Drug War Injustice and Us: Who's Fighting Wildfires?#links

Drug War Injustice and Us: Who's Fighting Wildfires?#links

Drug War Injustice and Us: Who's Fighting Wildfires?#links

Drug War Injustice and Us: Who's Fighting Wildfires?#links

WOMEN DRUG USERS AND THE CRIMINAL JUSTICE SYSTEM
by Alasdair Cant.
It is impossible to put an exact figure on the number of drug using women who come into contact with the criminal justice system, for the same reason that it is impossible to assess the exact proportion of drug users - because of the illegal and stigmatised nature of drug use. However, there are findings, both anecdotal and researched that give us some indication as to how drug using women are faring in the criminal justice system.
About prisons, Oscar Wilde said:
"..every prison that men build Is built with bricks of shame, And bound with bars lest Christ should see How men their brothers maim."
The term brothers in the last line is interesting. Historically, it is a true reflection of the gender imbalance in the prison population. Increasingly, however, 'brothers and sisters' would be more accurate. Although there are still far more men imprisoned than women, approximately four per cent of the adult prison population in the UK are women, the number of women in prison has been rising steadily in recent years.
In England and Wales, sentencing has become harsher, and women have been caught up by this trend. The 17 per cent rise in the number of women in prison compared to this time last year, reflects an overall trend in sentencing. The female prison population in March, stood at just under 2,000, an increase of around 11 per cent in 12 months. Contrary to popular belief, this is not due to any rising tide of female violence, least of all 'girl gangs'. This is, if I may use a little more alliteration, a media myth. According to the Prison Service, the number of women sent to prison for motoring offences has doubled in the past year, while those imprisoned for drug-related crimes has fallen by one third. The biggest single factor that results in women being given custodial sentences, is still that of non-payment of fines, which accounts for about a third of the women being jailed.
I wish to look at the thorny issue of sentencing, and in particular at the disparity in sentencing between men and women. We have to look carefully at this whole question, because the danger is to give a simplistic answer, which could then give rise to wrong assumptions.
The extent to which sentencers, and especially judges are predominantly men, is well catalogued. This situation has not improved much over the last few years, in spite of much publicity over this discrepancy. The scenario runs much along these lines:
A woman appears in the dock, looking down at heel, and evidently an established drug user. The male sentencer (wearing de rigueur half moon spectacles) is shocked at extent to which this woman has deviated from the 'normal path'. Normal to him, is a subjective judgement about how women should appear and behave. Hence he gives a harsher sentence than he might give to an equivalent male defendant.
Is this borne out by research and observation? Release has certainly observed that, in terms of sentencing alone, women are discriminated against in the courts on occasions, but not always. There have been instances, especially for first time offenders, where women drug users have seemed to get particularly harsh sentences. So, yes, this scenario does occur- in a variety of different shades and variations. But as in many situations where stereotyping is prevalent, it is not the whole picture.
Conversely, the Release legal advisers are aware that women do sometimes get treated more leniently by the courts. There may be convincing reasons why she should not go to prison, and in circumstances where it hangs in the balance, good legal representation and effective court report writing has made all the difference. Anyone who has been in a court of law will recognise that it is an artificial setting, designed to raise the stature of some, and humble the others. In blunt terms, it is something of a 'game', and I use this word with caution, because I don't wish to trivialise the seriousness of attending court, but rather draw attention to the fact that doing and saying the correct things is often in the best interests of the defendant. Women do seem to take on board better than men the hidden rules of attending a court - deferring to the court, dressing smartly, being polite to the bench and so on. However, this is anecdotal observation. What about evidence in research?
Criminal statistics across time and cultures, show that an overwhelming majority of those caught, convicted and sentenced by the courts are male. As well as this, numerous pieces of research, including findings from feminist criminology, suggest that men are more likely than women to receive custodial sentences for equivalent offences. According to most recent Home Office statistics, however, the notable exception to this is for drug offences, where the proportion of males to females sentenced to custody is roughly equal.
In the case of cautioning, the same situation seems to apply, where a conviction is the most common outcome for female offenders. In 1992, 61 per cent of all females convicted or cautioned for indictable offences received a caution, compared with 36 per cent of males. Women had higher cautioning rates across all age groups and most offences, but yet again, the exception to this was where drugs are involved.
So what do we make of this? Statistically, it does seem that where drugs and women are concerned, they buck the overall trend of women getting more lenient sentences from the courts. However, we must be very wary of drawing immediate conclusions from this. There are still too many unknowns. To properly research sentencing, many more factors must be taken into account, such as a detailed analysis of each case, taking previous offending, aggravating/mitigating circumstances and so on into account. My own observation in our local magistrates court makes me a little sceptical of research. The reason is that the character of the magistrates sentencing is as different as you are likely to find anywhere in London. One magistrate is renown for his harsh sentencing, and indeed demonstrated how in touch with reality he was by stopping court proceedings to ask what a can of Lilt is! The other is much more lenient, and I have heard him once suggesting to one defendent that he felt 10 pounds a week was too much to pay, and 5 per week over a longer period was much more realistic. Hence, someone tried in court on Monday afternoon might get a very different sentence from someone tried in court on Tuesday morning for exactly the same offence. Such factors must surely make accurate research nigh on impossible.
In trying to analyse the significance of data about women drug users in the criminal justice system, it is easy to lose sight of important overall concerns. It does seem for example that female drug users are discriminated against in the courts, but drug users generally are misrepresented and discriminated against in our society. Where should we direct our energies and resources to counter this?
Secondly, is there equally suitable provision for women as for men throughout the criminal justice system? In a system which deals largely with male offenders, the needs of women offenders are often not effectively addressed. An investigation by HM Inspectorate of Probation in 1991 found that a limited range of community penalties are available for women in some areas. This has been an on-going situation and probation officers often complain to me about the lack of provision for women. There are only a handful of bail hostels in the country that are for women only. There is Crowley House in Birmingham, where women are taken with children, but this serves a massive area. There is also Adelaide House in Liverpool and Kelley House in Camden, London. That is pitifully little provision for the whole of England and Wales. Proximity to men in custody, whether in a bail hostel or in prison, can be very distressing. The men may have records of violence, and research by the charity Women in Prison, shows that a high proportion of women prisoners have been victimised and abused by men. In mixed bail hostels, for example, out of 26 residents, it is quite usual for there to be only about four women
It is little wonder then, that where the question of custody hangs in the balance for drug using women, it often swings towards custody because of inadequate provision outside. Imaginative remand schemes that divert women from crime and custody by developing community-based programmes must be encouraged. I can cite one example as the Holloway Remand Scheme in London. Its function is to closely match and utilise community resources for selected women offenders. These resources include residential drug and alcohol rehabilitation programmes, but we are all too aware that one of the difficulties facing field probation officers is finding suitable resources for women in the community.
In considering prisons, the report on Styal prison and young offender institution for women, received a lot of publicity. The fact that drugs are used in prison is no longer headline news, but when this report was released, it received a lot of attention. In fact, it received more media attention in one week than the plight of foreign nationals being held in custody for drug trafficking offences (a staggering 35 per cent in one of the largest women's prisons in England) received over 18 months. I believe the reason for such interest in drugs in Styal was for two reasons. Firstly, the public is not aware of the extent of drug use among women, as it conflicts with the stereotyped image. Secondly, the extent of use as reported, took everyone by surprise, including those in the drugs field. The report by Dr Malcolm Faulk states:
"Inmates asserted, and staff agreed, that drugs were freely available in Styal, mainly brought in by visitors and by inmates who had been on home leave. They said that almost all inmates used cannabis, in addition to which 80 per cent used opiates (mainly heroin), 50 per cent cocaine/crack,15-20 per cent amphetamines, ten per cent LSD occasionally and 60 per cent benzodiazepines (mainly Temazepam). It was believed that 60 per cent of those who injected used shared needles. Inmates were aware of the risk of contaminated needles. Detergent was available but not bleach." (Extract from report of an unannounced short inspection of Styal.)
Styal prison had 207 female prisoners at the time of the inspection, 52 of whom had been convicted of, or were charged with drug-related offences. That works out at around 25 per cent, yet health care staff at the prison estimated that up to 90 per cent of inmates were using drugs during their stay at Styal. Yet there was no detoxification process, and little rehabilitation.
What conclusions can we draw from this? The overriding concern Release has, is that women are actually being put at risk by the state. This is not simply conjecture. On 4 February 1995, the British Medical Journal published an abstract of the first report of an outbreak of HIV infection occurring within a prison.
At Glenochil prison in Scotland, of a total of 378 male inmates, 227 (60 per cent) were counselled and 162 (43 per cent) tested for H IV. Twelve (seven per cent) of those tested were HIV positive. One third (76) of those counselled had injected drugs at some time, of whom 33 (43 per cent) had injected in Glenochil; all 12 seropositive men belonged to this group, and 32 of the 33 had shared needles and syringes in the prison. Evidence based on sequential results and time of entry into prison indicated that eight transmissions definitely occurred within the prison in the first half of 1993.
Release, along with many other organisations has plenty of anecdotal evidence that there is a high likelyhood of HIV infection occurring within a prison. For many years we have actively supported the view that at very least clean needles should be supplied in prisons. The findings at Styal were extremely alarming. But it is even more alarming that a significant piece of research should follow so quickly to confirm that in a similar environment "restricted access to injecting equipment resulted in random sharing and resulted in an outbreak of HIV infection".
In conclusion, since most women are not seen to posethreat to the community, and drug using women would be generally included in this, there is a strong argument for abolishing prison as a punishment for such offenders altogether. Added to this, there is now no question that the lives of many women in custody are at risk, and we wholeheartedly support the view of the academics academedics involved in the Glenochil prison research, that in the short term at very least, measures to prevent further spread of infection among prison injectors are urgently required.
But to give the final word to a woman prisoner:
"I don't think anything can be done that's going to be constructive until they get rid of the way they treat women and see women. If you're not like their women - Ah then we've got you like our women".
Alasdair Cant is training manager at Release.

Part One: The Overview
Government Seizures Victimize Innocent
February 27, 1991.
Willie Jones, a second-generation nursery man in his family's Nashville business, bundles up money from last year's profits and heads off to buy flowers and shrubs in Houston. He makes this trip twice a year using cash, which the small growers prefer.
But this time, as he waits at the American Airlines gate in Nashville Metro Airport, he's flanked by two police officers who escort him into a small office, search him and seize the $9,600 he's carrying. A ticket agent had alerted the officers that a large black man had paid for his ticket in bills, unusual these days. Because of the cash, and the fact that he fit a "profile" of what drug dealers supposedly look like, they believed he was buying or selling drugs.
He's free to go, he's told. But they keep his money -- his livelihood -- and give him a receipt in its place.
No evidence of wrongdoing was ever produced. No charges were ever filed. As far as anyone knows, Willie Jones neither uses drugs, nor buys or sells them. He is a gardening contractor who bought an airplane ticket. Who lost his hard-earned money to the cops. And can't get it back.
That same day, an ocean away in Hawaii, federal drug agents arrive at the Maui home of retirees Joseph and Frances Lopes and claim it for the U.S. government.
For 49 years, Lopes worked on a sugar plantation, living in its camp housing before buying a modest home for himself, his wife, and their adult, mentally disturbed son, Thomas.
For a while, Thomas grew marijuana in the back yard -- and threatened to kill himself every time his parents tried to cut it down. In 1987, the police caught Thomas, then 28. He pleaded guilty, got probation for his first offense and was ordered to see a psychologist once a week. He has, and never again has grown dope or been arrested. The family thought this episode was behind them.
But earlier this year, a detective scouring old arrest records for forfeiture opportunities realized the Lopes house could be taken away because they had admitted they knew about the marijuana.
The police department stands to make a bundle. If the house is sold, the police get the proceeds.
Jones and the Lopes family are among the thousands of Americans each year victimized by the federal seizure law -- a law meant to curb drugs by causing financial hardship to dealers.
A 10-month study by The Pittsburgh Press shows the law has run amok. In their zeal to curb drugs and sometimes fill their coffers with the proceeds of what they take, local cops, federal agents and the courts have curbed innocent Americans' civil rights. From Maine to Hawaii, people who are never charged with a crime had cars, boats, money and homes taken away.
In fact, 80 percent of the people who lost property to the federal government were never charged. And most of the seized items weren't the luxurious playthings of drug barons, but modest homes and simple cars and hard-earned savings of ordinary people.
But those goods generated $2 billion for the police departments that took them.
The owners' only crimes in many of these cases: They "looked" like drug dealers. They were black, Hispanic or flashily dressed.
Others, like the Lopeses, have been connected to a crime by circumstances beyond their control.
Says Eric Sterling, who helped write the law a decade ago as a awyer on a congressional committee: "The innocent-until-proven- guilty concept is gone out the window.
Airport drug team sieze cash from travelers suspected of being couriers
The Law: Guilt Doesn't Matter
Rooted in English common law, forfeiture has surfaced just twice in the United States since colonial times.
In 1862, Congress permitted the president to seize estates of Confederate soldiers. Then, in 1970, it resurrected forfeiture for the civil war on drugs with the passage of racketeering laws that targeted the assets of criminals.
In 1984 however, the nature of the law was radically changed to allow government to take possession without first charging, let alone convicting the owner. That was done in an effort to make it easier to strike at the heart of the major drug dealers. Cops knew that drug dealers consider prison time an inevitable cost of doing business. It rarely deters them. Profits and playthings, though, are their passions. Losing them hurts.
And there was a bonus in the law. the proceeds would flow back to law enforcement to finance more investigations. It was to be the ultimate poetic justice, with criminals financing their own undoing.
But eliminating the necessity of charging or proving a crime has moved most of the action to civil court, where the government accuses the item -- not the owner -- of being tainted by a crime.
This oddity has court dockets looking like purchase orders: United States of America vs. 9.6 acres of land and lake; U.S. vs. 667 bottles of wine. But it's more than just a labeling change. Because money and property are at stake instead of life and liberty, the constitutional safeguards in criminal proceedings do not apply.
The result is that "jury trials can be refused; illegal searches condoned; rules of evidence ignored," says Louisville, Ky. defense lawyer Donald Heavrin. The "frenzied quest for cash," he says, is "destroying the judicial system."
Every crime package passed since 1984 has expanded the uses of forfeiture, and now there are more than 100 statutes in place at the state and federal level. Not just for drug cases anymore, forfeiture covers the likes of money laundering, fraud, gambling, importing tainted meats and carrying intoxicants onto Indian land.
The White House, Justice Department and Drug Enforcement Administration say they've made the most of the expanded law in getting the big-time criminals, and they boast of seizing mansions, planes and millions in cash. But the Pittsburgh Press in just 10 months was able to document 510 current cases that involved innocent people -- or those possessing a very small amount of drugs -- who lost their possessions.
And DEA's own database contradicts the official line. It showed that big-ticket items -- valued at more than $50,000 -- were only 17 percent of the total 25,297 items seized by DEA during the 18 months that ended last December.
"If you want to use that 'war on drugs' analogy, the forfeiture is like giving the troops permission to loot," says Thomas Lorenzi, presidentelect of the Louisiana Association of Criminal Defense Lawyers.
The near-obsession with forfeiture continues without any proof that it curbs drug crime -- its original target.
"The reality is, it's very difficult to tell what the impact of drug seizure is," says Stanley Morris, deputy director of the federal drug czar's office.

Police Forces Keep the Take
The "loot" that's coming back to police forces all over the nation has redefined law-enforcement success. It now has a dollar sign in front of it.
For nearly eighteen months, undercover Arizona State Troopers worked as drug couriers driving nearly 13 tons of marijuana from the Mexican border to stash houses around Tucson. They hoped to catch the Mexican suppliers and distributors on the American side before the dope got on the streets.
But they overestimated their ability to control the distribution. Almost every ounce was sold the minute they dropped it at the houses.
Even though the troopers were responsible for tons of drugs getting loose in Tucson, the man who supervised the setup still believes it was worthwhile. It was "a success from a cost-benefit standpoint," says former assistant attorney-general John Davis. His reasoning: It netted 20 arrests and at least $3 million for the state forfeiture fund.
"That kind of thinking is what frightens me," says Steve Sherick, a Tucson attorney. "The government's thirst for dollars is overcoming any long-range view of what it is supposed to be doing, which is fighting crime."
George Terwilliger III, associate deputy attorney general in charge of the U.S. Justice Department's program emphasizes that forfeiture does fight crime, and "we're not at all apologetic about the fact that we do benefit (financially) from it."
In fact, Terwilliger wrote about how the forfeiture program financially benefits police departments in the 1991 Police Buyer's Guide of Police Chief Magazine.
Between 1986 and 1990, the U.S. Justice Department generated $1.5 billion from forfeiture and estimates that it will take in $500 million this year, five times the amount it collected in 1986.
