going make it. And if they weren't going make it in society, they were going to go back to using drugs. What we needed were programs that could deal with habilitation, rather than rehabilitation.

Was "habilitation" included in the national drug strategy?

It was part of the strategy. The White Paper on treatment that our office published emphasized the difference between "habilitation" and "rehabilitation," and pointed out the need for more programs that stressed habilitation. But we couldn't control where the block grant money went once it hit the states. That is, once it got to the state, our office could not tell the state whether they should spend it on the hardcore addict or the individual who was less in need of treatment. We couldn't tell them they should spend it on therapeutic communities or outpatient programs. Each state agency did that themselves. I tried to get legislation through Congress that would give us the power to hold the states responsible for the outcome of the money we were sending them on treatment, but Congress wouldn't pass it.

Why wasn't there an interest in funding treatment at that time? Or is treatment always a second priority?

Historically, funding for treatment has been a bipartisan failure. Neither Democratic congresses nor Republican congresses have voted for enough money for treatment. And that seems to be independent of who's in the White House. No matter who's running Congress, or the administration, treatment never seems to get adequate funding or adequate respect. I don't think the reasons for that are simple. There are a number of possible explanations, and I think they're probably taken together.

For one, there's a real feeling that addicts brought it on themselves--that rectifying what they're doing is not worthy of taxpayer dollars. Two, the messengers are not trusted. When scientists and researchers say we know how to treat addicts, Congress tends to view them suspiciously. They feel that the bunch of liberals who want to treat the addict do not worry about the law-abiding citizen who got mugged. Three, failures are obvious, but successes are anonymous.

And every congressman, probably everyone in the administration, has some family member, some neighbor, or someone they know who's been in treatment and failed. And so they think treatment doesn't work. You can give them all the statistics that you want--they know that Uncle Joe did not do well in treatment.



Is it difficult to generate funds for larger treatment policies?

Most people don't understand how Congress works. Various committees fund different agencies. If you take money out of the defense department or out of the Drug Enforcement Administration, that doesn't give you one penny more for treatment, because the committees that fund treatment use funds from the Health and Human Service. Even if you increase the money in those committees for treatment, you may be taking it away from AIDS research. And AIDS probably has a better lobby than drug addiction. So if you take money away from DEA, it probably goes to FBI. It doesn't go to treatment. Most people aren't aware of that. It's not a unitary budget.

Theres a gap between what we know and what is practiced between what the best programs do, and what the average or the poor programs do. So not only do you have these different fiefdoms in Congress, you also have different points of view at the Office of Management and Budget. All administration budgets have to go through OMB. I remember one time we had a marked increase in treatment that we thought had the president's blessing. But unfortunately, a key person at the OMB did not believe that treatment worked, for their own personal reasons. So our request got slashed. It's not simply fighting with Congress or fighting with members of the opposite party. It's sometimes fighting within your own administration.

Even increasing the federal commitment to drug treatment didn't necessarily translate into more treatment, because the federal dollars were often expressed by money going to the states. And too often the states pulled back their own money, so there was no new increase in treatment dollars. The size of the dollar increase was often not equal to the size of the treatment increase.

How secure do the various departments feel about their own budgets?

Everyone wants to protect their own budgets. They want to protect what they think is important. It's not simply that Health and Human Services opposes drug treatment. They don't oppose drug treatment. They're nice people. They're knowledgeable people. But they have other priorities. And they're afraid that if they go along with increasing treatment, money will be taken away from some project that they would rather fund.



Even when funds are dispensed, why is treatment still not as effective as it could be?

One of the reasons that treatment is not as effective as it can be is that there's a gap between what we know and what is practiced. There's a gap between what the best programs do, and what the average or the poor programs do. The best programs take into account many different factors. Some hardcore addicts have major psychological problems. But many don't. Some have no vocational skills, but many do. If we don't address the particular issues of a particular individual, it's not surprising that treatment won't work. And the poor programs offer a "one size fits all" approach.

This ineffectiveness is not only a matter of money. It's a matter of patient and treatment matching. It's a matter of holding programs accountable for their outcomes, and holding the individuals and agencies that fund those programs accountable. If a program is not doing as well as it should, the state should provide technical assistance. And if they still can't get their act together, the state should take the money away from that program and give it to a program that can do a better job. That requires a real political will that is absent in many states and many communities.

How did you feel the public should be educated about drug use during the 1980s?

