Addiction and Rehabilitation

What is Addiction?

In the world of science and medicine, ideas about what addiction is and what should be done about it have changed dramatically in the past ten years. Researchers now agree that addiction--whether to cocaine, heroin, amphetamines or some other chemical substance--is a single disease. According to much of the latest evidence, addicts will switch drugs when their choice is not available and will even display addictive behavior with drugs thought to be non-addictive (such as marijuana and over-the-counter diet pills). That fact is extremely important in the way we think about drugs and addiction, because it means that the chemical is not the problem; it is the individual's reaction to it that causes the difficulty.

In addition, there is a difference between physical dependence and addictive disease. A normal person can be given enough morphine to become physically dependent on it. (Yes, certain drugs, in and of themselves, can produce physical dependence.) He may even suffer withdrawal symptoms afterward. But he will not hit the street looking for drugs once he's taken off the morphine. Only an addict will do that.

What, then, is an addict?

An addict, exposed to the same amount of morphine (or to any mood-altering drug, such as cocaine or marijuana), will compulsively attempt to repeat and even to intensify the feeling produced by drugs--no matter what the consequences. The key to diagnosis of addictive disease is in the observation that the patient persists in using drugs in spite of the consequences. His failure to adapt is our clue that he suffers from a real disease (as opposed to moral bankruptcy, which was once thought to be the case with alcoholics).

In other words, simply taking away cocaine or marijuana--even if it could be done--would not solve the problem of drug addiction. At treatment centers across the country, we learned this: If his cocaine is taken away, the coke addict will become addicted to alcohol. If his alcohol is taken away, he'll come back a month or a year later addicted to Valium or Xanax. If his Valium is taken away, you'll find him somewhere down the line taking heroin. And if his heroin is taken away, he'll find morphine, Stadol, Demerol, codeine, Talwin, Percodan, Dilaudid ... the list is endless. So is the problem, unless society learns this: Addiction is addiction is addiction. Until we leave off attacking individual chemicals and take up treating the disease, more and more people will suffer and die without ever understanding what hit them.

•

Mark S. Gold, M.D., is director of research at Fair Oaks Hospital and one of the most prominent addiction researchers in the United States. Fair Oaks doesn't look like a hospital. It looks like someone's mansion, tucked away on a small wooded hill next to the high school in Summit, New Jersey. In the new field of addictionology, Dr. Gold is one of the old hands, having published some 460 scientific papers in the field. Gold was one of the first scientists to demonstrate that cocaine was addictive (at a time when scientists still thought that it was the substance, not the addict, that mattered). He developed the first treatment for heroin overdose, which has saved many lives. He has also developed nonaddictive treatments that relieve the pain of withdrawal from addiction to cocaine, heroin and amphetamines, so that addicts no longer have to fear "going cold turkey."

Fair Oaks Hospital is one of the most well-respected treatment facilities in the nation. In that quiet, wooded location, Gold has treated rock stars, professional football players and the sons of Senators. Fair Oaks has a special locked ward for people whose wealth gives them too easy an access to drugs. Its staff teaches addicts that the particular drugs they've been using are not the essential problem; once they have developed addictive disease, they are equally vulnerable to all mood-altering drugs. The recovering coke addict can't go out and become a social drinker. The recovering heroin addict can't smoke an occasional joint. Even going to the hospital for surgery can be risky, because a shot of morphine that wouldn't affect most people adversely could trigger the cycle of addictive behavior and kill an addict.

Even though a precise definition is hard to come by, most authorities agree that there are three good indicators of addictive disease: compulsion, loss of control and continued use in spite of adverse consequences. In the case of a coke addict, that might result in a cycle such as this: Noon: "I need a line." Midnight: "Just a few more." Noon: "That was the worst experience I've ever had; I need some blow."

Here's a simple law of nature: Normal people move away from painful stimuli. In addiction, the adaptive response fails. It should not be surprising, then, that the word inebriate has several meanings: to exhilarate, to stupefy and to disorder the senses. Here's what the book Alcoholics Anonymous has to say about those combined effects:

Our behavior is as absurd and incomprehensible ... as that of an individual with a passion, say, for jaywalking. He gets a thrill out of skipping in front of fast-moving vehicles. He enjoys himself for a few years in spite of friendly warnings. Up to this point you would label him as a foolish chap having queer ideas of fun. Luck then deserts him and he is slightly injured several times in succession. You would expect him, if he were normal, to cut it out. Presently he is hit again and this time has a fractured skull. Within a week after leaving the hospital a fast-moving trolley car breaks his arm. He tells you he has decided to stop jaywalking (continued overleaf) for good, but in a few weeks he breaks both legs.

The description goes on. The jaywalker gets even worse. And the conclusion is "Such a man would be crazy, wouldn't he?" Indeed, once exposed to any mood-altering substance, most people who are predisposed to addictive disease are inexorably drawn into that sort of downward spiral of irrational behavior. Of course it's insane.