District attorney's offices throughout Pennsylvania handled $4.5 million in forfeitures last year; Allegheny County (ED: Pgh is in Allegheny County) $218,000, and the city of Pittsburgh, $191,000 -- up from $9,000 four years ago.
Forfeiture pads the smallest towns coffers. In Lexana, Kan, a Kansas City suburb of 29,000, "we've got about $250,000 moving in court right now," says narcotic detective Don Crohn.
Despite the huge amounts flowing to police departments, there are few public accounting procedures. Police who get a cut of the federal forfeiture funds must sign a form saying merely they will use it for "law enforcement purposes."
To Philadelphia police that meant new air conditioning. In Warren County, N.J., it meant use of a forfeited yellow Corvette for the chief assistant prosecutor.
Judy Mulford, 31, and her 13-year old twins, Chris, left, and Jason, are down to essentials in their Lake Park, Fla., home, which the government took in 1989 after claiming her husband, Joseph, stored cocaine there. Neither parent has been criminally charged, but in April a forfeiture jury said Mrs. Mulford must forfeit the house she bought herself with an insurance settlement. The Mulfords have divorced, and she has sold most of her belongings to cover legal bills. She's asked for a new trial and lives in the near-empty house pending a decision.

'Looking' Like a Criminal
Ethel Hylton of New York City has yet to regain her financial independence after losing $39,110 in a search nearly three years ago in Hobby Airport in Houston.
Shortly after she arrived from New York, a Houston officer and Drug Enforcement Administration agent stopped the 46-year-old woman in the baggage area and told her she was under arrest because a drug dog had scratched at her luggage. The dog wasn't with them, and when Miss Hylton asked to see it, the officers refused to bring it out.
The agents searched her bags, and ordered a strip search of Miss Hylton, but found no contraband.
In her purse they found the cash Miss Hylton carried because she planned to buy a house to escape the New York winters which exacerbated her diabetes. It was the settlement from an insurance claim, and her life's savings, gathered through more than 20 years of work as a hotel housekeeper and hospital night janitor.
The police seized all but $10 of the cash and sent Miss Hylton on her way, keeping the money because of its alleged drug connection. But they never charged her with a crime.
The Pittsburgh Press verified her jobs, reviewed her bank statements and substantiated her claim she had $18,000 from an insurance settlement. It also found no criminal record for her in New York City.
With the mix of outrage and resignation voiced by other victims of searches, she says: "The money they took was mine. I'm allowed to have it. I earned it."
Miss Hylton became a U.S. citizen six years ago. She asks, "Why did they stop me? Is it because I'm black or because I'm Jamaican?"
Probably, both -- although Houston police haven't said.
Drug teams interviewed in dozens of airports, train stations and bus terminals and along other major highways repeatedly said they didn't stop travellers based on race. But a Pittsburgh Press examination of 121 travellers' cases in which police found no dope, made no arrest, but seized money anyway showed that 77 percent of the people stopped were black, Hispanic, or Asian.
In April, 1989, deputies from Jefferson Davis Parish, Louisiana, seized $23,000 from Johnny Sotello, a Mexican-American whose truck overheated on a highway.
They offered help, he accepted. They asked to search his truck. He agreed. They asked if he was carrying cash. He said he was because he was scouting heavy equipment auctions.
They then pulled a door panel from the truck, said the space behind it could have hidden drugs, and seized the money and the truck, court records show. Police did not arrest Sotello but told him he would have to go to court to recover his property.
Sotello sent auctioneer's receipts to police which showed he was a licensed buyer. the sheriff offered to settle the case, and with his legal bills mounting after two years, Sotello accepted. In a deal cut last March, he got his truck, but only half his money. The cops kept $11,500.
"I was more afraid of the banks than anything -- that's one reason I carry cash," says Sotello. "But a lot of places won't take checks, only cash, or cashier's checks for the exact amount. I never heard of anybody saying you couldn't carry cash."
Affidavits show the same deputy who stopped Sotello routinely stopped the cars or black and Hispanic drivers, exacting "donations" from some.
After another of the deputy's stops, two black men from Atlanta handed over $1,000 for a "drug fund" after being detained for hours, according to a hand-written receipt reviewed by the Pittsburgh Press.
The driver got a ticket for "following too close." Back home, they got a lawyer.
Their attorney, in a letter to the Sheriff's department, said deputies had made the men "fear for their safety, and in direct exploitation of that fear a purported donation of $1000 was extracted..."
If they "were kind enough to give the money to the sheriff's office," the letter said, "then you can be kind enough to give it back." If they gave the money "under other circumstances, then give the money back so we can avoid litigation."
Six days later, the sheriff's department mailed the men a $1,000 check.
Last year, the 72 deputies of Jefferson Davis Parish led the state in forfeitures, gathering $1 million -- more than their colleagues in New Orleans, a city 17 times larger than the parish.
Like most states, Louisiana returns the money to law enforcement agencies, but it has one of the more unusual distributions: 60 percent goes to the police bringing a case, 20 percent to the district attorney's office prosecuting it and 20 percent to the court fund of the judge signing the forfeiture order.
"The highway stops aren't much different from a smash-and-grab ring," says Lorenzi, of the Louisiana Defense Lawyers Association.
George Terwillger, who helps set justice Department's forfeiture policy, calls the law "effective."
Paying For Your Innocence
The Justice Department's Terwilliger says that in some cases "dumb judgement" may occasionally cause problems, but he believes there is an adequate solution. "That's why we have courts."
But the notion that courts are a safeguard for citizens wrongly accused "is way off," says Thomas Kerner, a forfeiture lawyer in Boston. "Compared to forfeiture, David and Goliath was a fair fight."
Starting from the moment that the government serves notice that it intends to take an item, until any court challenge is completed, "the government gets all the breaks," says Kerner.
The government need only show probable cause for a seizure, a standard no greater than what is needed to get a search warrant. The lower standard means the government can take a home without any more evidence than it normally needs to take a look inside.
Clients who challenge the government, says attorney Edward Hinson of Charlotte, N.C., "have the choice of fighting the full resources of the U.S. treasury or caving in."
Barry Kolin caved in.
Kolin watched Portland, Ore., police padlock the doors of Harvey's, his bar and restaurant for bookmaking on March 2.
Earlier that day, eight police officers and Amy Holmes Hehn, the Multnomah County deputy district attorney, had swept into the bar, shooed out waitresses and customers and arrested Mike Kolin, Barry's brother and bartender, on suspicion of bookmaking.
Nothing in the police documents mentioned Barry Kolin, and so the 40-year-old was stunned when authorities took his business, saying they believe he knew about the betting. He denied it.
Hehn concedes she did not have the evidence to press a criminal case against Barry Kolin, "so we seized the business civilly."
During a recess in a hearing on the seizures weeks later, "the deputy DA says if I paid them $30,000 I could open up again," Kolin recalls. When the deal dropped to $10,000, Kolin took it.
Kolin's lawyer, Jenny Cooke, calls the seizure "extortion." She says: "There is no difference between what the police did to Barry Kolin or what Al Capone did in Chicago when he walked in and said, 'This is a nice little bar and it's mine.' the only difference is today they call this civil forfeiture."

Minor Crimes, Major Penalties
Forfeiture's tremendous clout helps make it "one of the most effective tools that we have," says Terwilliger.
The clout, though, puts property owners at risk of losing more under forfeiture that they would in a criminal case under the same circumstances.
Criminal charges in federal and many state courts carry maximum sentences. But there's no dollar cap on forfeiture, leaving citizens open to punishment that far exceeds the crime.
Robert Brewer of Irwin, Idaho, is dying of prostate cancer, and uses marijuana to ease the pain and nausea that comes with radiation treatments.
Last Oct. 10, a dozen deputies and Idaho tax agents walked into the Brewer's living room with guns drawn and said they had a warrant to search.
The Brewers, Robert, 61, and Bonita, 44, both retired form the postal service, moved from Kansas City, Mo., to the tranquil, wooded valley of Irwin in 1989. Six months later, he was diagnosed.
According to police reports, an informant told authorities Brewer ran a major marijuana operation.
The drug SWAT team found eight plants in the basement under a grow light and a half-pound of marijuana. The Brewers were charged with two felony narcotics counts and two charges for failing to buy state tax stamps for the dope.
"I didn't like the idea of the marijuana, but it was the only thing that controlled his pain," Mrs. Brewer says.
The government seized the couples five-year-old Ford van that allowed him to lie down during his twice-a-month trips for cancer treatment at a Salt Lake City hospital, 270 miles away. Now they must go by car.
"That's a long painful ride for him ... He needed that van, and the government took it," Mrs. Brewer says. "It looks like they can punish people any way they see fit."
The Brewers know nothing about the informant who turned them in, but informants play a big role in forfeiture. Many of them are paid, targeting property in return for a cut of anything that is taken.
The Justice Department's asset forfeiture fund paid $24 mil. to informants in 1990 and has $22 million allocated this year.
Private citizens who snitch for a fee are everywhere. Some airline counter clerks receive cash awards for alerting drug agents to "suspicious" travellers. The practice netted Melissa Furtner, a Continental Airlines clerk in Denver, at least $5,800 between 1989 and 1990, photocopies of checks show.
Increased surveillance, recruitment of citizen-cops, and expansion of forfeiture sweeps are all part of a take-now, litigate-later syndrome that builds prosecutors careers, says a former federal prosecutor.
"Federal law enforcement people are the most ambitious I've ever met, and to get ahead they need visible results. Visible results are convictions, and, now, forfeitures," says Don Lewis of Meadville, Crawford County. (ED: a Pa county north of Pgh by two counties.)
Lewis spent 17 years as a prosecutor, serving as an assistant U.S. attorney in Tampa as recently as 1988. He left the Tampa Job -- and became a defense lawyer -- when "I found myself tempted to do things I wouldn't have thought about doing years ago."
Terwilliger insists U.S. attorneys would never be evaluated on "something as unprofessional as dollars."
Which is not to say Justice doesn't watch the bottom line.
Cary Copeland, director of the department' Executive Office for Asset Forfeiture, says they tried to "squeeze the pipeline" in 1990 when the amount forfeited lagged behind Justice's budget projections.
He said this was done by speeding up the process, not by doing a "whole lot of seizures."
Ending the Abuse
While defense lawyers talk of reforming the law, agencies that initiate forfeiture scarcely talk at all.
DEA headquarters makes a spectacle of busts like the seizure of fraternity houses at the University of Virginia in March. But it refuses to supply detailed information on the small cases that account for most of its activity.
Local prosecutors are just as tight-lipped. Thomas Corbett, U.S. Attorney for Western Pennsylvania, seals court documents on forfeitures because "there are just some things I don't want to publicize. the person whose assets we seize will eventually know, and who else has to?"
Although some investigations need to be protected, there is an "inappropriate secrecy" spreading throughout the country, says Jeffrey Weiner, president-elect of the 25,000 member National Association of Criminal Defense Lawyers.
"The Justice Department boasts of the few big fish they catch. But they throw a cloak of secrecy over the information on how many innocent people are getting swept up in the same seizure net, so no one can see the enormity of the atrocity."
Terwilliger says the net catches the right people: "bad guys" as he calls them.
But a 1990 Justice report on drug task forces in 15 states found they stayed away from the in-depth financial investigations needed to cripple major traffickers. Instead, "they're going for the easy stuff," says James "Chip" Coldren, Jr., executive director of the Bureau of Justice Assistance, a research arm of the federal Justice Department.
Lawyers who say the law needs to be changed start with the basics: The government shouldn't be allowed to take property until after it proves the owner guilty of a crime.
But they go on to list other improvements, including having police abide by their state laws, which often don't give police as much latitude as the federal law. Now they can use federal courts to circumvent the state.
Tracy Thomas is caught in that very bind.
A jurisprudence version of the shell game hides roughly $13,000 taken from Thomas, a resident of Chester, near Philadelphia.
Thomas was visiting in his godson's home on Memorial Day, 1990, when local police entered looking for drugs allegedly sold by the godson. They found none and didn't file a criminal charge in the incident. But they seized $13,000 from Thomas, who works as a $70,000-a-year engineer, says his attorney, Clinton Johnson.
The cash was left over from a Sheriff's sale he'd attended a few days before, court records show. the sale required cash -- much like the government's own auctions.
During a hearing over the seized money, Thomas presented a withdrawal slip showing he'd removed money from his credit union shortly before the trip and a receipt showing how much he had paid for the property he'd bought at the sale. The balance was $13,000.
On June 22, 1990, a state judge ordered Chester police to return Thomas' cash.
They haven't.
Just before the court order was issued, the police turned over the cash to the DEA for processing as a federal case, forcing Thomas to fight another level of government. Thomas is now suing the Chester police, the arresting officer, and the DEA.
"When DEA took over that money, what they in effect told a local police department is that it's OK to break the law," says Clinton Johnson, attorney for Thomas.
Police manipulate the courts not only to make it harder on owners to recover property, but to make it easier for police to get a hefty share of any forfeited goods. In federal court, local police are guaranteed up to 80 percent of the take -- a percentage that may be more than they'd receive under state law.
Pennsylvania's leading police agency-- the state police -- and the state's lead prosecutor -- the Attorney General -- bickered for two years over state police taking cases to federal court, an arrangement that cut the Attorney General out of the sharing.
The two state agencies now have a written agreement on how to divvy the take.
The same debate is heard around the nation.
The hallways outside Cleveland courtrooms ring with arguments over who will get what, says Jay Milano, a Cleveland criminal defense attorney.
"It's causing a feeding frenzy."
GOVERNMENT SEIZED HOME OF MAN WHO WAS GOING BLIND
James Burton says he loves America and wants to come home. But he can't. If he does, he'll wind up in prison, go blind, or both. Burton and his wife, Linda, live in an austere, concrete-slab apartment furnished with lawn chairs near Rotterdam in the Netherlands. It is home much different from the large house and 90-acre farm they owned near Bowling Green, Ky., before the government seized both.
For Burton, who has glaucoma, home-grown marijuana provided his relief - and his undoing.
Since 1972, federal health secretaries have reported to Congress that marijuana is beneficial in the treatment of glaucoma and several other medical conditions.
Yet while some officials within the Drug Enforcement Administration have acknowledged that medical value of marijuana, drug agents continue to seize property where chronically ill people grow it.
"Because of the emotional rhetoric connected with the marijuana issue, a doctor who can prescribe cocaine, morphine, amphetamines, and barbiturates cannot prescribe marijuana, which is the safest therapeutically active drug known to man," Francis Young, administrative law judge for DEA, was quoted as saying in Burton's trial.
In an interview this past July 4, Burton said, "We don't really have any choice right now but to stay" in the Netherlands, where they moved after he completed a one-year jail term for three counts of marijuana possession. "I can buy or grow marijuana here legally, and if I don't have the marijuana, I'll go blind.
Burton, a 43-year-old Vietnam War veteran, has a rare form of hereditary, low-tension glaucoma. All of the men on his mother's side of the family have the disease, and several already are blind. It does not respond to traditional medications.
At the time of Burton's arrest, N.C. ophthalmologist Dr. John Merritt was the only physician authorized by he government to test marijuana in the treatment of glaucoma patients. Merritt testified at Burton's trial that marijuana was "the only medication' that could keep him from going blind.
On July 7, 1987 Kentucky state police raided Burton's farm and found 138 marijuana plants and two pounds of raw marijuana. "It was the kickoff of Kentucky drug awareness month, and I was their special kickoff feature. It was all over television," Burton said.
Burton admitted growing enough marijuana to produce about a pound a month for the 10 to 15 cigarettes he uses each day to reduce pressure in his eye.
A jury decided he grew the dope for his own use - not to sell, as the government contended - and in March 1988 found him guilty of three counts of simple possession.
The pre-sentence report on Burton shows he had no previous arrests. The judge sentenced him to a year in a federal maximum security prison, with no parole.
On top of that, the government took his farm: 90 rolling, wooded acres in Warren Country purchased for $34,701 in 1980 and assessed at twice that amount when it was taken.
On March 27, 1989, U.S. District Judge Ronald Meredith - without hearing any witnesses and without allowing Burton to testify in his own behalf - ordered the farm forfeited and gave the Burtons 10 days to get off the land. When owners of property live at a site while marijuana is growing in their presence, there is no defense to forfeiture," Meredith ruled.
"I never got to say two words in defense of keeping my home, something we worked and saved for for 18 years," said Burton, who was a master electrical technician. Linda, 41, worked for an insurance company. "On a serious matter like taking a person's home, you'd think the government would give you a chance to defend it."
Joe Whittle, the U.S. Attorney who prosecuted the Burton case, says he didn't know about the glaucoma until Burton's lawyer raised the issue in court. His office has "taken a lot of heat on this case and what happened to that poor guy," Whittle says. "But we did nothing improper."
