drug wars

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interview: dr. jerome jaffe


photo of dr. jerome jaffe

Jaffe, a psychiatrist who promoted methadone treatment for heroin addicts, was appointed in 1971 as chief of President Richard Nixon's drug programs in the Special Action Office of Drug Abuse Prevention. Between 1971 and 1973, Jaffe established a network of methadone treatment facilities all over the United States. This is the edited transcript of an interview conducted in 2000.
What kind of drug treatment did you pioneer in Chicago? How was it different to what had been done before?

What we were trying to show was that there wasn't any single best road to recovery from addiction, but that many treatments could work well and synergistically together. We had methadone programs, we had detoxification programs, and therapeutic communities. We even had a residential program for people on methadone, where they could detoxify.

What was the science of addiction and treatment at that point?

It was better than it was ten years before, and nowhere near as well established as it is today. There was evidence that methadone treatment was effective. There were some good controlled studies. There was only a belief in the effectiveness of therapeutic communities. The relapse rates for those who stayed for a reasonable period of time were low. But we didn't expect much of detoxification, and we didn't get much from detoxification. The real issue was whether there were some kinds of people who were better suited to one rather than the other. Which ones worked best in the long run? Which did people prefer? I am not certain that anybody can say with absolute certainty, even today, who ought to go into which kind of program.

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Jaffe and Nixon
Were you seeing a relationship between treatment and criminal behavior?

Lots of the people that we began treating had histories of arrests, and had been in jail. When we did some of the studies on what was happening after treatment, there was a significant reduction in those kinds of behaviors. But totally apart from what we saw statistically, I knew these people personally. I knew their families. And you could see that their lives were dramatically different when they went into treatment.

Was there anyone who opposed the use of methadone?

Some policemen in Chicago were kind of skeptical about methadone. Minority communities were also more affected by heroin, and it was felt that, "Here's another medicine to control the minority communities, given out by the white establishment." But we tried to make it clear that this was not just giving out a medicine. It was a program that delivered a lot of services in addition.

What were the recommendations of your first [1970] report to President Nixon ?

I had the feeling, almost from the first day, that the willingness to look at the demand side, rather than the law enforcement approach, might be a transient phenomenon--and I was right. One was that we needed to do more to evaluate treatment. The National Institute on Drug Abuse did not exist, and we needed to know more about the effectiveness of treatment. We also noted that there were a dozen different agencies funding treatment that didn't talk to each other. There was no coordination, and they were bumping into each other when they finally got down to the places where treatment was being delivered. Here were lots of interacting pieces: law enforcement, epidemics and drug use, treatment and prevention; the government ought to think them through and see how each one affects the other. They needed a clear-cut national strategy.

The other thing we said was that, given the extent of heroin addiction, methadone treatment should not be considered a small research project. That was in late 1970, when there were at least 5,000 or 6,000 people who had been on methadone for a number of years. It was not just an experiment, and it ought to be made more widely available. People were waiting for treatment, and it could have a real benefit for society. At that time, there was very, very little in the way of treatment support. The big resources were still in the criminal justice system.

What happened when you first went to the Pentagon to talk about heroin use amongst the troops in Vietnam?

I told the assembled generals and the colonels that they needed a program of testing, so that people who were actively addicted to heroin would not be just put on the airplane and sent back and discharged, but would be treated in Vietnam. The news media was saying that maybe fifteen or twenty percent of the servicemen in Vietnam were addicted to heroin. There were suggestions in Congress for civilly committing all of these people. The idea of 150 untreated heroin addicts trained in combat, coming in every day, was not one that made people feel comfortable. Our plan was, "We'll test people when they leave. Those people who haven't used heroin will get on the plane, and those people who have will be our guests in Vietnam for a little longer, while we make sure they've had at least some treatment."

To the military, this was basically mollycoddling. This was being soft on the addicts. Under the Code of Military Justice then, if you were found using heroin, it was a court-martial offense. So in order to institute a program of universal testing, you had to change that. The president simply ordered the change in the Code of Military Justice. If you tested positive, it was no longer a court-martial offense. Later, we were able to reverse some of the bad conduct and dishonorable discharges that people had received simply as a result of having used drugs. This wasn't to encourage drug use, but there was no point in destroying peoples' lives for that kind of offense.