The frightening fact is this: Most people born with the tendency to become addicted will become addicted unless they never take drugs. A dope fiend can start or perpetuate the addictive cycle with over-the-counter diet pills or even with cough syrup if other drugs are unavailable. The controversy over whether or not marijuana "leads to the harder stuff" came from the mistaken idea that the chemicals are to blame. There are no gateway drugs. An addict finds his own gate and plunges through. The nonaddict does not, and not even making him physically dependent upon the drug by injecting him without his consent will turn him into an addict.

The only treatment for addictive disease is to give up all mood-altering chemicals. It used to be thought that taking drugs or drinking to excess was a symptom of some other disorder, but it is not. It is an illness in its own right--the cause, not the effect. The conclusion is the result of a simple but profound observation: Most addicts become normal people when they stop taking drugs.

Cocaine and the New Antidrug Movement

Professional sports teams have been instrumental in making people aware of the drug problem--all because of cocaine. "Why are the sports teams against cocaine?" Gold asks. "Because it makes wide receivers drop the ball. We have linemen with judgment problems, defensive ends who try to pick up the opposing player or a line backer who tries on national TV to do a one-and-a-half somersault over a tight end. Cocaine has anti-motor-performance effects. Athletes drank. Athletes used to take amphetamines. Athletes used to smoke marijuana. Not that they were good for the athlete, but it wasn't like time-lapse photography. With cocaine, you could watch an athlete decay in the same season. The core person rotted out from within somehow. The reason that cocaine has changed the way Americans think about drugs is that in a matter of months, you can see it all happen."

Over and over again, Gold emphasized that when he spoke of addiction, it wasn't important which drug the addict took. The disease is progressive, and it is fatal. A few years ago, the athlete who used amphetamines might have outlived his usefulness to the team before the drugs destroyed his performance. By then, it didn't matter. The team didn't suffer. There was no publicity. Today, that same athlete might find himself on national TV, because cocaine does its work so much faster.

The more we know, the more it looks as if the Nineties will be a risky time to experiment with drugs. Only 14 percent of the population may be susceptible to addiction, but those who are will have a wider array of more powerful drugs to get them into deeper trouble faster; and there appears to be no overwhelming philosophical or moral movement that will put a brake on our society's drive to seek ecstasy through chemicals. Perhaps most frightening is the fact that in an era when we believe we can cure any ill, addiction stands out as an incurable (but treatable) condition.

Memory and Addiction

Gold began to get interested in drugs at the University of Florida, when he noticed that students were taking amphetamines to improve their memory. He asked himself, "Do amphetamines really improve your memory?" He began doing research to find out.

"It turned out that speed improves your perception of your memory but not your memory. The truth of the matter is that memory is state-dependent." In other words, if a student learns something straight, he'll remember it best straight. If he learns something high, he'll remember it best high. For the best results, his mental state when he tries to recall what he has learned should be the same as when he tried to learn it. Thus, as Charles Dickens observed in April 1870, "If I hide my watch when I am drunk, I must be drunk again before I can remember where." In truth, the best performances are given by those who are straight both times.

"People who take amphetamines for memory kind of know that," Gold says. If they cram for an exam while they're high on speed and then start crashing during the exam, there is a mismatch and they can't remember. "Or if they're too high, there's a mismatch, too, and they can't grasp the memory. It's there, but they can't connect. And so we had the concept of state-dependency of memory."

That concept also explains why women tend to forget the pain of childbirth. Yet they'll remember the most minute details of a previous birth once they're experiencing labor again. "As the chemical states link up, they have full access to those memories again. It also explains relapse in drug abuse." When an addict goes through the detoxification process, the brain is cleared of chemicals. The sober addict cannot remember certain things from his stoned state. "However," Gold says, "with even one drug-use episode after a long period of abstinence, he can now match up those dormant memories, and they're all unlocked." Pandora's box is opened, neurologically speaking. "If it took him five years to get totally addicted, and then he's straight for five years, it could take him one dose and he'd be as bad as when fully addicted."

The fact that memory is dependent upon state of mind may eventually serve to explain a great deal about addiction, such as the failure of the adaptive response. We know what we know because of our ability to remember. The first time a toddler touches a hot radiator, he learns-- (continued on page 182)Addiction(continued from page 152) permanently learns--not to touch it again. Without that ability, he would not survive to adulthood. Without our memories intact, we are stupid. If we are unable to remember that drinking a quart of vodka causes us pain, we may do it again.

Science and the spirit of Addiction

Until a few years ago, the concept of addictive disease did not exist. No one had suggested that all addictions were the same. Therapists began to realize that the various drugs were just pressure points: Touch one and you'd set the entire continuum vibrating like a great spider web.

Gold explains addiction this way: "It's like that television commercial, 'Don't mess with mother nature.' There are areas of the brain that are meant to reward us for species-specific survival." In other words, when we have sex to reproduce more of our own species, when we eat to stay alive, when we drink water to keep from dying of thirst, certain areas of the brain--certain pleasure circuits, as it were--are activated. When those circuits are turned on, they make us feel so good that they guarantee that we'll eat, drink and reproduce. Before the advent of mood-altering drugs, the only way to excite those special cells was through sex, food or water. The system worked. The pleasure circuits helped preserve the species.