"Congress passed these laws, and we have to follow them. If the American people wanted to exempt certain marijuana activity - these mom and pop or personal use or medical cases - they should speak through their duly elected officials and change the laws. Until those laws are changed, we must enforce them to the full extent of our resources."
The action was "an unequaled and outrageous example of government abuse," says Louisville lawyer Donald Heavrin, who failed to get the U.S. Supreme Court to hear the case.
"To send a man trying to save his vision to prison, and steal the home and land that he and his wife had worked decades for, should have the authors of the Constitution spinning in their graves."

Part Three: INNOCENT OWNERS
Police profit by seizing homes of innocent
by Andrew Schneider and Mary Pat Flaherty
Four years after their son's marijuana arrest, police seized Hawaii home of Joseph and Frances Lopes
The second time police came to the Hawaii home of Joseph and Frances Lopes, they came to take it.
"They were in a car and a van, I was in the garage. They said, 'Mrs. Lopes, let's go into the house, and we will explain things to you.' They sat in the dining room and told me they were taking the house. It made my heart beat very fast."
For the rest of the day, 60-year old Frances Lopes and her 65-year-old husband, Joseph, trailed federal agents as they walked through every room of the Maui house, the agents recording the position of each piece of furniture on a video tape that serves as the government's inventory.
Four years after their mentally unstable adult son pleaded guilty to growing marijuana in their back yard for his own use, the Lopeses face the loss of their home. A Maui detective trolling for missed forfeiture opportunities spotted the old case. He recognized that the law allowed him to take away their property because they knew their son had committed a crime on it.
A forfeiture law intended to strip drug traffickers of ill-gotten gains often is turned on people, like the Lopeses, who have not committed a crime. The incentive for the police to do that is financial, since the federal government and most states let the police departments keep the proceeds from what they take.
The law tries to temper money making temptations with protections for innocent owners, including lien holders, landlords whose tenants misuse property, or people unaware of their spouse's misdeeds. The protection is supposed to cover anyone with an interest in a property who can prove he did not know about the alleged illegal activity, did not consent to it, or took all reasonable steps to prevent it.
But a Pittsburgh Press investigation found that those supposed safeguards do not come into play until after the government takes an asset, forcing innocent owners to hire attorneys to get their property back - if they ever do.
"As if the law weren't bad enough they just clobber you financially," says Wayne Davis, an attorney from Little Rock, Ark.
FEARED FOR THEIR SON
In 1987, Thomas Lopes, who was then 28 and living in his parents' home, pleaded guilty to growing marijuana in their back yard. Officers spotted it from a helicopter.
Because it was his first offense, Thomas received probation and an order to see a psychologist. From the time he was young, mental problems tormented Thomas, and though he visited a psychologist as a teen , he had refused to continue as he grew older, his parents say.
Instead, he cloistered himself in his bedroom, leaving only to tend the garden.
His parents concede they knew he grew the marijuana.
"We did ask him to stop, and he would say, 'Don't touch it', or he would do something to himself," says the elder Lopes, who worked for 49 years on a sugar plantation and lived in its rented camp housing for 30 years while he saved to buy his own home.
Given Thomas' history and a family history of mental problems that caused a grandparent and an uncle to be committed to institutions, the threats stymied his parents.
The Lopeses, says their attorney Matthew Menzer, "were under duress. Everyone who has been diagnosed in this family ended up being taken away. They could not conceive of any way to get rid of the dope without getting rid of their son or losing him forever."
When police arrived to arrest Thomas, "I was so happy because I knew he would get care," says his mother. He did, and he continues weekly doctor's visits. His mood is better, Mrs. Lopes says, and he has never again grown marijuana or been arrested.
But his guilty plea haunts his family.
Because his parents admitted they knew what he was doing, their home was vulnerable to forfeiture.
Back when Thomas was arrested, police rarely took homes. But since, agencies have learned how to use the law and have seen the financial payoff, says Assistant U.S. Attorney Marshall Silverberg of Honolulu.
They also carefully review old cases for overlooked forfeiture possibilities, he says. The detective who uncovered the Lopes case started a forfeiture action in February - just under the five-year deadline for staking such a claim.
"I concede the time lapse on this case is longer than most, but there was a violation of the law, and that makes this appropriate, not money-grubbing," says Silverberg. "The other way to look at this, you know, is that the Lopeses could be happy we let them live there as long as we did." They don't see it that way.
Neither does their attorney, who says his firm now has about eight similar forfeiture cases, all of them stemming from small-time crimes that occurred years ago but were resurrected. "Digging these cases out now is a business proposition, not law enforcement," Menzer says.
"We thought it was all behind us," says Lopes. Now, "there isn't a day I don't think about what will happen to us."
They remain in the house, paying taxes and the mortgage, until the forfeiture case is resolved. Given court backlogs, that likely won't be until the middle of next year, Menzer says.
They've been warned to leave everything as it was when the videotape was shot.
"When they were going out the door," Mrs. Lopes says of the police, "they told me to take good care of the yard. They said they would be coming back one day."
'DUMB JUDGMENT'
Protections for innocent owners are "a neglected issue in federal and state forfeiture law," concluded the Police Executive Research Forum in its March bulletin.
But a chief policy maker on forfeiture maintains that the system is actively interested in protecting the rights of the innocent.
George J. Terwilliger III, associate deputy attorney general in the Justice Department, admits that there may be instances of "dumb judgment." And says if there's a "systemic" problem, he'd like to know about it.
But attorneys who battle forfeiture cases say dumb judgment is the systemic problem. And they point to some of Terwilliger's own decisions as examples.
The forfeiture policy that Terwilliger crafts in the nation's capital he puts on use in his other federal job: U.S. attorney for Vermont.
A coalition of Vermont residents, outraged by Terwilliger's forfeitures of homes in which small children live, launched a grass roots movement called "Stop Forfeiture of Children's Homes." Three months old, the group has about 70 members, from school principals to local medical societies.
Forfeitures are a particularly sensitive issue in Vermont where state law forbids taking a person's primary home. That restriction appears nowhere in federal law, which means Vermont police departments can circumvent the state constraint by taking forfeiture cases through federal courts.
The playmaker for that end-run: Terwilliger.
"It's government-sponsored child abuse that's destroying the future of children all over this state in the name of fighting the drug war," says Dr. Kathleen DePierro, a family practitioner who works at Vermont State hospital, a psychiatric facility in Waterbury.
The children of Karen and Reggie Lavalle, ages 6, 9 and 11, are precisely the type of victims over which the Vermonters agonize. Reggie Lavalle is serving a 10-year sentence in a federal prison in Minnesota for cocaine possession.
Because police said he had been involved with drug trafficking, his conviction cost his family their ranch house on 2 acres in a small village 20 miles east of Burlington. For the first time, the family is on welfare, in a rented duplex.
"I don't condone what my husband did, but why victimize my children because of his actions ? That house wasn't much, but it was ours. It was a home for the children, with rabbits, chicken, turkeys and a vegetable garden. Their friends were there, and they liked the school," says Mrs. Lavalle, 29.
After the eviction, "every night for months, Amber cried because she couldn't see her friends. I'd like to see the government tell this 9-year-old that this isn't cruel and unusual punishment."
Terwilliger's dual role particularly troubles DePierro. "It's horrifying to know he is setting policy that could expand this type of terror and abuse to kids in every state in the nation."
Terwilliger calls the group's allegations absurd. "If there was some one to blame, it would be the parents and not the government."
Lawyers like John MacFadyen, a defense attorney in Providence, R.I., find it harder to fix blame.
"The flaw with the innocent owner thing is that life doesn't paint itself in black and white. It's often times gray, and there is no room for gray in these laws," MacFadyen says. As a consequence, prosecutors presume everyone guilty and leave it to them to show otherwise. "That's not good judgment. In fact, it defies common sense."
PROVING INNOCENCE
Innocent owners who defend their interests expose themselves to questioning that bores deep into their private affairs. Because the forfeiture law is civil, they also have no protection against self-incrimination, which means that they risk having anything they say used against them later.
The documentation required of innocent owner Loretta Stearns illustrates how deeply the government plumbs.
The Connecticut woman lent her adult son $40,000 in 1988 to buy a home in Tequesta, Fla, court documents show.
Unlike many parents who treat such transactions informally, she had the foresight to record the loan as a mortgage with Palm Beach County. Her action ultimately protected her interest in the house after the federal government seized it, claiming her son stored cocaine there. He has not been charged criminally.
The seizure occurred in November 1989, and it took until last May before Mrs. Stearns convinced the government she had a legitimate interest in the house.
To prove herself an innocent owner, Mrs. Stearns met 14 requests for information, including providing "all documents of any kind whatsoever pertaining to your mortgage, including but not limited to loan application, credit reports, record of mortgages and mortgage payments, title reports, appraisal reports, closing documents, records of any liens, attachments on the defendant property, records of payments, canceled checks, internal correspondence or notes (hand-written or typed) relating to any of the above and opinion letter from borrower's or lender's counsel relating to any of the above."
And that was just question No. 1.
Karen Lavalee and her 3 children are the type of forfeiture victims that concern a Vermont group trying to stop government seizure of homes of children whose parents face drug charges
LANDLORD AS COP
Innocent owners are supposed to be shielded in forfeitures, but at times they've been expected to become virtual cops in order to protect their property from seizure.
T.T. Masonry Inc. owns a 36-unit apartment building in Milwaukee, Wis., that's plagued by dope dealing. Between January 1990, when it bought the building, and July 1990, when the city formally warned it about problems, the landlord evicted 10 tenants suspected of drug use, gave a master key to local beat and vice cops, forwarded tips to police and hired two security firms - including an off-duty city police officer - to patrol the building.
Despite that effort, the city sized the property. Assistant City Attorney David Stanosz says, "once a property develops a reputation as a place to buy drugs, the only way to fix that is to leave it totally vacant for a number of months. This landlord doesn't want to do that."
Correct, says Jermome Buting, attorney for Tom Torp of Masonry. "If this building is such a target for dealers, use that fact," says Buting. "Let undercover people go in. But when I raised that, the answer was they were short of officers and resources."
IT LOOKS LIKE COKE
Grady McClendon, 53, his wife, tow of their adult children and two grandchildren - 7 and 8 - were in a rented car headed to their Florida home in August 1989. They were returning from a family reunion in Dublin, Ga.
In Fitzgerald, Ga, McClendon made a wrong turn on a one-way street. Local police stopped him, checked his identification and asked permission to serach the car. He agreed.
Within minutes, police pulled open suitcases and purses, emptying out jewelry and about 10 Florida state lottery tickets. They also found a registered handgun.
Then says McClendon, the police "started waving a little stick they said was cocaine. They told me to put on my glasses and take a good look. I told them I'd never seen cocaine for real but that it didn't look like TV."
For about six hours, police detained the McClendon family at the police station where officers seized $2,300 in cash and other items, as "instruments of drug activity and gambling paraphernalia" - a reference to the lottery tickets.
Finally, they gave McClendon a traffic ticket and released them, but kept the family's possessions.
For 11 months, McClendon's attorney argued with the state, finally forcing it to produce lab tests results on the "cocaine".
James E. Turk, the prosecutor who handled the case will say only "it came back negative."
"That's because it was bubble gum," says Jerry Froelich, McClendon's attorney. A Judge returned the McClendon's items.
Turk considers the search "a good stop. They had no proof of where they lived boyond drivers' licenses. They had jewelry that could have been contraband, but we couldn't prove it was stolen. And they had more cash than I would expect them to carry."
McClendon says: "I didn't see anything wrong with them asking me to search. That's their job. But the rest of it was wrong, wrong, wrong."
SELLER, BEWARE
Owners who press the government for damages are rare. Those who do are often helped by attorneys who forgo their usual fees because of their own indignation over the law.
For nearly a decade, the lives of Carl and Mary Shelden of Moraga, Calif., have been intertwined with the life of a convicted criminal who happened to buy their house.
The complex litigation began when the Sheldens sold their home in 1979, but took back a deed of trust from the buyer - an arrangement that made the Sheldens a mortgage holder on the house.
Four years later, the buyer was arrested and later convicted of running an interstate prostitution ring. His property, including the home on which the Sheldens held the mortgage, was forfeited. The criminal, pending his appeal, went to jail, but the government allowed his family to live in the home rent free.
Panicked when they read about the arrest in the newspaper, the Sheldens discovered they couldn't foreclose against the government and couldn't collect mortgage payments from the criminal.
After tortuous court appearances, the Sheldens got back the home in 1987, but discovered it was so severely damaged while in government control that they can now stick their hand between the bricks near the front door.
The home the Sheldens sold in 1979 for $289,000 was valued at $115,000 in 1989 and now needs nearly $500,000 in repairs, the Sheldens say, chiefly from uncorrected drainage problems that caused a retaining wall to let loose and twist apart the main house.
Disgusted, they returned to court, saying their Fifth Amendment rights had been violated. The amendment prohibits the taking of private property for public use without just compensation. Their attorney, Brenda Grantland of Washington, D.C., argues that when the government seized the property but failed to sell it promptly and pay off the Sheldens, it violated their rights.
Between 1983 and today, the Sheldens have defended their mortgage through every type of court: foreclosures , U.S. District Court, Bankruptcy, U.S. Claims.
In January 1990, a federal judge issued an opinion agreeing the Sheldens' rights had been violated. The government asked the judge to reconsider, and he agreed. A final opinion has not been issued.
"It's been a roller coaster," says Mrs. Shelden, 46. A secretary, she is the family's breadwinner. Shelden, 50, was permanently disabled when he broke his back in 1976 while repairing the house. Because he was unable to work, the couple couldn't afford the house, so they sold it - the act that pitched them into their decade-long legal quagmire.
They've tried to rent the damaged home to a family - a real estate agent showed it 27 times with no takers - then resorted to renting to college students, then room-by room boarders. Finally, they and their children, ages 21 and 16 moved back in.
"We owe Brenda (Grantland) thousands at this point, but she's really been a doll, " says Shelden. "Without people like her, people like us wouldn't stand a chance."
CIVIL FORFEITURES CAN THREATEN A COMPANY'S EXISTENCE
For businesses, civil forfeitures can be a big, big stick. Bad judgment, lack of knowledge or outright wrongdoing by one executive can put the company itself in jeopardy.
A San Antonio bank faces a $1 million loss and may close because it didn't know how to handle a huge cash transaction and got bad advice from government banking authorities, the bank says. The government says the bank knowingly laundered money for an alleged Mexican drug dealer.
The problems began when Mexican nationals came to Stone Oak National Bank, about 150 miles north of the border, to buy certificated of deposits with $300,000 cash. The Mexicans planned to start an American business, they said. They had drivers' licenses and passports.
Bank officers, who wanted guidance about the cash, called the Internal Revenue Service, Secret Service, Office of the Comptroller of the Currency, the Federal Reserve, and the Department of Treasury.
Federal banking regulators require banks to file CTRs - currency transaction reports - for cash deposits greater than $10,000.
That paper trail was created to develop leads about suspicious cash. Once the government was alerted, the thinking went, it could track the cash, put depositors under surveillance or set up a sting.
A tape-recorded phone line that Stone Oak, like many banks, uses for sensitive transactions captured a conversation between a Treasury official and then-bank president Herbert Pounds. According to transcripts, Pounds said: "We're a small bank. I've never had a transaction like that.....I talked to several of my banking friends. They've never had anybody bring in that much cash, and the guys say they've got a lot more where that came from."
Pounds asked for advice and was told to go through with the transaction. "That's fine...as long as you send the CTRs," the Treasury official said. "That's all you're responsible for."
The bank took the money and filed the form.
Between that first transaction in March 1987 and the government's March 1989 seizure of $850,000 in certificates of deposit, bank officials continued to file reports, according to photocopies reviewed by The Pittsburgh Press.
"The government had two years to come in and say, 'Hey, something smells bad here,' but it never did," says Sam Bayless, the bank's attorney.
But the government now charges that the bank customers were front men for Mario Alberto Salinas Trevino, who was indicted for drug trafficking in March 1989. Fourteen months later, the bank president and vice president were added to the indictment and charged with money laundering.
The bank never was criminally charged, and the officers' indictments were dismissed May 29.
The U.S. attorney's office in San Antonio said it would not discuss the case.
Because the Mexicans used their certificates as collateral for $1 million in loans from Stone Oak, the bank is worried it will lose the money. In addition, according to banking regulations, it must keep $1 million in reserve to cover that potential loss. For those reasons, it has asked the government for a hearing and has spent nearly $250,000 for lawyers' fees.
But the bank can't get a hearing because the forfeiture case is on hold pending the outcome of the criminal charges. And the criminal case has been indefinitely delayed because Salinas escaped six weeks after he was arrested.
Because the bank is so small, the $1 million set-aside puts it below capital requirements, meaning "regulatory authorities could well require Stone Oak National Bank to close before ever having the opportunity for its case to be heard," says its court brief.