To get a program like that up and running within two-and-a-half weeks, in retrospect, was quite unbelievable. The logistics were tremendous. They built detoxification facilities in Vietnam. They built special places where you could collect the urine, and they did it all in a couple of weeks. The new development of urine testing made it feasible to test the roughly 1,000 people who were leaving Vietnam every day. Testing had an immediate effect. As people learned that heroin use was no longer something that could not be detected, the tendency to use it dropped. The word got out very quickly that there is no way to leave this place if you're using heroin.

And so, the soldiers would stop. The only people who would show up as positive at the point of departure would be those people who were really addicted, who couldn't stop. There were also people who had been so isolated from the others, and who didn't hear about the testing, but I have a feeling they were exceedingly few. What that demonstrated was that even though heroin remained available and cheap, that sort of intervention could still reduce the extent of heroin use. We found that, of those people who were addicted in Vietnam, there was only a five-percent relapse rate over the first year after returning home. I think, at most, there might have been a ten-to-fifteen percent relapse over three years. This was totally counter to everything everybody had expected, at least in the beginning.

Was your primary mission to deal with heroin?

Heroin was the serious drug problem at the time. In 1971, 1972, there was very little cocaine use. It might have been on the distant radar screen, but there was almost nobody seeking treatment. Marijuana was also a problem in terms of drug use, but there was virtually nobody seeking treatment.

What was your sense of Nixon and his own feelings about drugs and drug abuse?

It's clear that he had very strong feelings about it. He felt that drug use really eroded the fabric of society. It wasn't just that this policy was a way to reduce crime. Nixon really thought that drugs themselves needed to be reduced. I felt that it wasn't just for political purposes that he wanted to do this. He was willing to make some changes in the Controlled Substances Act, so that first-time offenders would not necessarily be subject to imprisonment. Nixon seemed very pragmatic. I was given absolute carte blanche in terms of recruiting. And for the first time, the federal government was making a commitment to treatment in the community, and to supporting it. We were able to say that we intended to make treatment available, so that nobody could say they committed a crime because they couldn't get treatment. That was a major commitment, and we went about trying to make good on that promise. I think, for a brief time, we did.

What were the goals of the drug initiative you ran under Nixon?

A national strategy had to be developed, and we had to develop some confidentiality regulations. One of the issues was that people would not step forward to get treatment unless they believed that the records would be protected from the police, who might see this as a convenient way of finding people that they could arrest. That was a major effort.

And then, of course, there was this issue: if you're going to approve methadone or something like it as a treatment, there's a whole chain of consequences that has to be dealt with. Who should be able to prescribe it? How much? Is there going to be take-home? In a sense, we began this issue of defining what treatment was in various modalities, and tying the resources to that. We had to build an infrastructure that ensured people could basically send out the checks and make sure the treatment was delivered. We also needed to almost immediately launch some effort to test how effective that treatment was. We set up things like the household survey and the DAWN [Drug Abuse Warning Network] system, and the National Institute on Drug Abuse was put into the original legislation.

We also instituted a program in the drug courts called "treatment alternatives to street crime," which basically linked treatment with the court system. It was a way of trying to reduce crime by getting people who had been arrested into treatment. But the reality was that the kinds of programs that we were putting into place didn't happen overnight, and there was at least a year or two before they had their maximum impact--before people got fully trained and really delivered services. Within a year or so, you could see the number of programs expanding, and the number of people coming into treatment expanding. But at the same time, we were very preoccupied with overseeing the Vietnam intervention.

We knew that what we were doing was probably the right thing to do--that treatment helped people, so it was a good thing to make available. But we did not have the data that we now have to show that not only is it helpful, but it's cost effective. In terms of what society gets for every dollar invested, it's terrific. We have that data now.

What was unique about the approach to the drug problem during that period in history?

I had the feeling, almost from the first day, that the willingness to look at the demand side, rather than the traditional American law enforcement approach might be a transient phenomenon--that it might pass, and we would go back to our old ways of more and more law enforcement. And I was right. We have never had that proportion of federal resources devoted to intervention on the demand side. We'd never had it before, and we've never had it since. Up to that time, we had about 65 years of a law enforcement approach. I wasn't certain that the general attitudes of Congress had totally changed. It seemed as if every day was an important day in getting things done, and putting things into place. We really had to move quickly to institutionalize the treatment system so that it would not just decay and fall apart when the current interest in treatment faded.

What was your relationship to the law enforcement side of things?