Cocaine use, and drug use in general, was normalized in the 1970s and early 1980s. People used marijuana. A lot of the middle and upper classes used cocaine. They used it at parties, they used it at work, they thought nothing of it. What we did was to try to undo that. We tried to say that drug use is not normal. We said that it wasn't simply the addict that needed to be dealt with; it was the middle-class user as well. We said that the lawyer who was buying cocaine for his weekend party was supporting the drug cartels just as much as the addict was.

Do you think addicts were stigmatized in a way that limited the possibilities of treatment?

That's an interesting question--whether, by emphasizing the dangers and problems of drug abuse, you at the same time end up demonizing the people that are doing it. It's a tradeoff. If you're trying to diminish drug use, you need to de-glamorize and de-normalize drug use. But the more you de-normalize, then the less the addict is seen as "one of us." And that's always a problem.

The politics of the Reagan years and the Bush years probably made it somewhat harder to get treatment expanded, but at the same time, it probably had a good effect in terms of decreasing initiation and use. For example, marijuana went from thirty-three percent of high-school seniors in 1980 to twelve percent in 1991. That was an enormous decrease. But then you pay a price for that in terms of how people who are using are going to be regarded.

Is crack instantly addictive?

No drug is instantly addictive. Some drugs are so pleasurable that when you take them you say, "Boy, I'd like to have more of that." So, in that sense, crack is very addicting, because it produces this intense, immediate high, which wears off very quickly. And as it wears off, you get the flip side. Instead of the elation, you're feeling some depression. Instead of energy, you feel irritable. And you know what the cure for that is--more crack. Unlike the powdered cocaine which you may snort every 30 to 45 minutes, with crack it was not unusual to go on binges where you would use it every 15 minutes. But no drug is instantly addictive.

Was there too much hype about crack? During its peak, crack was reported as being instantly addictive.

In retrospect, it's easy to say that something was made extreme. But at the time, you were seeing crack destabilize whole neighborhoods. In many ways, the black woman was the pillar of the inner-city community, and we had not seen a drug that had that same kind of devastating impact on the black women as crack did. Heroin had been around for a long time but it wasn't the same. Women who had been the pillars of the community, who'd kept it stable, got addicted to crack. Because crack was also sold so cheaply, it made everything worth stealing. And most people stole where they lived. They didn't steal on the Upper East Side or the Upper West Side. They stole in the Bronx and Harlem and it had an enormous devastating impact on the neighborhoods. Looking back you can say, "Oh, we exaggerated crack." But I don't think so. I've been in this field for over 35 years, and crack is the most devastating drug that I've ever encountered.

What about the scare surrounding "crack babies?" Was that exaggerated?

What happened with the so-called "crack baby" was that the pendulum went through a full cycle, from one extreme to the other. I think that now it has settled in the middle. The first extreme was that people thought crack was so devastating that practically all the infants that had been exposed to it in utero were going to be significantly damaged--they'd be prone to violence, and they wouldn't be able to learn, etc. Then the pendulum swung too far in the other direction, and people said, "Crack doesn't harm these babies at all. What really harms these babies is poverty, malnutrition, tobacco, alcohol." Now what we're seeing is that crack is dangerous for the fetus. It does produce biological damage. The good news is it doesn't produce it in all of the people exposed to it. And many of the defects that it produces can be remedied by appropriate nurturing after birth.

Were the 1980s the peak of what you thought was going to be an ongoing cocaine epidemic?

In hindsight, 1985-1986 turns out to be the high point of the cocaine epidemic, and it has been going down ever since. But even though the data then indicated that there had been a drop, it was not clear that the drop was going to continue. It could have been a downward blip caused by things like Len Bias's death, or the death of Don Rogers. It does look like we've turned the corner on the drug that was our major problem then: cocaine. But in the last seven or eight years, we've had a marked rise in heroin addiction. And there's been a sharp rise in marijuana between 1992 and 1997.

What about the argument that these drugs have a cycle when they're in fashion--that the crack cycle was particularly intense, but burned itself out on its own?

It's easy to say that you have drug epidemics that run their course. But why do they run their course? They run their course because they bring into play a number of forces which, taken together, will help to end the epidemic. At the turn of the century, a number of forces brought about the decrease in cocaine use. It was the police, it was parents, it was community leaders, and religious leaders. And the same thing happened in the 1980s. What decreased cocaine use was not any one thing. It was a putting together of our law enforcement activities with a push at the local level, in communities, from religious leaders, from the presidential leadership. I don't believe that epidemics simply run their own course. I believe that an epidemic sows the seeds of its own destruction. If no one is watering those seeds of destruction, and nurturing them, the epidemic may still eventually burn out. But it may take a lot longer to burn out. And there'll be a lot more casualties. A lot more of our young people will be destroyed.

· Read a social history of the use of various drugs in the U.S.

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