To brace for a loss, Stone Oak closed one of its branches. "For the life of me," says Bayless, "I can't understand why the government would want to sink a bank. And, to boot, why would the government want another Texas bank?"
Bayless, who says, "I'm very conservative, I'm a bank lawyer, for heaven's sake," derides the federal action as "narco-McCarthyism."
Problems with paperwork also led to the seizure of $227,000 from a Colombian computer company.
The saga started in January, 1990 when Ricardo Alberto Camacho arrived in Miami with about $296,000 in cash to pay for an order of computers.
Camacho is a representative of Tandem Limitada, the authorized dealer in Colombia and Venezuela for VeriFone products, says VeriFone spokesman Tod Bottari. The cash covered a previously placed order for about 1,600 terminals.
Both the government and Camacho agree that when he arrived in Miami, he declared the amount he was carrying with Customs. They also agree that the breakdown of the amount - cash vs. other monetary instruments, such as checks - was incorrect on his declaration form.
Camacho and the government disagree about whether the incorrect entry was intentional - the government's position - or a mistake made by an airport employee.
The airport employee, in a deposition, said he had filled out the form and handed it to Camacho for him to initial, which he did. "Mr. Camacho assumed the agent had correctly written down the information provided to him," says Camacho's court filings over the subsequent seizure of the money. The government says Camacho deliberately misstated the facts to hide cash made form drug sales.
Camacho brought in the suitcase full of U.S. cash which he had purchased at a Bogata bank, because he thought it would speed delivery of his order, he told federal agents.
VeriFone lawyers directed Camacho to deposit the money in their account in Marietta, Ga, says Bottari. The final bill for the computers was $227,000.
VeriFone arranged for an employee to meet Camacho at the bank and told the bank he was coming, Bottari says, The bank notified U.S. Customs agents that it was expecting a large deposit. When Camacho arrived, federal agents were waiting with a drug-sniffing dog.
The agents asked Camacho if he would answer "a few questions about the currency." Camacho agreed.
The handler walked the dog past a row of boxes, including one containing some of Camacho's money. The dog reacted to that box.
At that point, the agents said they were taking the money to the local Customs office, where they retrieved information from the report Camacho had filed in Miami.
The reporting discrepancy, and the dog's reaction, prompted the government to take the cash.
Although the computer deal went through several weeks later when Tandem wired another $227,000, that wasn't enough to convince Albert L. Kemp Jr., the assistant U.S. attorney on the case, that the first order was real.
After the seizure, Kemp said, the government checked Camacho's background. He is a naturalized American citizen who went to business school in California and then returned to help run several family businesses in Colombia.
He travels to the United States "four of five times a year," says Kemp. "He has filled out the currency reports correctly in the past, but now he says there was a mistake and he didn't know about it.
"C'mon," says Kemp. "In total his whole story doesn't wash with me."
"We believe the money is traceable to drugs, but we don't have the evidence. So instead of taking it for drugs, we're using a currency reporting violation to grab it."

Part Four: THE INFORMANTSby Andrew Schneider and Mary Pat Flaherty
Crime pays big for informants in forfeiture drug cases
They snitch at all levels, from the Hell's Angel whose testimony across the country has made him a millionaire, to the Kirksville, Mo., informant who worked for the equivalent of a fast-food joint's hourly wage.
They snitch for all reasons, from criminals who do it in return for lighter sentences to private citizens motivated by civic-mindedness.
But it's only with the recent boom in forfeiture that paid informants began snitching for a hefty cut of the take.
With the spread of forfeiture actions has come a new, and some say, problematic, practice: guaranteeing police informants that if their tips result in a forfeiture, the informant will get a percentage of the proceeds.
And that makes crime pay. Big.
The Asset Forfeiture Fund of the U.S. Justice Department last year gave $24 Million to informants as their share of forfeited items. It has $22 million earmarked this year.
While plenty of those payments go to informants who match the stereotype of a shady, sinister opportunist, many are average people you could meet on any given day in an airport, bus terminal or train station.
In fact, if you travel often, you likely have met them - whether you know it or not.
Counter clerks notice how people buy tickets. Cash ? A one-way trip ?
Operators of X-ray machines watch for "suspicious" shadows and not only for outlines of weapons, which is what signs at checkpoints say they're scanning. They look for money, "suspicious" amounts that can be called to the attention of law enforcement - and maybe net a reward for the operator.
Police affidavits and court testimony in several cities show clerks for large package handlers, including United Parcel Service and Continental Airlines" Quick Pak, open "suspicious" packages and alert police to what they find. To do the same thing, police would need a search warrant.
Underground economy
At 16 major airports, drug agents, counter and baggage personnel, and management reveal an underground economy running off seizures and forfeitures.
All but one of the airports' drug interdiction teams reward private employees who pass along reports about suspicious activity. Typically, they get 10 percent of the value of whatever is found.
The Greater Pittsburgh International Airport team does not and questions the propriety of the practice.
Under federal and most states' laws, forfeiture proceeds return to the law enforcement agency that builds the case. Those agencies also control the rewards of informants.
The arrangement means both police and the informants on whom they rely now have a financial incentive to seize a person's goods - a mix that may be too intoxicating, says Lt. Norbert Kowalski.
He runs Greater Pitt's joint 11-person Allegheny County Police Pennsylvania State Police interdiction team.
"Obviously, we want all the help we can get in stopping these drug traffickers. But having a publicized program that pays airport or airline employees to in effect, be whistle-blowers, may be pushing what's proper law enforcement to the limit", he says.
He worries that the system might encourage unnecessary random searches.
His team checked passengers arriving from 4,230 flights last year. Yet even with its avowed cautious approach, the team stopped 527 people but netted only 49 arrests.
At Denver's Stapelton Airport - where most of the drug team's cases start with informant tips - officers also made 49 arrests last year. But they stopped about 2,000 people for questioning, estimates Capt. Rudy Sandoval, commander of the city's Vice and Drug Control Bureau.
As Kowalski sees it, the public vests authority in police with the expectation they will use it legally and judiciously. The public can't get those same assurances with police disignees, like counter clerks, says Kowalski.
With money as an inducement, "you run the risk of distorting the system, and that can infringe on the rights of innocent travelers. If someone knows they can get a good bit of money by turning someone in, then they may imagine seeing or hearing things that aren't there. What happens when you get to court?"
In Nashville, that's not much of an issue. Juries rarely get to hear from informants.
Police who work the airport deliberately delay paying informants until a case has been resolved "because we don't want these tipsters to have to testify. If we don't pay them until the case is closed they don't have to risk going to court," says Capt. Judy Bawcum, commander of the vice division for Nashville Police Department.
That means their motivation can't be questioned.
Bawcum says it may appear that airport informants are working solely for the money, but she believes there's more to it. "I admit these (X-ray) guards are getting paid less than burger flippers at McDonald's and the promise of 10 percent of $50,000 or whatever is attractive. But to refuse to help us is not a progressive way of thinking," says Bawcum. "This is a public service."
But not all companies share the view that their employees should be public servants. Package handling companies and Wackenhut, the X-ray checkpoint security firm, refuse to allow Nashville police to use their workers as informants.
"They're so fearful a promise of a reward will prompt their people to concentrate on looking for drugs and money instead of looking for weapons," says Bawcum.
Far from being uncomfortable with the notion of citizen-cops, Bawcum says her department relies on them. "We need airport employees working for us because we've only got a very small handful of officers at the airports", she says.
For her, the challenge comes in sustaining enthusiasm, especially when federal agencies like the DEA are "way too slow paying out." Civic duty carries only so far. "It's hard to keep them watching when they have to wait for those rewards. We can't lose that incentive."
The deals
Most drug teams hold tight the details of how their system works and how much individual informants earn, preferring to keep their public service private.
But in a Denver court case, attorney Alexander DeSalvo obtained photocopies of police affidavits about tipsters and copies of three checks payable to a Continental airline clerk, Melissa Furtner. The checks, from the U.S. Treasury and Denver County, total $5,834 for the period from September 1989 to August 1990.
Ms. Furtner, reached by phone at her home, was flustered by questions about the checks.
"What do you want to know about the rewards?" I can't talk about any of it. It's not something I'm supposed to talk about. I don't feel comfortable with this at all." She then hung up.
As hefty as the payments to private citizens can be, they are pin money compared to the paychecks drawn by professional informants.
Among the best paid of all: convicted drug dealers and self-confessed users.
Anthony Tait, a Hell's Angel and admitted drug user who has been a cooperating witness for the FBI since 1985, earned nearly $1 million for information he provided between 1985 and 1988, according to a copy of Tait's payment schedule and FBI contract obtained by the Pittsburgh Press.
Of his $1 million, $250,000 was his share of the value of assets forfeited as a result of his cooperation. His money came from four sources, FBI offices in Anchorage and San Francisco; the state of California and the federal forfeiture fund.
Likewise, in a November 1990 case in Pittsburgh, the government paid a former drug kingpin handsomely.
Testimony shows that Edward Vaughn of suburban San Francisco earned $40,000 in salary and expenses between August 1989 and October 1990 Working for DEA, drew and additional $500 a month from the U.S. Marshal Service and was promised a 25 percent cut of any forfeited goods.
Vaughn had run a multimillion dollar, international drug smuggling ring, been a federal fugitive, and twice served prison time before arranging an early parole and paid informant deal with the government, he said in court.
As an informant, he said, he preferred arranging deals for drug agents that are known as reverse stings: the law enforcement agents pose as sellers and the targets bring cash for the buy. Those deals take cash, but not dope, directly off the streets. In those stings, he said, the cash would be forfeited and Vaughn would get his pre-arranged quarter-share.
To pay or not to pay
His testimony in Pittsburgh resulted in one man being found guilty of conspiracy to distribute marijuana. The jury acquitted the other defendant saying they believed Vaughn had entrapped him by pursuing him so aggressively to make a dope deal.
The practice of giving informants a share of forfeited proceeds goes on so discreetly that Richard Wintory, an Oklahoma prosecutor recently headed the National Drug Prosecution Center in Alexandria, Va. says, "I'm not aware of any agency that pays commissions on forfeited items to informants."
Although the federal forfeiture program funnels millions of dollars to informants, it does not set policy at the top about how - or how much - to pay.
"Decisions about how to pursue investigations within the guidelines of appropriate and legal behavior are best left to people in the field," Says George Terwilliger III, the deputy attorney general who heads the Justice Department's forfeiture program.
That hands-off approach filters to local offices, such as Pittsburgh, where U.S. Attorney Thomas Corbett says the discussion of whether to give informants a cut of any take "is a philosophical argument. I won't put myself in the middle of it."
The absence of regulations spawns "privateers and junior G-men," says Steven Sherick, a defense attorney in Tucson, Ariz., who recently recovered $9,000 for John P. Gray of Rutland, Vt., after a UPS employee found it in a package and called police.
Gray, says Sherick, is "an eccentric older guy who doesn't use anything but cash." In March 1990, Gray mailed a friend hand-money for a piece of Arizona retirement property Gray had scouted during an earlier trip West, say court records. The court ordered the money returned because the state couldn't prove the cash was gained illegally.
Expanding payments to private citizens, particularly on a sliding scale rather than a fixed fee, raises unsavory possibilities, says Eric E. Sterling, head of the Criminal Justice Policy Foundation, a think tank in Washington, D.C.
Major racketeers and criminal enterprises were the initial targets of forfeiture, but its use has steadily expanded until now it catches people who never have been accused of a crime but lose their property anyway.
"You can win a forfeiture case without charging someone," says Sterling. "You can win even after they've been acquitted. And now, on top of that, you can have informants tailoring their tips to the quality of the thing that will be seized.
"What paid informant in their right mind is going to turn over a crack house - which may be destroying an inner city neighborhood - when he can turn over information about a nice, suburban spread that will pay off big when it comes tome to get his share?" asks Sterling.
35 ARRESTED DESPITE BUMBLING WAYS OF INFORMANTS
The Farrells face forfeiture of their Missouri farm
The undercover operation was called BAD. The main informant was named Mudd.
And the entire affair was....a bust.
The prosecutor in Adair County in Missouri's northeast corner chuckles now about the "bumbled" investigation.
But Sheri and Matthew Farrell, whose 60-acre farm remains tied up in a federal forfeiture action due to the bumbling, can't see the humor.
A paid police informant named Steve R. Mudd, who went under cover for $4.65 an hour in a marijuana investigation near Kirksville, Mo., accused Farrell of selling and cultivating marijuana on his land. Mudd was the only witness in the joint city-county drug investigation called Operation BAD - Bust a Dealer.
For a year starting in November 1989, Mudd worked for city and county police identifying alleged dealers around Kirksville, population 17,000. He received "buy money" and would return after his deals - minus the money and with what he said were drugs.
Mudd went to supposed traffickers' homes "but didn't wear a wire (tap) and didn't take any undercover officer with him. He said he was in a rut and didn't want a lot of supervision," says prosecutor Tom Hensley. When he came back to the office, Mudd would write reports - but the dates and times often didn't match what he would say later in depostions.
Mudd himself had gone through drug rehabilitation, and had drug sales and possession on his criminal record, says Hensley. Mudd also had a history of passing bad checks and was always near broke, wroking odd jobs.
Nevertheless, Mudd became the linchpin of Operation BAD.
Based on his word, police arrested 35 people in Adair County, including Farrell. As Mudd told it, Farrell had sold him marijuana and confided he used tractors outfitted with special night lights to harvest fields of dope.
He "whipped up quite the story. He had us out there at night banging around, renting big trucks to carry dope. There's no receipts, nothing to show that. And wouldn't someone have seen us?" asks Mrs. Farrell.
Hensley confirms that Farrell has no criminal record, yet on Mudd's allegation, the county sheriff first arrested Farrell then ordered his house and farm seized in November.
"They came out and searched everything. They took away tea, birdseed, they vacuumed our ashtrays in the truck and didn't find anything. Then they told us the house was seized and in governmental control. They told us to keep paying the taxes, but not to do anything else to the land," says Mrs. Farrell, 36, a U.S. Postal Service worker in Kirksville. Her husband, 38, runs a metal working shop out of his home.
Of the 35 cases initiated by Mudd, only Farrell's involved seized land.
Adair County kept the criminal cases in local court.
But to make the most of the seizure, the county turned the Farrell forfeiture case over to the federal government. Missouri state law directs that forfeiture proceeds go to the general fund where they are earmarked for public school support. Under federal regulations, though, the local police who bring a forfeiture case get back up to 80 percent of any proceeds.
"The federal sharing plan is what affected how the case was brought, sure," says Hensley. "Seizures are kind of like bounties anyway, so why shouldn't you take it to the feds so it comes back to the local law enforcement effort?"
With the forfeiture case firmly lodged in federal court, the county criminal cases began to be heard - and promptly fell apart.
All 35 cases "went down the tubes," says Hensley. At the first hearing, which included Farrell's case, Mudd failed to appear due to strep throat. It took him two months to regain his voice, says Hensley, and then he couldn't regain his memory.
"The dates he was saying didn't mesh with what he'd put down on reports. And I coldn't go out on the street without someone stopping to tell me a Mudd bad-check story. I decided my only witness was not worth a great deal, especially if he was having trouble with his recall."
The case crumbled into powder when the powder turned out to be Tylenol 3. Hensley said lab tests showed Mudd had brought back fake drugs as evidence.
Hensley withdrew the criminal charges against Farrell and the others.
Says Hensley of his star witness, "My honest impression is the guy is just dumb and watched too much 'Miami Vice.' You never see 'Miami Vice' guys write anything down, do you?"
The prosecutor doesn't feel Mudd "scammed us that bad. He took us once to a patch of dope growing along a country road across the state line in Iowa. It was out of the way, sh he had to know something. But he couldn't say for sure who was growing it."
Although Mudd was less than an ideal informant, local police relied on him "because there is marijuana use here and we had to get somebody. We don't get big enough cases to get the state police here to do an investigation up right."
Hensley says he "couldn't say how" Mudd might have come up with Farrell's name, but Mrs. Farrell has a theory. Several years ago, Mike Farrell, Matthew's brother, received probation for a marijuana possession charge - his only arrest. Hensley confirms that.
"I think he figured he could say 'Farrell' and it would stick," says Mrs. Farrell.
Though the criminal case has faded, the Farrells' forfeiture case rolls on.
Philosophically, Hensley agrees with the notion "that if you're not guilty or charges are dismissed then you ought to be off the hook on the forfeiture since no one could prove that case against you. But that isn't the was it works with the federal government."
He is not inclined "to call down to St. Louis and tell the U.S. attorney to drop it. I've got other things to do with my time. I don't want to sound malicious but this will all work out."
So far, it is merely working its way through federal court.