But "those are quiet areas of the brain," Gold warns. "They're not meant to be abused or overstimulated. In gaining access to those areas, drugs become an acquired primary drive." In Cocaine: A Special Report (Playboy, September 1984), Contributing Editor Laurence Gonzales wrote:

Cocaine somehow gets access to the areas of the brain (the amygdalae and the lateral hypothalamus) in which those chemical changes occur and allows you to make those changes at will. In addition, cocaine takes control of the use and manufacture within the body of essential chemical message transmitters, such as dopamine, which transmits sexual and feeding signals, and norepinephrine, which transmits signals to flee in the face of danger. When you take cocaine, it feels as if it's the most important function in life, because cocaine causes your body and brain to send those essential life-protecting and life-producing signals: the need for sex, food, water, flight. So, of course, you take more.

Stimulating those areas of the brain artificially causes terrible problems. For one thing, after being overstimulated, the pleasure circuits don't work anymore. Pleasure cannot be had. Pain is all that is left--pain and craving. The result is the classic clinical picture of addictive behavior: continued compulsive use of the drug despite the horrible consequences.

When the pleasure circuits in the brain no longer produce pleasure, the result is depression, anxiety, panic. The brain says, "You are dying of thirst. Get cocaine or you will die." That's why addicts steal.

Later, when the chemicals are gone from his brain, the addict can't believe he did it. He can't remember why he did it, because the memory states do not match. Remorse and anxiety set in. And not even getting high will make everything all right again. That's why addicts talk about needing to take drugs just to feel normal.

•

One of the most difficult jobs in treating addicts is to convince them that they cannot recover unless they avoid all mood-altering chemicals--forever. Cocaine addicts will want to be treated only for cocaine addiction: "Hey, I've never had a problem with drinking. Why hassle me about having a few beers?" Therapists hear it all the time: "How did this happen to me? I can't understand it. I never drank before." Or, even worse for the addict, "Hey, what's the problem if I smoke a joint after work? Grass isn't even addictive." That may be true, but it's not the drug, it's the person; and any mood-altering drug can reignite the inferno. Indeed, animal tests bear out that fact. No laboratory monkey, when offered a particular drug, says, "No, thanks, I use only Peruvian flake." An animal addicted to cocaine will substitute alcohol if he's deprived of his coke. Substitute heroin; he'll become a junkie. Give him the choice of any drug and he'll choose cocaine. Cocaine appears to be most dangerous because it is most efficient in triggering the reward circuitry of the brain.

Gold says (and authorities agree), "Any treatment program that isn't based on total abstinence is risking the person's chances for success. On clinical grounds we know that. The addict who uses any mood-altering substance can recapture and almost relive latent drug memories. Then he loses higher brain control." In other words, mood-altering drugs interfere with the addict's ability to remember why he can't use drugs. That sets him up for relapse. In fact, even while abstaining, most addicts have to be reminded daily why they can't use drugs, because their worst experiences happened while they were high. Because the memory is dependent upon the state of mind, those memories are not readily accessible to the sober brain.

"Once you're an addict, you're always at risk for relapse. What that means to a scientist is that relapse is a biological imperative. This is more or less a new principle of drug addiction: There's an active drive to relapse," Gold says.

We can now understand a few of the mysteries. For example, why is the first one free? It's free because it's free of anxiety. To inebriate means to exhilarate and then to stupefy. That's why the first one's free, because the first one is the exhilarating one. Then comes the stupefaction. The first one gives direct access to the controls in the brain that operate the most fundamental circuitry of pleasure and happiness. The first time out, the addict is God, with his hand on the throttle of ecstasy.

Why, then, doesn't everyone repeat this ecstatic process over and over again? No one knows. As Dr. David E. Smith, founder of the Haight-Ashbury Clinic in San Francisco and one of the pioneers of addiction research, said, the potential addict "responds differently the very first time he uses" a drug. Most addicts interviewed said the same thing: "I was hooked the first time I got high. I was no longer lonely, no longer self-conscious; I could be with people; I was not afraid." Normal people don't react to chemicals that way when they first take them. That's why normal people can take them or leave them.

•

What, then, are the new scientific secrets of treatment? If, say, cocaine depletes dopamine, a chemical messenger in the brain, then is there some nonaddictive, benign drug that we can use to replace dopamine? "There was an approved treatment for low-dopamine diseases called bromocriptine," Gold says. "We tried that in cocaine withdrawal and it worked. So we give that during the first ten days of abstinence and then stop." Similarly, the drug clonidine is used for heroin addiction.

"We don't have anything after that," Gold says. "But the power of the viable peer group, family treatment and involvement are usually sufficient to keep the person from relapse."

The what? The "viable peer group"? What happened to all those nice, hard-edged, scientific answers?

Gold explained, "Once you do fool with mother nature, there is an acquired drive for readdiction. That's the reason people have to remain in treatment their whole lives. The well ex-addict is the person who believes that going to meetings is his or her insurance policy."

