Take us back to the late 1980s. How was treatment viewed, specifically in
terms of crack?
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.
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
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
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.
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
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
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
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
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.
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