The prosecutor on the Farrell case verifies that the state case was adopted by the federal government which means "the facts of their criminal case are the same facts that underlie the forfeiture action, " says Daniel Meuleman, assistant U.S. attorney. "But that doesn't mean we can't go ahead because there are different standards of proof involved."
Different is lower. To get a criminal conviction, prosecutors need proof beyond a reasonable doubt. To pursue a federal forfeiture, they need only show a probable cause.
Meuleman refuses to say whether he will use Mudd as a witness.
Meanwhile, the Farrells wait.
Their attorney's bills already are $5,600 "and that put a crimp in our style. We were in shock for a good two months. Every day we thought something else might happen and we were scared in our own home."
"That's gotten a little better," says Mrs. Farrell, "But in a town this small there's still a lot of talk, you know."
WITH SKETCHY DATA, GOVERNMENT SEIZES HOUSE FROM MAN'S HEIRS
In Fort Lauderdale, Fla., last summer, forfeiture reached beyond the grave, seizing the $250,000 home of a dead man.
A confidential informant told police that in 1988 the owner, George Gerhardt, took a $10,000 payment from drug dealers who used a dock at the house along a canal to unload cocaine.
The informant can't recall the exact date, the boat's name or the dealers' names, and the government candidly says in its court brief it "does not possess the facts necessary to be any more specific."
But its sketchy information convinced a judge to remove the house from heirs, who now must prove the police wrong.
"I was flabbergasted. I didn't think something like this could happen in this country,' said Gerhardt's cousin, Jeanne Horgan of Hartsdale, N.J. She, a friend of Gerhardt's from high school, and a home health aide who cared for Gerhardt while he was dying of cancer, are his heirs.
Gerhardt, who died at the age of 49, was an only child who inherited "substantial amounts" from his parents and lived in a home that had been in his family for 20 years, says Marc H. Gold, attorney for the heirs.
Gerhardt ran a marina until he was 38, then retired and lived off the estate left him by his parents.
"I've gone back through his tax returns and every penny is accounted for. I can't find an indication he ever was arrested or charged with anything in his life," says Gold.
The heirs have filed a motion to have the case dismissed.
While that request is pending, the government is renting the house to other tenants for roughly $2,200 a month which the government keeps.
Although the government had its tip six months before Gerhardt's death, it didn't file a charge against him. It also didn't seize his house until three months after he died.
The notice the government was taking the home came with a sharp rap on the door, and a piece of paper handed to Brad Marema, the heir who had cared for Gerhardt and moved into the house. The notice gave Marema a few days to pack up before the government changed the locks.
The point of trying to take the house, "is not so much to punish at this stage. The motivation really is to use the proceeds from the sale of the property to prevent other drug offenses," says Robyn Hermann, assistant chief of the civil section for the U.S. attorney's office in the Southern district of Florida.
The government's case depends on the informant's tip, says Ms. Hermann. "Even if I knew more about him (Gerhardt) I wouldn't say, but I don't think we do."
The answer to how heirs counter allegations against a dead man "is real easy," she says. "Answers are acquired through discovery," a procedure in which both sides respond to questions from the other. "We'll take depositions, they'll take depositions. That's when they get their answers."
But that isn't how the law is supposed to work, counters Gold.
Who am I supposed to subpoena ?
Where do I send an investigator ? The government is supposed to have a case a reason for kicking someone out of their home. It's not supposed to remove them, then build a case.

Part Five: CRIME AND PUNISHMENTby Andrew Schneider and Mary Pat Flaherty
Crimes are small but 'justice' takes it all
A Vermont man was found guilty of growing six marijuana plants. He received a suspended sentence and was ordered to do 50 hours of community work. But there was an added penalty: He and his family nearly lost their 49-acre farm.
In Washington, where the maximum criminal penalty could have been a $10,000 fine, an elderly couple served 60 days for growing 35 marijuana plants - and lost their $100,000 house.
In Bismarck, N.D., a young couple received suspended sentences after pleading guilty to growing marijuana. The judge who ordered them to forfeit the three-bedroom house where they lived with their three children worried from the bench that he might be throwing them onto the welfare rolls. But he says he had no choice.
All three families are the victims of a federal law that allows the government to take homes, lands, vehicles and other possessions from Americans convicted of possessing drugs or violating a host of other statutes.
The law was intended to penalize major drug dealers and organized crime figures by taking their property, selling it and returning the proceeds to the cops for other investigations. But the dollar return to the cops has been so great that it's now being used for scores of crimes, some no more than misdemeanors by first-time law-breakers.
Because of the law, more and more people are losing their property. For many, the punishment no longer fits the crime.
TOWN: BACK OFF
Community outrage helped Robert Machin and Joann Lidell keep their farm in South Washington, Vt., after the federal government tried to seize it in 1989.
Signs decrying "Cruel and unusual punishment - remember the Eighth Amendment" were posted along local roads. Lawmakers and politicians got involved. Nearly all their neighbors signed petitions.
Machin and Lidell, advocates of the back-to-nature movement, support themselves and their three children off their 49 acres. They boil maple sap into syrup, press apples into cider and educate their children in the rustic, gas-lit rooms of their eight-sided wooden house.
Their trouble began in September 1988, when a teenager busted for a traffic violation traded his way out of a ticket by telling state police he could show them 200 marijuana plants growing on Machin's farm.
Police raided the property and found only six plants, which Machin admitted to growing.
He received a suspended sentence and spent 50 hours doing community service. Tranquility returned to the Machin farm, but the government wasn't through.
On Aug. 12, 1989, U.S. Attorney George Terwilliger III filed action to seize the Machin house and property. Vermont state law does not permit the seizures of a home, so the case was pursued through federal courts.
But the political pressure and the outpouring of concern from the community forced Terwilliger, who also runs the Justice Department's forfeiture fund, to back off.
"The Machin case is one where public scrutiny forced the government to do it right. What about all the others where no one is watching?" Machin's lawyer, Richard Rubin, asks.
LET THE FEDS DO IT
There was little public scrutiny in November 1989 after Robert and Brenda Schmalz pleaded guilty to marijuana charges in Bismarck, N.D., and got probation.
North Dakota state law does not allow the forfeiture of real estate involved in crimes. So, in order to seize the house, prosecutors took the Schmalz case to federal court, says federal Judge Patrick Conmy, who got the case. Conmy said at the hearing that the couple had grown marijuana in their basement for their own use. Even so, because they used their house in the crime, Conmy says, he had no choice but to order them to forfeit their home.
"I don't really care if somebody loses their Cadillac, or their coin collection, the cash that's with the drugs. That's fine. It's looked on as a hazard of doing business," the federal judge says.
"But you get a husband, wife and several children in a three-bedroom home and the husband raises marijuana in the basement with some grow lights, and you take their house for that. That, to me, is different.
HEADACHES
The marijuana Jack Blahnik grew in his yard controlled severe pain from his cluster headaches, he says.
Blahnik completed 68 years of his life without a single brush with the police. But in his 69th year, he and his 61-year-old wife, Patricia, were arrested, convicted and jailed for 60 days for growing 35 marijuana plants.
On March 6, 1990, the state of Washington also seized the couple's three- bedroom home and the five acres it sat on.
Blahnik admits he was growing the dope.
"I showed it to the police, I took them out to the shed in the back yard and told them that I was growing the stuff for my own use, to try to control the pain from these cluster headaches that I have," Blahnik says.
Blahnik heard that marijuana helps such headaches, and his doctor confirmed its value.
"My wife was against my growing the stuff, but she went to jail because she copied some growing instructions for me," Blahnik says.
The statute under which the Blahnik's house was seized requires the state to provide "evidence which demonstrated the offender's intent to engage in commercial activity." The police never made that link, affidavits show.
The Blahnik's $100,000 property in Woodland, about 130 miles south of Seattle, was their nest egg.
"It was our life savings," Blahnik says. "Everything we had went into that house and land."
Police charged that drug sales financed the house.
"They knew that wasn't true," Mrs. Blahnik says. "Our bank statements and tax forms show that everything we ever put into buying that house, and everything else we have, came from money that we worked hard 40 years to save."
The Blahniks' lawyer, Michael McLean, calls the seizure unconstitutional and punitive.
"The maximum fine for this crime in the state of Washington, is $10,000. The Blahnik's property was worth 10 times that amount."
Blahnik does not question that he should be punished for breaking the law. However, he questions the manner in which it was done.
"The prosecuting attorney went on television, putting our mug shots on and claiming they had made the biggest seizure ever made in either Washington or Oregon and we could possible be connected to a nationwide drug ring," Blahnik says.
"They failed to mention that their big seizure was our retirement money," Blahnik says.
Don and Ruth Churchill's land was seized after marijuana was found in the cornfields
A COSTLY CATCH
Sometimes the government's push to seize property drives it to spend far more than it makes. For example, it's estimated that the state of Iowa spent more than $100,000 defending the seizure of a $6,000 fishing boat.
It has been three years since the Iowa Department of Natural Resources agents charged Dickey Kaster with having three illegally caught fish.
the officers stopped Kaster, a 63-year-old retired gas company foreman, leaving Clear Lake. In the back of his truck the fish cops found a silver bass, a northern pike and a muskie, and said they had "net marks" on them. Kaster was charged with gill-netting, a misdemeanor in Iowa punishable at the time by up to 30 days in jail and a $100 fine for each fish. Altogether, he paid about $500 in fines.
But the officers also seized Kaster's 16-foot boat, 40-hp motor and trailer - worth about $6,000.
"No doubt they had net marks on them, but so do 75 percent of the fish in the lake. I caught them with a rod and night crawlers, " Kaster says.
District Court Judge Stephen Carroll said the seizure was unconstitutional and ordered the boat, motor and trailer returned.
But Cerro Gordo County Attorney Paul Martin appealed to the Iowa Supreme Court, which ruled the property could be seized.
Kaster's saga of the three fish has been on local court dockets four times and before the Iowa Supreme Court twice.
A court clerk in Mason City estimated that "probably a lot more than $100,000" was spent in pursuit of justice for those fish.
Kaster says he knows exactly what the ordeal cost him.
"Just about everything I own. I auctioned off the inventory of my bait and tackle shop at about a dime on the dollar and sold my house to pay the legal bills and keep the bank happy," he says.
"I didn't get my boat back, but I'm still trying," he says. "You can't let the government ignore the Constitution. I'm fighting this over a boat that shouldn't have been taken, but it really deals with how fair our government is supposed to be."
MIXED CROP
And fairness is what is worrying Don and Ruth Churchill, who are fighting to keep their family farm in Indiana.
"Salt of the earth" and "good God-fearing people" are how some neighbors in the southern Indiana farming community describe the 54-year-old couple.
In 1987, Churchill had found some marijuana plants mixed in with his corn and immediately notified state police.
Farmers in the area were aware that a group called "the Cornbread Mafia" was planting marijuana in other people's cornfields throughout nine Midwestern states.
The cops destroyed the crop, and the Churchills thought they were done with marijuana.
But two years later, while they were watching a TV newscast about thousands of marijuana plants being found on farmland, they recognized the land as theirs.
The next morning, the Churchills went to the sheriff to say it was their land. Ten days later, state police arrived at their door to arrest Churchill and his 34-year-old son, David, charging them with numerous felony counts, including possession of and cultivating marijuana.
An informant had reported that he saw Churchill, his son and a third, unidentified man tending marijuana crops on land they own in Harrison County. The informant later reported that dope was also growing on other Churchill land in Crawford County, court affidavits show.
In February, four months before their first criminal trial, the federal government - prodded by state police who would get the bulk of any forfeiture proceeds - seized the 149 acres the Churchills own in both counties.
They are awaiting the outcome of the case.
While the Churchills anguish over the possible loss of their property, they don't dispute that police found thousands of marijuana plants growing on their two tracts.
What Churchill disputes is that he or anyone else in his family grew it.
"I farm part time. We plant in the spring and harvest in the fall and don't mess with the corn in between." Before the large cache of marijuana was discovered, "we hadn't been out there for weeks," says Churchill, who leaves for work at 4 a.m. to get to the Ford truck plant 43 miles away in Louisville, where he has worked for 27 years.
Planting of "no-till" crops is very common in the area as a way to make extra money.
The farmland, especially valuable because it contains the largest natural spring in Indiana, has been in Mrs. Churchill's family for generations.
Standing on the steps of a woodframe chapel in the midst of some of the land the government is trying to take, Mrs. Churchill expressed her disillusionment.
"This church is built on my family's land. I was baptized here, and Don and I were married here. This used to be a place of peace and happiness," Mrs. Churchill says. "Now, this place, our community, our lives, our faith in government, everything has changed.
"If they take our land, I'm going to lose faith in everything," she says.
Ron Simpson, the state's primary persecutor of the criminal charges, questions the fairness of the federal government's seizure of the Churchills' land when most of it was inherited from the wife's family.
"Under our system, if someone is punished, they should have been charged with something, and we've brought no charges against Mrs. Churchill. We have no evidence that she know anything about the marijuana that was growing," Simpson says. "You just have to wonder about how fair this seizure is," Churchill says.
"We assumed the legal system was fair, that if we were innocent, we had nothing to worry about. Now I'm in one court defending myself and my son against drug charges, and in another court, they're trying to take my land away. I'm worrying about a lot of things now."
A HANDFUL OF TROUBLE
The issues of proportionality and fairness pose challenges for even strong supporters of forfeiture laws, including Gwen Holden, a director of the National Criminal Justice Association in Washington, D.C., a group that represents state law enforcement interests.
If an individual is clearly a major trafficker and everything he ever bought is dirty, no one has major heartburn, If someone owns 200 acres of land and there's drugs on a corner ant the guy never knew it was there, then the rule of reason should kick in." Ms. Holden says. "You shouldn't be taking the whole farm if he didn't know it was there."
Taking Bradshaw Bowman's whole farm is exactly what the government is trying to do.
The 80-year-old man was arrested for growing marijuana, and the local sheriff has seized his 160-acre ranch in the breathtaking high desert area of southern Utah.
A convicted drug dealer-turned sheriff's informant blew the whistle on a handful of marijuana plants growing on Bowman's property.
Bowman's "Calf Creek Ranch" is 300 miles south of Salt Lake City, at the entrance to a National Scenic Vista area of stunning canyons.
The marijuana was found on a hiking trail far from Bowman's house.
"I've had this property for almost 20 years, and it's absolute heaven. I love this place. My wife's buried here,:" Bowman says. "I can't believe they're trying to take it away from me, and I didn't even know the stuff was growing there.
"I used to serve on jury duty, but at 70 they make you stop. In all my time sitting in the jury box, I never heard of the Constitution treated this way."
Garfield County Attorney Wallace Lee, who is prosecuting both the criminal charges and the civil effort to seize Bowman's house, says, "He's getting his day in court."
"The fact that he's 80 years old has no bearing on the case at all and certainly not with me," Lee says. "I'm out to prosecute a criminal case here, and it doesn't matter whose house it is."
Bowman's lawyer, Marcus Taylor says: "This is the classic example of the absurdity, injustice and almost immoral nature of forfeiture.
"You could hold that entire bundle of 67 plants in one hand."
JET SEIZED, TRASHED, OFFERED BACK FOR $66,000
Billy and Karon Munnerlyn's Las Vegas air charter service was sold off to pay legal bills to fight the government's seizure of their Lear Jet
With more than 9,000 flights under his belt, Billy Munnerlyn has survived lots of choppy air. But it took only one flight into a government forfeiture action to send his small air charter service crashing to the ground.
Munnerlyn and his wife, Karon, both 53, worked for years building their Las Vegas business. Their four planes - a jet and three props - flew businessmen, air freight, air ambulance runs and Grand Canyon tours.
"It wasn't a big operation, but it was ours," Mrs. Munnerlyn says.
Today, Munnerlyn is making 22 cents a mile truckling watermelons and frozen carrots across the country in an 18-wheeler.
He has filed for bankruptcy. He sold off his three smaller planes and office equipment to pay $80,000 in legal fees. His 1969 Lear Jet - his pride and joy - is being held by the federal government at a storage hangar in Texas.
Munnerlyn's life went into a tailspin the afternoon of Oct. 2, 1989, when he flew an old man and four padlocked, blue plastic boxes to the Ontario International Airport, outside Los Angeles.
His passenger was 74-year-old Albert Wright, a convicted cocaine trafficker. The plastic boxes contained $2,795,685 in cash.
But Munnerlyn says he didn't know that until three hours after they landed and Drug Enforcement Administration agents handcuffed him and took him to the Cucamonga County Jail. Munnerlyn was charged with drug trafficking and ordered to pay $1 million bail. Seventy-one hours later, he was released without being charged.
When he went to get his plane, a drug agent told him "it belongs to the government now" - a simple statement that launched a devastating legal battle that continues today.
An informant had told Ontario Airport police that Wright would arrive Oct. 2 with a large amount of currency to purchase narcotics.