Going to meetings?

The Heritage of Synanon

"You're going to be knocked over by the love," the monsignor shouted as his helicopter rose out over the Hudson River. The Empire State Building, the World Trade Center and all Manhattan fell away as the thundering rotors shattered the cold sunlight and ripped up the waters below. In the front seat was Monsignor William O'Brien, founder of Daytop Village, one of the oldest drug-treatment programs in the United States. We immediately liked the monsignor; he knew how to have a good time without drugs.

The monsignor was a large, well-dressed man in snap-brim cap and horn-rimmed glasses. He had a good sense of the showman. He wore a suit with no collar or tie. (He called his clerical garb "my monkey suit.") His demeanor seemed to suggest that in the land of God, the man of God is at home no matter where he goes. Especially in a helicopter.

He'd been a parish priest in the heart of New York during the Fifties, and he'd handled a lot of tough customers during his 24 years of building Daytop Village up from a house on Staten Island to an international therapeutic community with drug-rehabilitation centers all over the United States (including Alaska) and Canada, as well as in Italy, Spain, Thailand, Ireland, Brazil, Malaysia, Israel, Sweden, Germany and the Philippines. In fact, outside of Alcoholics Anonymous, the monsignor's was the largest drug-treatment empire on earth. His New York operation alone had a $15,000,000 budget.

As we thundered away over the red-and-green bowl of Giants Stadium, the monsignor whipped out some heavy leather picture albums full of color blowups showing himself with the Big Guy--Pope John Paul II. "Two weeks after he was shot," the monsignor said, "he was visiting Daytop in Italy."

As we circled Daytop's Catskill Mountain retreat, dozens of people came out of the red, barnlike buildings to stand in the snow and wave. The monsignor sat up in his Plexiglas bubble, waving and smiling. We looked at the photo albums. There was the Pope in his Plexiglas bubble, waving and smiling.

The chopper descended into the leafless trees where a circle had been cleared in the snow, and when we hopped out and approached the crowd, a tumultuous applause broke out amid much hugging and cheer. We were knocked over by the love.

We sat in a bright dining room overlooking pine forest and hills. On one wall were some of the traditional A.A. slogans (one day at a time, you have to give it away to keep it). At the front of the room, two large tables had been set with white linen. The monsignor and a few other special people (a Federal prosecutor, for example) were seated there, while 190 drug addicts sat at bare tables and watched them eat pastries and drink coffee, attended by waiters. There was a long, dizzying silence as those scores of addicts sat straight up in their hard chairs, watching them eat. Every one of them seemed positively riveted, as if he'd never seen grown men eat before. Or perhaps they were just hungry. Then, without explanation, they all filed silently out of the room, leaving us with our coffee and cakes in the big empty dining hall. No one attempted to explain what the demonstration meant.

"We don't teach the disease concept of addiction," the monsignor said.

Indeed, he and his followers believe that taking drugs is a symptom of family problems. "We are a family-repair station," he is fond of saying.

The course of treatment at Daytop takes two years and involves breaking down the ego, a technique used by Synanon leader Charles E. Dederich in the Fifties and also by the Moonies. It's called "love bombing," and many psychologists now recognize it as the method developed by the North Koreans for use on captured prisoners of war. It inspired the novel The Manchurian Candidate. The Koreans didn't realize that the effects they were after could be achieved without torture and violence. (In fact, physical violence is forbidden at Daytop.) All that's necessary is to remove the subject from his normal environment for a while (usually a few days is sufficient) and bombard him with stimulation and suggestion. The stimulation can be affectionate or cruel (or both); it hardly matters, as long as it is constant. The effect is the same: The suggestion gradually turns to belief. It is a kind of brainwashing, and many religious groups use it in one form or another.

New "prospects" coming to Daytop are systematically besieged by recovering addicts, who call them names, humiliate them and make them admit, "I'm a baby, I'm an addict." To get help from Daytop, one must beg for it. There is a chair called the Prospect Chair, and every new applicant must sit there for an indeterminate length of time, contemplating his commitment to treatment and recovery. The prospect is made to stand up on the chair and beg for help.

Once the prospect's will has been broken, the community showers him with hugs and encouragement and puts him to work cleaning the toilets and the kitchen.

Rule infractions are dealt with by ostracism. A resident might be in the chair for a day and a half (with time out for sleep) because of an attitude problem. That may sound harsh, but for an addict, an attitude problem can lead to relapse, and relapse is often fatal. People who shoot junk into their arms sometimes need to sit quietly for 36 hours or so. In any event, no one has ever died from treatment at Daytop and no one is held hostage.

But there's a long waiting list to get into Daytop, and it costs only $35 a day, so the citizens at Daytop Village aren't interested in losers. (By comparison, a survey of private hospitals in the New York area showed the average price for treatment to be about $490 a day.)