We had discussed that if law enforcement was successful at raising the price, at reducing the trafficking, more and more people would seek treatment for their addiction. We saw eye to eye on the way in which the law enforcement could be synergistic with reduction of demand and so, at least for a brief time, we saw that they were both needed to deal with a problem like heroin addiction.

What happened when the medical community discovered the growth of cocaine use in America?

When the issue was just heroin, and it was limited to perhaps poor, underclass, inner-city drug users, medical interest was not as great as when the cocaine spread into the general population. At least for a few years, the spread of cocaine resulted in an expansion of interest on the part of medicine in general.

Within the addiction community, did the discovery of cocaine addiction make you feel like you had to go back to the books again? Was this a significant problem?

The short answer is, yes. It was clear that we could not assume that cocaine addicts would respond to the same kinds of treatments as heroin addicts. You had to go back and start again. At first, there was even a question of whether there were hardcore cocaine addicts. When cocaine first came on the scene, some people doubted its addictiveness.

What was the political atmosphere like when crack emerged?

Crack emerged at a time when, at least at the national level, there was a growing belief that treatment was ineffective. That was the mid-1980s. There was a general feeling that we had to have zero tolerance for drug use in general. There was a law enforcement approach that applied to marijuana, to cocaine, to all drugs. And when crack came onto the scene, the penalties for sale or possession were escalated. It was portrayed in the media as even more addictive than cocaine. I felt that this was going to result in a lot of people serving a lot of time in jail. Some of that long-term cost could perhaps have been avoided.

Where did the hype surrounding crack come from?

Where people got the idea that crack was instantly addictive is not clear to me. But once somebody had said it, everybody seemed to repeat it in sort of an automatic fashion. It became an accepted bit of wisdom that was not scientifically validated, but was nevertheless a bit of information on which legislation was made. Mostly, cocaine had been used by inhalation of the powder, and people were truly concerned about the powerful effect of taking the drug by inhaling the freebase. This induces an effect, which is as powerful, in terms of its euphoric effect, as injecting it. But it certainly didn't make it instantly addictive, nor did it mean that treatment was impossible. There were also "crack babies." Some women who used cocaine during pregnancy had babies who had some odd behaviors when they were born. The fears of brain-damaged kids were perhaps exaggerated, but still the issue is not fully resolved.

What changes did you see with cocaine use in the 1980s?

By the mid-1980s, we were beginning to see a decrease in casual use of cocaine. I think the decrease was accelerated when the media widely publicized the death of Len Bias. There was the case of an athlete in great physical condition who died after what was reported to be his first experience with cocaine. There were some other deaths also given wide publicity at the same time. And in that sense, the media probably gets some credit for publicizing the deaths of otherwise healthy people. I think that brought home to the average user that cocaine was not benign; that there were real risks to a life in using it. Fads also pass, and people move on to other things. And so casual use dropped, but hardcore use did not.

So what we got was a kind of residuum of a large group of hardcore users who seemed unable to break their association with cocaine. That group was a lot smaller than the millions who had used it casually, but we believed them to be responsible for a lot of the cocaine-associated crime. I don't see that it was primarily law enforcement that brought about the decline in casual use. I think it was far more an appreciation by the public on the real dangers of this drug.

The other part of the decline is that, by the late-1980s, we started to get some notion that treatment was effective. There was very little treatment available for cocaine use in the mid-1980s, and certainly none that had been carefully evaluated. A lot of people say it should have been supported more generously, but at least something was better than nothing.

How did the moralizing of the drug issue affect treatment?

Making something illegal, declaring it to be somewhat immoral, often gets the great majority of people often adhering to that. But it also results in a stigmatization of those who deviate: the sinners. There's then a reluctance to invest in the redemption of the sinners, at least in those terms. There is a belief that people who behave that way must therefore be immoral, and perhaps a little unworthy of treatment. It is a very difficult balance to achieve.

How does the availability and quality of treatment today compare to treatment in the 1970s?

When you adjust for inflation and you adjust for the number of people who need treatment, I don't think that support for treatment, at least within the public sector, is actually as generous as it was back in the 1970s. Treatment that the public sector is able to deliver is just not of the same quality that it was 25 years ago. I think the people who are involved in treatment are more knowledgeable, and often they're better trained, but they're overworked. I think that they try to see too many patients. And I think they're under continuous pressure to somehow do more with less. Inevitably, this is going to reduce the effectiveness of treatment.

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