Police were waiting when the Lear landed. They watched Wright get off the plane. For the next three hours, agents followed him as he met two other people, picked up a rented van, returned to the airport and unloaded the plastic containers from Munnerlyn's jet.
Police followed the van to a residence about 20 miles away. They surrounded the van and four people nearby. All were identified as being major cocaine traffickers.
A search of the plastic boxes found $2,795,685.
At the airport, agents told Munnerlyn he was in trouble. They searched the jet. No drugs were found, but they seized $8,500 in cash that he had been paid for the charter.
"I guessed they would figure out I had nothing to do with that guy and his drug money, and give me my plane and $8,500 back," Munnerlyn says.
He was wrong.
Two weeks later, drug agents showed up at Munnerlyn's Las Vegas home and office and carried off seven boxes of document and flight logs.
It was just the beginning of the government's efforts to prove he was a drug trafficker and had flown for Wright for years.
Munnerlyn says he didn't even know Wright was the man's name.
Several days before the seizure, Munnerlyn was contacted by a man identifying himself as "Randy Sullivan," a banker, who was willing to discuss financing a new aircraft that Munnerlyn had been telling business contacts he wanted to buy.
Munnerlyn agreed to meet him Oct. 2 at Little Rock Airport. "We were going to fly back to Las Vegas, where I was going to show him my operation and talk about him financing my purchase of a larger plane." Munnerlyn picked up "Sullivan" and four boxes of "financial records."
"He was a distinguished-looking, very old man dressed in a dark suit. He looked like a banker is supposed to look," Munnerlyn says.
They stopped in Oklahoma City to refuel. When they took off 45 minutes later headed to Las Vegas, "Sullivan" told Munnerlyn he had made a telephone call and had to go to the Ontario airport instead. They would discuss the loan at a later date, he told the pilot.
While en route, he paid Munnerlyn $8,300, the normal tariff for a jet charter, and gave him a $200 tip.
"I told the DEA that I never saw that man before in my life, and I've never had anything to do with drugs," Munnerlyn says. "All I want is my plane back."
Assistant U.S. Attorney Alejandro Mayorkas is still fighting to prevent that from happening.
In court documents Mayorkas filed he acknowledged the government "will rely in part on circumstantial evidence and otherwise inadmissible hearsay" to try to justify the forfeiture.
The government "need not establish a substantial connection to illegal activity, but need only establish probable cause," the prosecutor wrote.
Mayorkas says the fact the aircraft flew into Los Angeles, "an area known as a center of illegal drug activity," is probable cause.
The prosecutor faulted Munnerlyn for not knowing what was in the boxes, but government regulations do not require charter pilots to question or examine baggage.
Munnerlyn wanted Wright to testify, but the government said he couldn't.
"He was the only guy other than me who could tell the court that we didn't know each other. But Mayorkas said they couldn't find him," Munnerlyn says.
At a three-day trial that began last Oct. 30, Mayorkas sprang a surprise witness. A ramp worker from Detroit's Willow Run Airport testified that he had seen Munnerlyn and Wright at his airport "in the fall of 1988."
The witness, Steven Antuna, described Munnerlyn to a T. right down to the full reddish, gray streaked "Hemingway-like" beard he had when he was arrested.
The only problem was that Munnerlyn didn't have a beard until the summer of 1989.
Mrs. Munnerlyn and her 31-year-old son took the stand and refuted the statement about the beard.
The six-member jury ruled that the plane should be returned to the pilot and his wife.
In December, Mayorkas asked for another trial - and held on to the plane. He said Munnerlyn's family members had lied.
But Munnerlyn submitted 51 affidavits from FAA and Las Vegas officials, U.S. marshals, bank officers, customers and business contacts swearing he did not have a beard in the fall of 1988.
Photos and a TV news tape of Munnerlyn being interviewed after rescuing a couple from Mexico after a hurricane, both taken that fall, showed him beardless.
But the government kept the plane.
Munnerlyn and his wife shuttled between Las Vegas and Los Angeles more than 20 times.
"Each time we went we thought this nightmare would be over, but each time there was some new game that the government wanted to play," Mrs. Munnerlyn says.
First, Mayorkas demanded that pilot pay the government $66,000 for his plane.
"We didn't have any money left and we couldn't figure out why we should have to pay the government anything, when a jury said we were innocent," Munnerlyn says.
Mayorkas lowered the "settlement" to $30,000 still far more than the Munnerlyns could raise.
In April, Munnerlyn went to the U.S. Marshal Service's aircraft storage site in Midland, Texas. He climbed over, under and through his plane, which had been torn apart during the DEA search for drugs.
"The whole thing was a mess," he says. "That plane's going to need about $50,000 worth of work to bringing it up to FAA standards again, to make it legal to fly."
In mid-June, Mayorkas made what he called a "final offer."
"We have to pay the government $6,500 to get back my plane, that a jury says shouldn't have been taken in the first place, and they want to keep the $8,500 that I was paid for the flight," Munnerlyn says.
Last month, when asked if the settlement request was fair, Mayorkas said: "If he was innocent, he would have taken reasonable steps to avoid any involvement in illicit drug activity, " Mayorkas says.
But he wouldn't detail what preventive measures Munnerlyn should have taken.
The Munnerlyns are trying to borrow the money to get their plane back.

Last Part: REFORMSby Andrew Schneider and Mary Pat Flaherty
Forfeiture threatens constitutional rights
The bottom line in forfeiture.....is the bottom line.
And that, say critics, is the crucial problem.
The billions of dollars that forfeiture brings in to law enforcement agencies is so blinding that it obscures the devastation it causes the innocent.
A 10-month study by THE PITTSBURGH PRESS found numerous examples of innocent travelers being detained, searched and stripped of cash. Of small-time offenders who grew a little marijuana for their own use and lost their homes because of it. Of people who had to hire attorneys and fight the government for years to get back what was rightfully theirs.
Attorney Harvey Silverglate of Boston says: "There is a game being played with forfeiture. They go after the drug kingpins first, then when everyone stops looking, they turn the law and its infringement of constitutional protections against the average person."
Many people who have watched seizure and forfeitures burgeon as a law- enforcement tool say changes must be made quickly if the traditional American system of justice, based on the constitutional rights of its citizenry, is to remain intact.
NO CRIME, NO PENALTY
When Nashville defense attorney E.E. "Bo" Edwards cites remedies, he lists first the need to make forfeiture possible only after a criminal conviction. Edwards heads a newly created forfeiture task force for the national Association of Criminal Defense Lawyers.
As the forfeiture law now stands, property owners who never were charged with a crime or were charged and cleared still can lose their assets in a forfeiture proceeding.
Under forfeiture, the government must only show that an item was used in a crime or bought with crime-generated money. The government doesn't have to prove the property owner is the criminal.
Changing the law to allow forfeiture only after a property owner's criminal conviction would ensure the government proves its cases beyond a reasonable doubt, Edwards says.
The legal fiction "of property violating the law, that 'property' can do wrong, is ludicrous and offensive to the American scheme of government," says Edwards. "Arresting a plane, for instance, when there is no proof that the pilot broke any laws is not only an abuse of our judicial system but a moronic game."
The narrow legal view holds that because forfeiture usually is a civil case, it involves monetary penalties and not punishment, like jail, that takes away personal freedoms.
Taking that narrow view, it seems unnecessary to include the due process protections of criminal court - such as the presumption of innocence - because the potential penalties never would be as severe as those in a criminal case.
But prosecutors and appeals courts who say forfeiture is not a punishment are "denying reality," says Thomas Smith, head of the American Bar Association's criminal justice section. "The law was enacted to punish, and if you ask anyone who has lost a house or a bank account to it, they will tell you it is punishment."
Allowing forfeiture only in the event of a conviction also would eliminate the risk owners are exposed to when they face a criminal charge against them in one courtroom and the civil forfeiture case in another.
Under criminal and civil proceedings, the defendant has a constitutional guarantee that he needn't testify to anything that may incriminate him.
But because a person may face two trials on the same issues, it raises the possibility that a civil forfeiture case could be brought in the hope that information divulged there could later shore up an otherwise weak criminal case.
ILL-DEFINED PROCEDURES
The gusto for seizure is weakening the traditional protections that surround police work. The definition of "reasonable search and seizure," for example, has been stretched to include tactics that some believe aren't reasonable at all.
The U.S. Supreme Court this June said it is legal for police - wearing full drug-raid gear and with guns showing - to board buses about to depart a station and ask random passengers if they will consent to a search.
In his dissent, Justice Thurgood Marshall branded the tactic coercive and in violation of the Fourth Amendment. "It is exactly because this 'choice' is no 'choice' at all that police engage in this technique," he wrote.
Training films for state police or drug agents in Arizona, Michigan, Massachusetts, Texas, Louisiana, New Mexico and Indiana show, that drug searches involve much more than a visual scan or quick hand search.
Officers in the films obtained by The Pittsburgh Press didn't just look. They opened suitcases in car trunks and pulled out back seats, side door panels and roof linings. In several of the films, they went so far as to remove the gas tank. When they're done, they may or may not put the car back together. The owner's ability to collect damages will depend on the protections offered bay state law.
Grady McClendon had to fight in court for nearly a year to get back about $2,300 taken by police in Georgia following a highway search. His money was seized after police said they'd found cocaine in the car. Lab tests later showed it was bubble gum, but for 11 months police held McClendon's money without charging him with a crime.
During the search, McClendon says, "they made us stand four car lengths away. If I'd have known that, I wouldn't have said yes, because I couldn't see what they were doing in the dark. that isn't what I expected in a search."
NO ACCOUNTING FOR MONEY
The public is often left in the dark about how the proceeds of forfeiture are spent.
A Georgia legislator who this year drafted a law that added real estate to the items that can be taken in his state, also inserted a "windfall" provision for funds.
Under the provision, once forfeiture proceeds equal one-third of a police department's regular budget, any additional forfeiture money will spill over to the general treasury.
State Rep. Ralph Twiggs says he worried that once police began seizing real estate it would bloat their budgets, especially in Georgia's many small towns. "I was looking at all the money going into the federal program and I was thinking ahead. I don't want gold-plated revolvers showing up."
Gold-plated revolvers may be an extreme worry. But as it now stands, it is very hard to determine how police spend their money.
The money or goods returned to local police departments through the federal forfeiture system do not have to be publicly reported. Congress, in its "zeal to pass this feelgood (drug) law, " says Philadelphia City Council member Joan Specter, "apparently forgot to require an accounting of the money.
"The happy result for the police is that every year they get what can only be called drug slush funds," says Specter.
A department that receives forfeiture funds from cases it pursued through federal court or with the help of a federal agency is merely required to assure the U.S. attorney in writing that it will use the money for "law enforcement purposes." And even that minimal requirement wasn't met in Philadelphia.
The Philadelphia police didn't file the forms last year, says Specter, and used the money to cover the costs of air conditioning, car washes, emergency postage, office supplies and fringe benefits.
"That would be fine," she says, "except that the intent of the federal law was for the money to go back into the war on drugs."
It also meant Philadelphia city council "made budgetary decisions in the absence of complete information." At a time when $4 million in forfeiture funds was on hand or in the pipeline for Philadelphia, the city's chemical lab, where drugs are analyzed, had a backlog of more than 3,000 cases, she says. The lab bottleneck caused court delays and prolonged jailing of suspects before their trials began, Specter says.
The Philadelphia Police Department had estimated $1.2 million would double the lab's capacity, but the forfeiture funds were spent elsewhere. "Who should be setting the priorities?" she asks.
Sen. Arlen Specter of Pennsylvania, echoed his wife's view in an address to colleagues in the U.S. Senate. The absence of public accounting by the police who received federal shared funds, he says, "is a glaring oversight in the law, which ought to be corrected."
What legislators have done, says Chicago defense attorney Stephen Komie, "is emboldened prosecutors and police to create this slush fund of unappropriated money for which nobody votes a budget."
The federal forfeiture fund itself, which has taken in $1.5 billion in the last four years and expects to get another $500,000 this year, had its first standard audit only last year.
CIRCUMVENTING STATE LAW
The relationship between state and federal forfeiture systems is thorny in other respects. Washington, D.C. helps local law enforcement do end runs around state law.
The process is formally known as "adoption" - and U.S. Rep. William Hughes of New Jersey, who devised it, now says he made a mistake that he would like to undo.
In adoption, a U.S. attorney's office will take over prosecution of a case developed entirely by local police.
Theoretically, local law enforcement officials go to federal prosecutors because the federal government has more resources available to dissect complicated criminal enterprises and its jurisdiction reaches beyond state lines.
But more often, The Pittsburgh Press review of forfeiture found, the cases are passed along because local police find state laws too restrictive in what can be seized and how much money police can make.
If local departments choose to use the federal system, "then it seems to me it's entirely appropriate for us - so long as the resources are there and what not - to help in that process," says Associate Deputy Attorney General George Terwilliger III, the head of forfeiture for the Justice Department.
"But I don't know that we'd encourage it." But his department clearly does. The Justice Department's "Quick Reference to Federal Forfeiture Procedures" says on Page 203 that "adoptive" seizures are encouraged."
Hughes says including "adoption" in his legislation "was a mistake, " because it has become a way for police to game the forfeiture system.
When he introduced legislation that would have ended federal adoption, "it went nowhere, because law enforcement rallied and convinced everyone they needed those cuts of the pie."
Local police have started using the federal courts to do end-runs around state laws that earmark forfeiture money for the likes of schools instead of cops, or else guarantee police less money than they would get in federal court. There, the cut for local law enforcement can be as much as 80 percent of the value of forfeited items.
But it's not always money that propels police into federal court. It can also be differences over prosecution.
In Allegheny County, for instance, District Attorney Robert Colville will not pursue a forfeiture unless he first wins a criminal conviction against the property owner on a drug charge. Local police know that and avoid Colville's office - and go to federal court - when they aim to seize items from owners who aren't even charged with a crime, Colville says.
The departments argue their approach is legal, "but for me, legal isn't necessarily fair, " Colville says.
"It was never intended states would be able to use the federal process to avoid state policy. (Former Attorney General Dick) Thornburgh in particular" has supported adoption. "We want to clean that up," Hughes says, adding that "for the chief law enforcement office of the country to permit that process" of end-runs is "absolutely wrong."
SHORT-SIGHTED SOLUTIONS
Colville also believes the law's requirement that the money go for enforcement purposes restricts other, equally beneficial, uses. He would like to use more money for drug prevention and rehabilitation programs - uses that are strictly limited under federal sharing rules.
For example, federal guidelines permit forfeiture funds to be used to underwrite classroom drug education programs but only if they're presented by police in uniform, Colville says. He's like to send in health officials as well, to "get a different, equally important message across.
"I've come to the belief as a prosecutor that aggressive prosecution alone won't solve the problem. Guys I arrested 25 years ago when I was a policeman I still see coming back into the system. We need to address underlying social and economic problems." He has advocated using forfeiture money for the likes of summer jobs programs in drug-plagued neighborhoods, an idea rejected by the federal government.
Hughes, the New Jersey congressman, says he regrets earmarking all the federal forfeiture funds for law enforcement purposes, but cannot find support for changing the stipulation.
He originally thought police would need every dime they took in to pay for complicated investigations and assumed the forfeited goods would just cover the cost. Once the kitty grew, he figured then money could be set aside for areas such as drug treatment.
But the coffers grew much faster than expected and now it is proving hard to get police to give up the money. "We never dreamed we would be seizing $1 billion. Now the coffers are overflowing, but using the money in different ways is a touchy point at Justice."
Not even appeals from Louis Sullivan, secretary of Health and Human Services, compel a change. During an interview in Pittsburgh last week, Sullivan said he has asked that forfeiture funds go partially toward drug rehab but Justice turned him down repeatedly.
Justice recently turned down a proposal from Jackson Memorial Hospital, a cash-poor public hospital in Miami, to use $6 million seized during a south Florida money-laundering case to build a new trauma center.
The hospital is known in the industry as a "knife-and-gun-club" because of the volume of shootings and stabbings it handles. Police investigate nearly 85 percent of the hospital's cases.
In its proposal, Jackson suggested training medical staff to spot injuries that are the result of a crime, adding on-call photographers who would specialize in taking pictures of victims for use during trials and improving preservation of damaged clothing, bullets and other pieces of evidence.
The idea had bipartisan support from Miami's congressional delegation, Metro-Dade police and the U.S. attorney's office in Miami.
The memorandum from Justice rejecting the idea came from Terwilliger, who wrote that seized money must go to official use which "typically, has included activities such as the purchase of vehicles and equipment," including guns and radios.
But, says Hughes, "if the purpose is to deal with the drug problem effectively, Justice's reluctance to consider new ideas - particularly when it comes to treatment programs - seems to me to undercut their ultimate goal."