The monsignor's methods are controversial; but, in fact, any responsible medical authority will agree that without some form of brainwashing, the disease will follow its fatal course. Indeed, in the Thirties, Carl Jung attempted to treat alcoholics--with no success. (Many psychiatrists have tried over the years, but patients who seek psychiatric help for addictive problems are wasting their money.) Jung gave one patient this prognosis: "You have the mind of a chronic alcoholic. I have never seen one single case recover where that state of mind existed to the extent that it does in you." The patient would, quite simply, drink himself to death unless he was locked up. The only hope Jung held out was this: "Here and there, once in a while, alcoholics have had what are called vital spiritual experiences.... They appear to be in the nature of huge emotional displacements and rearrangements. Ideas, emotions and attitudes which were once the guiding forces of the lives of these men are suddenly cast to one side, and a new set of conceptions and motives begins to dominate them."

Oddly enough, that is precisely what both Fair Oaks and Daytop seek to trigger: huge emotional displacements. Gold and the monsignor may laugh at each other's beliefs, but they strive for the same end. It doesn't matter what they theorize about their methods. Every treatment program must accomplish a spiritual transformation if the addict is to recover.

The National Tragedy Business

Gold understands that the method of treating addiction at Fair Oaks and places like it is not the only answer. "It's like each substance-abuse program is a special vehicle and they teach you how to drive it. But every vehicle isn't appropriate for every person. You have to be able to learn how to drive that vehicle or you have to go find another one." In other words, those who seek relief from addictive disease may have to try several programs before they find one that works for them. "It may be that that program really did work for other people. But it's not like in the rest of medicine, where prospectively, in advance, we can tell with a good degree of likelihood what it is you're going to respond to." Another element in the problem is that it costs money to try out each new scheme, and most insurance policies pay for only the first one. Most working people are left to play a roulette game, hoping they hit on a legitimate treatment program the first time and that it happens also to be the one that works for them.

Addiction may be one disease, no matter what the chemical, but not all addicts are created equal, and the rigors of science have not yet found a language for dealing with the variety of addictive experience. An addict may take any number of paths. Some researchers believe that most never get counted, because they solve their own problems. They find that they are in trouble and simply quit. They join a self-help group and maintain recovery in that way. Or they make a pact with their wives or their employers to quit and the pact alone keeps them straight.

Typically, the addict who fails in those methods and who then seeks treatment will begin a process of migration from program to program until something takes--until that mysterious spiritual transformation takes place. It is not uncommon to find people who have completed a recognized, legitimate course of treatment ten or even 20 times. Most people start with "the best" treatment program insurance money can buy and move toward more and more restrictive treatment environments until they are locked up if nothing else works. Daytop is one of the most restrictive treatment environments, requiring, as it does, prolonged residence in a community removed from the rest of society. You can't remove drugs from society, but you can remove society from drugs.

A young, fresh-looking Ivy League student at Daytop said he'd been in a coma for 30 hours after an extended spree of smoking cocaine. Black curls fell around his high cheekbones. He wore a sports coat and T-shirt in the current mode, and a shy smile flickered across his face as he recalled his visits to various hospitals. He'd been in and out of treatment many times. When asked what type of impoverished background he had come from to wind up in a nonprofit program such as Daytop's, he said, "My grandfather is a Nobel Peace Prize winner, and my father is a wealthy businessman in New York." No amount of family money could buy what he needed. He knew that he needed to be brainwashed good and proper, or he was going to die.

"They didn't do anything for our spiritual growth," said another Daytopper who'd been to a for-profit private treatment center. "There weren't any group-therapy sessions. We just basically got detoxed and were cut loose."

A fireman at Daytop said his union health-insurance plan paid $28,000 for his 30-day stay at Regent Hospital in New York. (By comparison, a year at Daytop costs about $13,000.) Regent is one of several drug-treatment facilities owned by a Los Angeles giant called National Medical Enterprises, Inc., which also owns Fair Oaks. Unquestionably, Regent has a legitimate treatment program, but it still didn't work for that fireman.

Another man told of spending $7000 in a private clinic in Pennsylvania for 28 days. Hazelden in Minnesota is one of the oldest and most respected addiction-treatment centers in this country. It costs about $4000 for 28 days.

Monsignor O'Brien and his disciples sneer at the scientists--the Mark Golds of the world--and the new breed of country-club rehabilitation centers that have sprung up in response to the so-called drug crisis in America. O'Brien calls their methods "ping-pong therapy," meaning that they think they can cure addicts by giving them pleasant surroundings and a ping-pong table to play on. He thinks it is cynical and wrong for private companies to lead people with life-threatening problems to believe that they can be cured in 28 days. "Those programs are 28 days long because that's what the insurance companies will pay for," he says.