The Justice Department, which champions forfeiture as the law enforcement tool of the '90s, declines to talk about where the law is headed.
"I don't think it's appropriate in the context of a press interview to discuss potential policy and legislative issues," says Terwilliger.
But in not talking, the government "masks that details of the total emasculation of the Bill of Rights," says John Rion, a Columbus, Ohio lawyer.
"The taxpayer thinks this forfeiture stuff is wonderful, until he's the one who loses something. Then, he realizes that it's not just the criminal's rights that have been taken away, it's everybody's."
Drug-fighting sheriff puts compassion before forfeitures
Robert Ficano says his Detroit-area drug team gives warning before seizing property
In Detroit, Wayne County Sheriff Robert Ficano is an unabashed supporter of grabbing the spoils of the war on drugs, but he tempers his fervor for forfeiture with controls.
Fïcano appears to be running precisely the type of drug interdiction program authors of forfeiture and seizure legislation envisioned.
It aggressively pursues drug criminals. it has procedures that protect innocent citizens, and it shows compassion - right down to the teddy bears narcotics agents carry to drug raids on homes where children live. In addition, it turns forfeited money right back into more drug investigations. It can do that, because the confiscated money has allowed it to create a new interdiction team devoted to stopping narcotics.
"We started with two officers out of the Wayne County Jail and we wanted to see if they would be able to seize enough in their raids, for them to pay for their own salaries," he says.
That first year, in 1984, they seized $250,000.
"Last year we seized over $4 million. And we've been able to completely fund the narcotic unit out of these
forfeited funds," Ficano says. Today he has 35 officers. 3 drug dogs and all the weapons. surveillance and communication gear needed to equip a modern drug team, with a $22 million budget.
"There isn't a dime of it from taxpayers' money that's used. So in essence, you have the crooks paying for their own busts," he says.
The public's fear of drugs helps win support for forfeiture. "However, we in law enforcement have to ensure that a balance is always kept. You can't violate people's rights.
"Whenever you push a law, a tool, as far as you can go and get up toward the edge, it becomes a difficult balance. There's a responsibility that goes with it.
Teddy bears that police in Detroit area give to children present during drug raids
In the area of forfeiture and seizure, I think we've probably gone as far as, we can and still be accepted by the public and by the courts. I think we're near that edge," the sheriff says.
To maintain balance. Ficano instituted a series of steps that had some of his 900 deputies grumbling at first that he was going soft.
One of his major targets,. he says, is closing crack houses, shooting galleries and other residential drug operations.
"We want these properties cleaned up and under the law we can seize them, but a surprising number of owners of drug houses have no idea of the activity, so we make sure they know what's going on," the sheriff says.
Ficano sends owners two written warnings that illegal activities are occurring on their property and that repeated arrests have been made.
"The first time we do it, we tell them what we found on their property and some of the things they can legally do to get these drug traffickers out," Ficano says. "We'll warn them a second time. The third time, we move to seize the house."
He admits he could make more money if he grabbed the property at the first violation, as many other departments do.
"But the motivation shouldn't be just seizing property. If we can get the public, the owners, to stop the trafficking, then we've accomplished an important goal," he says. "The warnings are needed because you just shouldn't wipe someone out, someone who may be innocent, without giving them a chance."
He also gives warning to drug buyers driving into the county.
In some crack areas, he says, neighborhood streets that in the middle of the afternoon should be peaceful and tranquil look like the parking lots at the University of Michigan stadium on a football Saturday.
In conjunction with local police departments, Ficano took out newspaper ads cautioning: "Buyers of Illegal Drugs, Take Notice." The ads listed descriptions of some of the 210 cars that have been seized from recreational drug users - and the neighborhoods of their owners -- and warned drug buyers to stay out of Wayne County or risk losing their vehicles.
Similarly, he gives a couple of chances to innocent owners of cars used by someone else in drug trafficking: After the first warning, they can claim innocence. that they didn't know that someone else was using the car to buy drugs. The second time the car is stopped it costs owners $750 to get it back If there's a third time, it's a seizure.
"A lot of these people need the cars to go to work or school, so we give them every chance we can, but it's got to stop."
He bristles when asked if he's soft on drug traffickers.
"Look at our arrest records - over 300 raids and 1,000 arrests last yearwe're not soft at all," Ficano says. "We can enforce the law and be aggressive about it. but we can also do it with some compassion and the common sense that is supposed to come with the badge."
Safeguards and tight controls are a must, he insists.
"We do not want cowboys. We do not want officers who follow the typical stereotype drug cop from 'Miami Vice' and other sews. Seizure is an important tool, but we'll lose it unless we keep a heavy emphasis on respecting individual rights."
Sitting atop the TV set in his office is a very un-"Miami Vice" prop: an 18inch, black-and-white speckled teddy bear.
"The biggest deputies we have can be distressed watching a child react to a parent or both parents being arrested after a drug raid. It eats away at you," the sheriff says.
The bears are kept in the trunk of the unit's cars and vans, he says.
"If there is a raid or property is being seized and there are children involved, our deputies can pull the bears out to, hopefully, calm down the children," . Ficano says.
It's difficult to envision a brawny SWAT officer, decked out in a helmet and bullet proof vest, carrying a gun in one hand and a teddy bear m the other. But the narcotic unit's weekly search warrant and arrest report has a column headed "Number of Bears."
The reports for the first two weeks of May show that two of nine bears given out were given as officers seized property.
"If there's something that can be done to reduce the pain that accompanies some of the things we have to do, why not do it?" Ficano asks.
The one area Ficano was hesitant to discuss in detail was the activity of his men as part of the Drug Enforcement Administration's joint task force at Detroit's Metro airport.
Some lawyers, including the American Civil Liberties Union. have criticized the DEA team for being overzealous in seizing cash from suspected drug dealers.
The sheriff did say safeguards exist to prevent improper stops, but added that DEA directed him not to discuss his airport work
While his drug unit is among the biggest moneymakers in the country, and the forfeited funds are key to financing that unit, he says there is a "very clear limit" on how far he will go.
"These new laws open all sorts of new areas for seizing the assets of drug traffickers. We'll use accountants, people with business and banking expertise - all sorts of nontraditional police skills to try to track and forfeit every dollar these dealers are making.
"But there's a line that we won't cross," Ficano says.

Part Two: THE WAY YOU LOOK
Drug agents more likely to stop minorities
by Andrew Schneider and Mary Pat Flaherty
Willie Jones had $9.600 seized and is now fighting to keep his landscaping business
Look around carefully the next time you're at any of the nation's big airports, bus stations, train terminals or on a major highway, because there may be a government agent watching you. If you're black, Hispanic, Asian or look like a "hippie, " you can almost count on it.
The men and women doing the spying are drug agents, the frontline troops in the government's war on narcotics. They count their victories in the number of people they stop because they suspect they're carrying drugs or drug money.
But each year in the hunt for suspects, thousands of guiltless citizens are stopped, most often because of their skin color.
A 10-month Pittsburgh Press investigation of drug seizure and forfeiture included an examination of court records on 121 "drug courier" stops where money was seized and no drugs were discovered. The Pittsburgh Press found that black, Hispanic and Asian people account for 77 percent of the cases.
In making stops, drug agents use a profile, a set of speculative behavioral traits that gauge the suspect's appearance, demeanor and willingness to look a police officer in the eye.
For years, the drug courier profile counted race as a principal indicator of the likelihood of a person's carrying drugs.
But today the word "profile" isn't officially mentioned by police. Seeing the word scrawled in a police report or hearing if from a witness chair instantly unnerves prosecutors and makes defense lawyers giddy. Both sides know the racial implications can raise constitutional challenges.
Even so, far away from the courtrooms, the practice persists.
In Memphis, Tenn, in 1989, drug officers have testified, about 75 percent of the people they stopped in the airport were black.
In Eagle Country, Colo., the 60 mile-long strip of Interstate 70 that winds and dips past Vail and other ski areas is the setting of a class action suit that charges race was the main element of the profile used in drug stops.
According to court documents in one of the cases that led to the suit, the sheriff and two deputies testified that "being black or Hispanic was and is a factor" in their drug courier profiles.
Lawyer David Lane says that 500 people - primarily Hispanic and black motorists - were stopped and searched by Eagle County's High Country Drug Task Force during 1989 and 1990. Each time Lane charged, the task force used an unconstitutional profile based on race, ethnicity and out-of-state license plates.
Byron Boudreaux was one of those stopped.
Boudreaux was driving from Oklahoma to a new job in Canada when Sgt. James Perry and three other task force officers pulled him over.
"Sgt. Perry told me that I was stopped because my car fit the description of someone trafficking drugs in the area," Boudreaux says. He let the officers search his car.
"Listen, I was a black man traveling alone up in the mountains of Eagle County and surrounded by four police officers. I was going to be as cooperative as I could," he recalls.
For almost an hour the officers unloaded and searched the suitcases, laundry baskets and boxes that were wedged into Boudreaux's car. Nothing was found.
"I was stopped because I was black, and that's not a great testament to our law enforcement system," says Boudreaux, who is now an assistant basketball coach at Queens College in Charlotte, N.C.
In a federal trial stemming from another stop Perry made on the same road a few months later, he testified that because of "astigmatism and color blindness" he was unable to distinguish among black, Hispanic and white people.
U.S. District Court Judge Jim Carrigan didn't buy it and called the sergeant's testimony "incredible".
"If this nation were to win its war on drugs at the cost of sacrificing its citizens' constitutional rights, it would be a Pyrrhic victory indeed," Carrigan wrote in a court opinion. "If the rule of law rather than the rule of man is to prevail, there cannot be one set of search and seizure rules applicable to some and a different set applicable to others."
LIVELIHOOD IN JEOPARDY
In Nashville, Tenn, Willie Jones has no doubt that police still use a profile based on race.
Jones, owner of a landscaping service, thought the ticket agent at the American Arilines counter in Nashville Metro Airport reacted strangely when he paid cash Feb. 27 for his round-trip ticket to Houston.
"She said no one ever paid in cash anymore and she'd have to go in the back and check on what to do," Jones says.
What Jones didn't know is that in Nashville - as in other airports - many airport employees double as paid informers for the police.
The Drug Enforcement Administration usually pays them 10 percent of any money seized, says Capt. Judy Bawcum, head of the Nashville police division that runs the airport unit.
Jones got his ticket. Ten minutes later, as he waited for his plane, two drug team members stopped him.
"They flashed their badges and asked if I was carrying drugs or a large amount of money. I told them I didn't have anything to do with drugs, but I had money on me to to buy some plants for my business," Jones says.
They searched his overnight bag and found nothing. They patted him down and felt a bulge. Jones pulled out a black plastic wallet hidden under his shirt. It held $9,600.
"I explained that I was going to Houston to order some shrubbery for my nursery. I do it twice a year and pay cash because that's the way the growers want it," says the father of three girls.
The drug agents took his money.
"They said I was going to buy drugs with it, that their dog sniffed it and said it had drugs on it," Jones says. He never saw a dog.
The officers didn't arrest Jones, but they kept the money. They gave him a DEA receipt for the cash. But under the heading of amount and description, Sgt. Claude Byrum wrote, "Unspecified amount of U.S. Currency."
Jones says losing the money almost put him out of business.
"That was to buy my stock, I'm known for having a good selection of unusual plants. That's why I go South twice a year to buy them. Now I've got to do it piecemeal, run out after I'm paid for a job and buy plants for the next one," he says.
Jones has receipts for three years showing that each fall and spring he buys plants from nurseries in other states.
"I just don't understand the government. I don't smoke. I don't drink. I don't wear gold chains and jewelry, and I don't get into trouble with the police," he says. "I didn't know it was against the law for a 42 year-old black man to have money in his pocket."
Tennessee police records confirm that the only charge ever filed against Jones was for drag racing 15 years ago.
"DEA says I have to pay $900, 10 percent of the money they took from me, just to have the right to try to get it back," Jones says.
His lawyer, E.E. "Bo" Edwards filled out government forms documenting that his client couldn't afford the $900 bond.
"If I'm going to feed my children, I need my truck, and the only way I can get that $900 is to sell it," Jones says.
It's been more than five months, and the only thing Jones has received from DEA are letters saying that his application to proceed with out paying the $900 bond was deficient. "But they never told us what those deficiencies were," says Edwards.
Jones is nearly resigned to losing the money. "I don't think I'll ever get it back. But I think the only reason they thought I was a drug dealer was because I'm black, and that bothers me."
It also bothers his lawyer.
"Of course he was stopped because he was black. No cop in his right mind would try that with a white businessman. These seizure laws give law enforcement a license to hunt, and the target of choice for many cops is those they believe are least capable of protecting themselves: blacks, Hispanics and poor whites," Edwards says.
MONEY STILL HELD
In Buffalo, N.Y., on Oct. 9, Juana Lopez, a dark-skinned Dominican had just gotten off a bus from New York City when she was stopped in the terminal by drug agents who wanted to search her luggage.
They found no drugs, but DEA Agent Bruce Johnson found $4,750 in cash wrapped with rubber bands in her purse. The money, the 28 year-old woman said, was to pay legal fees or bail for her common law husband. After he began questioning her, Johnson realized that he had arrested the husband for drugs two months earlier in the same bus station.
Johnson called the office of attorney Mark Mahoney, where Ms. Lopez said she was heading, and verified her appointment.
Johnson then told the woman she was free to go, but her money would stay with him because a drug dog had reacted to it.
Ms. Lopez has receipts showing the money was obtained legally - a third of it was borrowed, another third came from the sale of jewelry that belonged to her and her husband, and the rest from her savings as a hair stylist in the Bronx.
It has been more than nine months since the money was taken, and Assistant U.S. Attorney Richard Kaufman says the investigation is continuing.
Robert Clark, a Mobile, Ala., lawyer who has defended many travelers, says profile stops are the new form of racism.
"In the South in the '30s, we used to hang black folks. Now, given any excuse at all, even legal money in their pockets, we just seize them to death," he says.
Former New York Giants center Kevin Belcher is one of hundreds whose cash was seized at airports
TRIVIAL PURSUIT
"If you took all the racial elements out of profiles, you'd be left with nothing," Says Nashville lawyer Edwards, who heads a new National Association of Criminal Defense Lawyers task force to investigate forfeiture law abuses.
"It would outrage the public to learn the trivial indicators that police officers use as the basis for interfering with the rights of the innocent."
Examination of more than 310 affidavits for seizure and profiles used by 28 different agencies reveals a conflicting collection of traits that agents say they use to hunt down traffickers.
Guidelines for DEA drug task force agents in three adjacent states give conflicting advice on when officers are supposed to become suspicious.
Agents in Illinois are told it's suspicious if their subjects are among the first people off a plane, because it shows they're in a hurry.
In Michigan, the DEA says that being the last off the plane is suspicious because the suspect is trying to appear unconcerned.
And in Ohio, agents are told suspicion should surface when suspects deplane in the middle of a group because they may be trying to lose themselves in the crowd.
One of the most often mentioned indicators is that suspects were traveling to or from a source city for drugs.
But a list of cities favored by drug couriers gleaned from the DEA affidavits amounts to a compendium of every major community in the United States.
Seeming to be nervous, looking around, pacing, looking at a watch, making a phone call - all things that business travelers routinely do, especially those who are late or don't like to fly - sound alarms to waiting drug agents.
Some agents change their mind about what makes them suspicious.
In Tennessee, an agent told a judge he was leery of a man because he "walked quickly through the airport." Six weeks later, in another affidavit, the same agent said his suspicions were aroused because the suspect "walked with intentional slowness after getting off the bus."
In Albuquerque, N.M., people have been stopped because they were standing on the train platform watching people.
Whether you look at a police officer can be construed to be a suspicious sign. One Maryland state trooper said he was wary because the subject deliberately did not look at me when he drove by my position." Yet, another Maryland trooper testified that he stopped a man because the "driver stared at me when he passed."
Too much baggage or not enough will draw the attention of the law.
You could be in trouble with drug agents if you're sitting in first class and don't look as if you belong there.
DEA Agent Paul Markonni, who is considered the "father" of the drug courier profile, testified in a Florida court about why he stopped a man.
"We do see some real slimeballs you know, some real dirt bags, that obviously could not afford, unless they were doing something, to fly first class," he told the court.
The newest extension of the drug courier profile are pagers and cellular telephones.
Based on the few cases that have reached the courts, the communication devices - which are carried by business people, nervous parents and patients waiting for a transplant as well as drug couriers - are primarily suspicious when they are found on the belts or in the suitcases of minorities or long haired whites.
For police intent on stopping someone, any reason will do.
"If they're black, Hispanic, Asian or look like a hippie, that's a stereo type, and the police will find some way to stop them if that's their intent," says San Antonio lawyer Gerald Goldstein.