Drug-treatment centers can, indeed, seem cynical when analyzed in business terms. The Comprehensive Care Corporation of Irvine, California, has CareUnits at hospitals all over the nation. Chairman and president B. Lee Karns made a telling statement in his company's 1986 annual report. He cited "six positive indicators about our future, which should enable us to perform well...." One of them was that "the indisputable fact remains that the use and abuse of alcohol and drugs in this country continue at epidemic proportions. Chemical abuse constitutes a national tragedy, which is becoming worse, not a problem that is being solved." Now, clearly chairman Karns doesn't think that a national tragedy is a good thing. But his role as chairman forces him to admit that it is a "positive indicator" for his company. In other words, the private, for-profit drug-treatment centers reap their benefits in direct proportion to the depth of this national tragedy. Furthermore, according to Karns, the problem is getting worse, and that's going to boost sales. CompCare had revenues of $192,936,000 in 1986.

A few years ago, rising medical costs and an economic recession resulted in more and more empty beds in hospitals. People weren't having enough elective surgery. So someone suggested this: Why not find another condition that insurance companies cover and devote those empty beds to that condition and fill them? Comprehensive Care Corporation came up with the idea of the CareUnit to do just that: "McTreatment," as some therapists call it, an instant drug facility in any local hospital that has empty beds to fill.

It turned out that treating addiction was better than performing surgery. The patient didn't need a doctor; he decided on his own whether or not to buy the service. One surgeon can perform only so many unnecessary hysterectomies, but a couple of therapists can handle hundreds of addicts. A potential patient simply needs to be convinced that he has a problem. And that means advertising. Then create an attractive environment, make treatment seem like fun and, above all, keep it simple.

It sounds pretty terrible, doesn't it? Are the private, for-profit drug-treatment centers helping people or are they simply taking advantage of a national tragedy?

Michael Darcy, head of the Gateway Foundation in Chicago and a man highly qualified to treat addictive disease, says, "I'm all in favor of them. They are a tremendous help. The TV ads are something we could never afford, and they've made it possible for people out there to diagnose themselves. That would not have been possible a few years ago. Secondly, the private clinics are getting people into A.A. who wouldn't otherwise get there." A.A., especially in the past few years, has become a self-help haven for substance abusers of all stripes (some under the affiliated groups of C.A. [Cocaine Anonymous] and N.A. [Narcotics Anonymous]). Without the 28-day programs, Darcy says, either those people would have to spend decades poisoning themselves before they really "hit bottom" or else they might die before ever getting to self-help groups. In many cases, the 28-day programs catch people who are on the brink of suicide or verging on overdose. Furthermore, says Darcy, "more young people are getting into A.A. than ever before. They get their lives back earlier."

"Bringing up the Bottom"

If it is a characteristic of the disease to deny its existence, how, then, can an addict be persuaded to seek treatment? The television ads tell wives that their husbands are drunks, tell parents their kids are dope fiends, tell everyone, "Surely, someone you love has this problem. Why don't you help him-slash-her?" Denial is one reason that the for-profit drug-treatment centers use what's known as the Minnesota Model of therapy. The Minnesota Model is the method of treatment developed by Hazelden (which is nonprofit). It has a magical ingredient that some other treatment programs lack, without which treatment for profit would be much less productive of cash flow. That ingredient is known as intervention.

The A.A. philosophy holds that an alcoholic--or a cocaine or heroin addict--has to "hit bottom" before he can enter treatment. Until he hits bottom, he's going to be more interested in getting drunk than in getting sober. (Remember, it's become a primary drive, more important than food, water and sex.) Now, hitting bottom may mean nothing more than becoming so sick of himself that the abuser can't stand it any longer. Or it may mean utter devastation. In the early days of A.A., if a problem drinker went for help too early, old-timers might have deemed him still too healthy to appreciate fully what A.A. was all about. They might have been inclined to tell him, "You're not ready. Go on out and get some more experience." Then, when he had finally lost his house, his car, his job, his wife, his reputation, his money, his dog, his health and, most important, his self-esteem--then and only then did those A.A. pioneers embrace him. (Today, A.A. accepts anyone who is chemically dependent.)

Clearly, a program such as that would not work well for profit. No, on the contrary: Get those addicts into treatment long before even they realize the need for it. From a medical standpoint, it made more sense, anyway. A doctor wouldn't diagnose cancer and tell the patient, "Well, the tumor is only the size of a pea. Come back when it's the size of a football and we'll operate." Addictive disease, like any disease, is best treated early; and research has shown that any treatment is better than no treatment, even if it doesn't result in total abstinence the first time around. And so the idea of "bringing up the bottom" to meet the addict was developed. It is described in Easy Does It:

An essential part of Minnesota Model treatment is direct intervention in the [addict's] life.... Since denial is a central characteristic in [addiction], the Minnesota Model supports getting the practicing [addict] into treatment through constructive coercion if necessary, by using either involuntary commitment or "voluntary" admission resulting from an arranged crisis confrontation. The [addict] is a motivated person, motivated to feel better, and [drug taking] is used as a means of trying to feel better. Once the denial system is dismantled, the motivation to feel better can be used constructively in the rehabilitation process.

The most important fact about intervention is that it works. People who seek treatment voluntarily do no better than people coerced into it. As a consequence, most for-profit treatment facilities today can feel confident that using trained intervention specialists is a legitimate way to generate business while helping the addict.

A typical intervention involves getting the addict's relatives, friends, employer--anyone who has influence over him--to have, as it were, a surprise party for him coordinated by a professional counselor. Each person has a prepared list of what the addict has done lately to make life miserable. (A daughter might be enlisted, for example, to say, "Mom, I brought my new boyfriend over and you came out of the bathroom naked." Or "Dad, you missed my graduation because you couldn't get out of bed.") Each person also has an ultimatum. (A boss might be brought in to say, "Jim, if you don't get into this treatment program, you're going to be fired.")

Mark Gold calls it "organized coercion. And that's really what it comes down to, short of catastrophic intervention, such as an accident, hitting bottom, you crack up your car, you're busted going through the metal detectors. Your family may have called Customs to arrange an involuntary commitment. They'll call the local police and say, 'I'll turn in my loved one if you promise me that you'll give him the choice of treatment or prosecution.' This happens all the time. Once the addict's relationship to the drug is stronger than any other relationships, then you need some organized intervention." Timing may be of the essence. "There may be just an instant when the person is truly receptive to getting help."

Once the addict is in treatment, especially treatment before he has hit bottom, "it appears that the person is never more than 51 percent in favor of getting better," Gold says. "There really are these two forces within him: the drug speaking and trying to preserve itself--the parasite trying to remain in some equilibrium with the host--and the other side of the person that's getting all this support from work, from friends, from loved ones, to try to bolster itself, to make it assert itself so that treatment becomes possible."

The essential aim of Hazelden's treatment plan--the Minnesota Model--is to get the addict fully involved in A.A. or one of its sister organizations, so that when he leaves treatment, he will continue going to meetings. The same is true of Gateway, Fair Oaks, the Betty Ford Center, Comprehensive Care's CareUnits and every responsible treatment facility. In fact, one measure of a treatment program's effectiveness is how far it will go to get the addict to join A.A. after his insurance money is gone. At some hospitals, a staff member will hand the phone to the addict when his 28 days are up and say, "Call A.A. Here's the number. Good luck." Others have A.A. meetings in the hospital throughout the treatment program and insist upon follow-up meetings on hospital grounds. Some private programs won't accept anyone who can't commit himself to at least a year of treatment. Another key to good treatment is including the family. The addict cannot go it alone. Addiction is a disease that affects the entire family. Being married to an addict, being the child or the parent of an addict makes one ill. Family members must be treated, or the patient will relapse. And even with A.A., there is a 50 percent chance of relapse within 24 months.

Relapse

The small percentage of the people in any society who suffer from addictive disease suffer greatly. Part of the reason is relapse. The American Medical Association includes in its definition of alcoholism the fact that it is a disease "characterized by a tendency to relapse." (The same is true of addiction to any other drug.) Of those who are treated, half to two thirds relapse within two years, whatever their method of treatment. Yet few treatment facilities address that issue, either before or during treatment; and few programs provide the long-term therapy necessary to give the patient the best chance against relapse. The reason for that is simple: Treatment costs money. And most insurance policies cover only 28 days of treatment in the hospital and extremely limited follow-up and outpatient treatment.

When relapse occurs, it seems to come out of the blue, blanking out all reason, all experience, all logic. But there are warning signs. It may begin as anger or depression. It may begin as a sense of well-being, confidence, a warm glow of pride at how well everything is going. As one A.A. member said, "In my 30 years, no one ever called me to ask to be prevented from taking a drink. I myself never called for help at the threshold of relapse, probably because I did not want to be stopped." From Alcoholics Anonymous, here's a description of relapse after a promising period of sobriety:

I felt hungry, so I stopped at a roadside place where they have a bar. I had no intention of drinking. I just thought I would get a sandwich.... I had eaten there many times during the months I was sober. I sat down at a table and ordered a sandwich and a glass of milk. Still no thought of drinking. I ordered another sandwich and decided to have another glass of milk. Suddenly the thought crossed my mind that if I were to put an ounce of whiskey in my milk, it couldn't hurt me on a full stomach. I ordered a whiskey and poured it into the milk. I vaguely sensed I was not being any too smart but felt reassured as I was taking the whiskey on a full stomach. The experiment went so well that I ordered another whiskey and poured it into more milk. That didn't seem to bother me, so I tried another.

That adventure landed that addict in an asylum. The scientists would call what happened to him selective memory or euphoric recall, in which the addict suddenly remembers the good times he had while high. It is a cunning and baffling and cruel trick of neurochemistry. Charles Crewe of Hazelden concludes that "the tendency to relapse should receive as much attention as does initial recovery." In other words, any program that slights the importance of a deep and lifelong involvement in A.A. (or Cocaine Anonymous or Narcotics Anonymous) is not for the addict who is serious about protecting his recovery.

In the Thirties, Alcoholics Anonymous emerged from the disastrous inability of the medical and psychiatric professions to do anything about alcoholism. One historian described what early A.A. members did and how it worked:

Drinking experiences and alcoholic histories were dramatically revealed at the slightest provocation; suggestions were freely given based on one's own experiential background of alcoholism--and recovery; hope and enthusiasm were openly expressed about the good prospects that most patients had for recovery; and coffee was consumed extensively throughout the day and night.... This finding that, somehow, sick, disturbed people could help each other in small peer groups without the benefit of professional assistance surprised us very much.... We now call this therapeutic peer-group experience the "helper-therapy principle," meaning that in such groups the helper seems to get as much help as the person being helped.

The A.A. tradition of telling stories is not for the benefit of the person to whom they are told. It is for the benefit of the person telling them. Historian Ernest Kurtz wrote, "The sober alcoholic told his own story out of the conviction that such honesty was required only by and necessary only to his own sobriety. This example was evidence of the A.A. understanding that honesty was necessary to get sobriety." The happy by-product of self-therapy for the one who has already attained sobriety is that the would-be A.A. member identifies with the stories he hears. He says, "Hey, this guy was almost as pan-fried as I was. And look at him now. How did he get sober?" Once that moment of identification--of constructive envy--is achieved, the addict is on his way to recovery.

Becoming addicted is like being in a near-fatal car accident and having both legs cut off. In relative terms, it doesn't happen to many people. And it shouldn't discourage everyone else from driving. But for those unfortunate enough to be victims, there is no quick fix, only a lifetime of coping; and any advertisement that suggests otherwise is misleading people.

There is only one proven way to maintain abstinence: one day at a time for a lifetime. Drug treatment has become big business, but no one stays in business providing lifelong treatment. No one could afford it, and no insurance company would cover it. Not even the nonprofit places offer unlimited treatment. And that is why, no matter where an addict goes for his initial treatment or detoxification, he will find the same thing: All roads lead to A.A. (or C.A. or N.A.). The reason is simple. It's free and it works.

"The addict suffers from a real disease and will compulsively use mood-altering drugs no matter what the consequences."

What we've learned in 14 years

We published this chart almost 15 years ago, in September 1972, when lack of overt use and hard evidence made some drugs (such as cocaine) seem less harmful than they are now known to be. New drugs, both dangerous and unpredictable, have been developed; they pose new risks. Furthermore, a new understanding of addiction has come about: While certain chemicals do have a peculiar power to produce physical dependence, true addiction is possible only for people who suffer from addictive disease. Therefore, to say that cocaine is extremely addictive while marijuana is not misses the point. Those prone to addiction will become addicted. Based on the latest scientific and behavioral research, we've indicated the most important new information, but bear in mind that the "risk" ratings are no longer as meaningful as they once were. All mood-altering chemicals are dangerous to addiction-prone people. Some, such as cocaine, merely kill you faster. PCP (phencyclidine), now a major drug of abuse, was not generally known in 1972. It can be sniffed, smoked or injected. In small amounts, it produces hallucinations, euphoria, anesthesia and stimulation. In larger amounts, it produces severe hallucinations, sweating, flushing, drooling, dizziness, lack of physical coordination, slurred speech and violent psychotic reactions. For some reason, people on PCP are drawn to water but are unable to swim; many drownings result from PCP intoxication. PCP is both habit-forming and addictive. The long-term effects are psychosis and death. (Some 30 percent of involuntary psychiatric patients have been users of PCP.)

Valium, a tranquilizer, became the most popular prescription drug in the world during the Seventies. In combination with alcohol, Valium is dangerous and can be fatal. (This is true of all tranquilizers and barbiturates.) The risk of addiction is extremely high.

Ecstasy (methylenedioxyamphetamine, or MDA--also MMDA and MDMA) is one of the many new designer drugs whose effects are not well known. However, it is presumed by medical authorities to be highly addictive, as are the other amphetamines.

Caffeine is addictive.

Potent new compounds, such as China White, increase the risk of fatality.

Marijuana is addictive. It carries a high risk of habituation, and tolerance to its effects develops quickly. Although not generally thought to be a common condition, dependence upon marijuana alone, especially among adolescents, is now known to occur. Additional effects include deterioration of hand--eye coordination, infertility, panic, anxiety, paranoia and trancelike states. Marijuana cultivation has led to strains of Cannabis that contain far more THC (the psychoactive ingredient) than plants did 14 years ago. The long-term effects of marijuana are not entirely known. One thing is certain: It is no longer considered to be harmless by any responsible medical authority.

Amphetamine use carries a high risk of addiction.

The high cost of cocaine, its scarce supply and impure quality prevented its addictiveness from being recognized for a time. However, it's now known that the risk of addiction is extremely high for people who take cocaine. Crack, or free-based cocaine, has become dangerously popular. Short-term toxic effects of cocaine can include heart failure, fever, respiratory collapse and sudden death. Long-term effects include impotence, anxiety, depression and heart ailments, in addition to the other effects mentioned in the chart.

Nicotine is addictive.

" 'Why are sport teams against cocaine? Because it makes wide receivers drop the ball.... With cocaine, you could watch an athlete decay in the same season.' "

By the editors of Playboy, based on reporting by Laurence Gonzales.