THE PERFECT PROFILE
A DEA agent thought that former New York Giants center Kevin Belcher matched his profile. When Belcher got off a flight from Detroit March 2, he was stopped by DEA's Dallas/Fort Worth Airport Narcotics Task Force.
The Texas officers had been called a short while earlier by a DEA agent at Detroit's Metro Airport. A security screener had spotted a big, black man carrying a large amount of money in his jacked pocket, the Detroit agent reported to his Southern colleagues.
Belcher was questioned about the purpose of the trip and was asked whether he had any money. He gave the agents $18,265.
Belcher explained that he was going to El Paso to buy some classic old cars - "1968 or '69 Camaros are what I'm looking for." Belcher, whose professional football career ended after a near-fatal traffic accident in New Jersey, told the agents he owned four Victory Lane Quick Oil Change outlets in Michigan. The money came from sales, he said, and cash was what auctioneers demanded.
A drug-sniffing dog was called, it reacted, and the money was seized.
Agent Rick Watson told Belcher he was free to go "but that I was going to detain the monies to determine the origin of them."
In his seizure affidavit, Watson listed the matches he made between Belcher and the profile of "other narcotic currency couriers encountered at DFW airport.
Included in Watson's profile was that Belcher had bought a one way ticket on the date of travel; was traveling to a "source" city, El Paso, "where drug dealers have long been known to be exporting large amounts of marijuana to other parts of the country"; and was carrying $100, $50, $20, $10 and $5 bills, "which is consistent with drug asset seizures."
Watson made no mention as to what denomination other than $1 bills was left for non-drug traffickers to carry.
"The drug courier profile can be absolutely anything that the police officer decides it is at that moment," says Albuquerque defense lawyer Nancy Hollander, one of the nation's leading authorities on profile stops.
WIDE NET CAST
Officials are reluctant to reveal how many innocent people are ensnared each day by profile stops. Most police departments say they don't keep that information. Those that do are reluctant to discuss it.
"We don't like to talk much about what we seize at the (Nashville) airport because it might stir up the public and make the airport officials unhappy because we are somehow harassing people. It would be great if we could keep the whole operation secret," says Capt. Bawcum, in charge of the airport's drug team.
Capt. Rudy Sandoval, commander of Denver's vice bureau, says he doesn't keep the airport numbers but estimates his police searched more than 2,000 people in 1990, but arrested only 49 and seized money from fewer than 50.
At Pittsburgh's airport, numbers are kept. The team searched 527 people last year, and arrested 49.
A federal court judge in Buffalo, N.Y., says police stop too many innocent people to catch too few crooks.
Judge George Pratt said he was shocked that police charged only 10 of the 600 people stopped in 1989 in the Buffalo airport and decried encroaching on the constitutional rights of the 590 innocent people.
In his opinion in the case, Pratt said that by conducting unreasonable searches: "It appears that they have sacrificed the Fourth Amendment by detaining 590 innocent people in order to arrest 10 - who are not - all in the name of the 'war on drugs.' When, pray tell, will it end ? Where are we going?"
U.S. Customs agent Leon Senecal and drug dog Amber check a bus in Buffalo
DRUGS CONTAMINATE NEARLY ALL THE MONEY IN AMERICA
Police seize money from thousands of people each year because a dog with a badge sniffs, barks or paws to show that bills are tainted with drugs.
If a police officer picks you out as a likely drug courier, the dog is used to confirm that your money has the smell of drugs.
But scientists say the test the police rely on is no test at all because drugs contaminate virtually all the currency in America.
Over a seven-year period, Dr. Jay Poupko and his colleagues at Toxicology Consultants Inc. in Miami have repeatedly tested currency in Austin, Dallas, Los Angeles, Memphis, Miami, Milwaukee, New Youk City, Pittsburgh, Seattle and Syracuse. He also tested American bills in London.
"An average of 96 percent of all the bills we analyzed from the 11 cities tested positive for cocaine. I don't think any rational thinking person can dispute that almost all the currency in this country is tainted with drugs," Poupko says.
Scientists at national Medical Services, in Willow Grove, Pa., who tested money from banks and other legal sources more than a dozen times, consistently found cocaine on more than 80 percent of the bills.
"Cocaine is very adhesive and easily transferable," says Vincent Cordova, director of criminalistic for the private lab. "A police officer, pharmacist, toxicologist or anyone else who handles cocaine, including drug traffickers, can shake hands with someone, who eventually touches money, and the contamination process begins."
Cordova and other scientists use gas chromatography and mass spectroscopy, precise alcohol washes and a dozen other sophisticated techniques to identify the presence of narcotics down to the nanogram level - one billionth of a gram. That measure, which is far less than a pin point, is the same level a dog can detect with a sniff.
What a drug dog cannot do, which the scientists can, is quantify the amount of drugs on the bills.
Half of the money Cordova examined had levels of cocaine at or above 9 nanograms. This level means the bills were either near a source of cocaine or were handled by someone who touched the drug, he says.
Another 30 percent of the bills he examined show levels below 9 nanograms, which indicated "the bills were probably in a cash drawer, wallet or some place where they came in contact with money previously contaminated."
The lab's research found $20 bills are most highly contaminated, with $10 and $5 bills next. The $1, $50 and $100 bill usually have the lowest cocaine levels.
Cordova urges restraint in linking possession of contaminated money to a criminal act.
"Police and prosecutors have got to use caution in how far they go. The presence of cocaine on bills cannot be used as valid proof that the holder of the money, or the bills themselves, have ever been in direct contact with drugs," says Cordova, who spent 11 years directing the Philadelphia Police crime laboratory.
Nevertheless, more and more drug dogs are being put to work.
Some agencies, like the U.S. Customs Service, are using passive dogs that don't rip into an item - or person - when the dogs find something during a search. These dogs just sit and wag their tails. German shepherds with names like Killer and Rambo are being replaced by Labradors named Bruce or Memphis "chocolate Mousse."
Marijuana presents its own problems for dogs since its very pungent smell is long-lasting. Trainers have testified that drug dogs can react to clothing containers or cars months after marijuana has been removed.
A 1989 case in Richmond, Va., addressed the issue of how reliable dogs are in marijuana searches.
Jack Adams, a special agent with the Virginia State Police, supervised training of drug dogs for the state.
He said the odor from a single suitcase filled with marijuana and placed with 100 other bags in a closed Amtrak baggage car in Miami could permeate all the other bags in the car by the time the train reached Richmond.
And what happens to the mountain of "drug-contaminated" dollars the government seized each year ? The bills aren't burned, cleaned, or stored in a well-guarded warehouse.
Twenty-one seizing agencies questioned all said that tainted money was deposited in a local bank - which means it's back in circulation.

Last Part: REFORMSby Andrew Schneider and Mary Pat Flaherty
Forfeiture threatens constitutional rights
The bottom line in forfeiture.....is the bottom line.
And that, say critics, is the crucial problem.
The billions of dollars that forfeiture brings in to law enforcement agencies is so blinding that it obscures the devastation it causes the innocent.
A 10-month study by THE PITTSBURGH PRESS found numerous examples of innocent travelers being detained, searched and stripped of cash. Of small-time offenders who grew a little marijuana for their own use and lost their homes because of it. Of people who had to hire attorneys and fight the government for years to get back what was rightfully theirs.
Attorney Harvey Silverglate of Boston says: "There is a game being played with forfeiture. They go after the drug kingpins first, then when everyone stops looking, they turn the law and its infringement of constitutional protections against the average person."
Many people who have watched seizure and forfeitures burgeon as a law- enforcement tool say changes must be made quickly if the traditional American system of justice, based on the constitutional rights of its citizenry, is to remain intact.
NO CRIME, NO PENALTY
When Nashville defense attorney E.E. "Bo" Edwards cites remedies, he lists first the need to make forfeiture possible only after a criminal conviction. Edwards heads a newly created forfeiture task force for the national Association of Criminal Defense Lawyers.
As the forfeiture law now stands, property owners who never were charged with a crime or were charged and cleared still can lose their assets in a forfeiture proceeding.
Under forfeiture, the government must only show that an item was used in a crime or bought with crime-generated money. The government doesn't have to prove the property owner is the criminal.
Changing the law to allow forfeiture only after a property owner's criminal conviction would ensure the government proves its cases beyond a reasonable doubt, Edwards says.
The legal fiction "of property violating the law, that 'property' can do wrong, is ludicrous and offensive to the American scheme of government," says Edwards. "Arresting a plane, for instance, when there is no proof that the pilot broke any laws is not only an abuse of our judicial system but a moronic game."
The narrow legal view holds that because forfeiture usually is a civil case, it involves monetary penalties and not punishment, like jail, that takes away personal freedoms.
Taking that narrow view, it seems unnecessary to include the due process protections of criminal court - such as the presumption of innocence - because the potential penalties never would be as severe as those in a criminal case.
But prosecutors and appeals courts who say forfeiture is not a punishment are "denying reality," says Thomas Smith, head of the American Bar Association's criminal justice section. "The law was enacted to punish, and if you ask anyone who has lost a house or a bank account to it, they will tell you it is punishment."
Allowing forfeiture only in the event of a conviction also would eliminate the risk owners are exposed to when they face a criminal charge against them in one courtroom and the civil forfeiture case in another.
Under criminal and civil proceedings, the defendant has a constitutional guarantee that he needn't testify to anything that may incriminate him.
But because a person may face two trials on the same issues, it raises the possibility that a civil forfeiture case could be brought in the hope that information divulged there could later shore up an otherwise weak criminal case.
ILL-DEFINED PROCEDURES
The gusto for seizure is weakening the traditional protections that surround police work. The definition of "reasonable search and seizure," for example, has been stretched to include tactics that some believe aren't reasonable at all.
The U.S. Supreme Court this June said it is legal for police - wearing full drug-raid gear and with guns showing - to board buses about to depart a station and ask random passengers if they will consent to a search.
In his dissent, Justice Thurgood Marshall branded the tactic coercive and in violation of the Fourth Amendment. "It is exactly because this 'choice' is no 'choice' at all that police engage in this technique," he wrote.
Training films for state police or drug agents in Arizona, Michigan, Massachusetts, Texas, Louisiana, New Mexico and Indiana show, that drug searches involve much more than a visual scan or quick hand search.
Officers in the films obtained by The Pittsburgh Press didn't just look. They opened suitcases in car trunks and pulled out back seats, side door panels and roof linings. In several of the films, they went so far as to remove the gas tank. When they're done, they may or may not put the car back together. The owner's ability to collect damages will depend on the protections offered bay state law.
Grady McClendon had to fight in court for nearly a year to get back about $2,300 taken by police in Georgia following a highway search. His money was seized after police said they'd found cocaine in the car. Lab tests later showed it was bubble gum, but for 11 months police held McClendon's money without charging him with a crime.
During the search, McClendon says, "they made us stand four car lengths away. If I'd have known that, I wouldn't have said yes, because I couldn't see what they were doing in the dark. that isn't what I expected in a search."
NO ACCOUNTING FOR MONEY
The public is often left in the dark about how the proceeds of forfeiture are spent.
A Georgia legislator who this year drafted a law that added real estate to the items that can be taken in his state, also inserted a "windfall" provision for funds.
Under the provision, once forfeiture proceeds equal one-third of a police department's regular budget, any additional forfeiture money will spill over to the general treasury.
State Rep. Ralph Twiggs says he worried that once police began seizing real estate it would bloat their budgets, especially in Georgia's many small towns. "I was looking at all the money going into the federal program and I was thinking ahead. I don't want gold-plated revolvers showing up."
Gold-plated revolvers may be an extreme worry. But as it now stands, it is very hard to determine how police spend their money.
The money or goods returned to local police departments through the federal forfeiture system do not have to be publicly reported. Congress, in its "zeal to pass this feelgood (drug) law, " says Philadelphia City Council member Joan Specter, "apparently forgot to require an accounting of the money.
"The happy result for the police is that every year they get what can only be called drug slush funds," says Specter.
A department that receives forfeiture funds from cases it pursued through federal court or with the help of a federal agency is merely required to assure the U.S. attorney in writing that it will use the money for "law enforcement purposes." And even that minimal requirement wasn't met in Philadelphia.
The Philadelphia police didn't file the forms last year, says Specter, and used the money to cover the costs of air conditioning, car washes, emergency postage, office supplies and fringe benefits.
"That would be fine," she says, "except that the intent of the federal law was for the money to go back into the war on drugs."
It also meant Philadelphia city council "made budgetary decisions in the absence of complete information." At a time when $4 million in forfeiture funds was on hand or in the pipeline for Philadelphia, the city's chemical lab, where drugs are analyzed, had a backlog of more than 3,000 cases, she says. The lab bottleneck caused court delays and prolonged jailing of suspects before their trials began, Specter says.
The Philadelphia Police Department had estimated $1.2 million would double the lab's capacity, but the forfeiture funds were spent elsewhere. "Who should be setting the priorities?" she asks.
Sen. Arlen Specter of Pennsylvania, echoed his wife's view in an address to colleagues in the U.S. Senate. The absence of public accounting by the police who received federal shared funds, he says, "is a glaring oversight in the law, which ought to be corrected."
What legislators have done, says Chicago defense attorney Stephen Komie, "is emboldened prosecutors and police to create this slush fund of unappropriated money for which nobody votes a budget."
The federal forfeiture fund itself, which has taken in $1.5 billion in the last four years and expects to get another $500,000 this year, had its first standard audit only last year.
CIRCUMVENTING STATE LAW
The relationship between state and federal forfeiture systems is thorny in other respects. Washington, D.C. helps local law enforcement do end runs around state law.
The process is formally known as "adoption" - and U.S. Rep. William Hughes of New Jersey, who devised it, now says he made a mistake that he would like to undo.
In adoption, a U.S. attorney's office will take over prosecution of a case developed entirely by local police.
Theoretically, local law enforcement officials go to federal prosecutors because the federal government has more resources available to dissect complicated criminal enterprises and its jurisdiction reaches beyond state lines.
But more often, The Pittsburgh Press review of forfeiture found, the cases are passed along because local police find state laws too restrictive in what can be seized and how much money police can make.
If local departments choose to use the federal system, "then it seems to me it's entirely appropriate for us - so long as the resources are there and what not - to help in that process," says Associate Deputy Attorney General George Terwilliger III, the head of forfeiture for the Justice Department.
"But I don't know that we'd encourage it." But his department clearly does. The Justice Department's "Quick Reference to Federal Forfeiture Procedures" says on Page 203 that "adoptive" seizures are encouraged."
Hughes says including "adoption" in his legislation "was a mistake, " because it has become a way for police to game the forfeiture system.
When he introduced legislation that would have ended federal adoption, "it went nowhere, because law enforcement rallied and convinced everyone they needed those cuts of the pie."
Local police have started using the federal courts to do end-runs around state laws that earmark forfeiture money for the likes of schools instead of cops, or else guarantee police less money than they would get in federal court. There, the cut for local law enforcement can be as much as 80 percent of the value of forfeited items.
But it's not always money that propels police into federal court. It can also be differences over prosecution.
In Allegheny County, for instance, District Attorney Robert Colville will not pursue a forfeiture unless he first wins a criminal conviction against the property owner on a drug charge. Local police know that and avoid Colville's office - and go to federal court - when they aim to seize items from owners who aren't even charged with a crime, Colville says.
The departments argue their approach is legal, "but for me, legal isn't necessarily fair, " Colville says.
"It was never intended states would be able to use the federal process to avoid state policy. (Former Attorney General Dick) Thornburgh in particular" has supported adoption. "We want to clean that up," Hughes says, adding that "for the chief law enforcement office of the country to permit that process" of end-runs is "absolutely wrong."
SHORT-SIGHTED SOLUTIONS
Colville also believes the law's requirement that the money go for enforcement purposes restricts other, equally beneficial, uses. He would like to use more money for drug prevention and rehabilitation programs - uses that are strictly limited under federal sharing rules.
For example, federal guidelines permit forfeiture funds to be used to underwrite classroom drug education programs but only if they're presented by police in uniform, Colville says. He's like to send in health officials as well, to "get a different, equally important message across.
"I've come to the belief as a prosecutor that aggressive prosecution alone won't solve the problem. Guys I arrested 25 years ago when I was a policeman I still see coming back into the system. We need to address underlying social and economic problems." He has advocated using forfeiture money for the likes of summer jobs programs in drug-plagued neighborhoods, an idea rejected by the federal government.
Hughes, the New Jersey congressman, says he regrets earmarking all the federal forfeiture funds for law enforcement purposes, but cannot find support for changing the stipulation.
He originally thought police would need every dime they took in to pay for complicated investigations and assumed the forfeited goods would just cover the cost. Once the kitty grew, he figured then money could be set aside for areas such as drug treatment.
But the coffers grew much faster than expected and now it is proving hard to get police to give up the money. "We never dreamed we would be seizing $1 billion. Now the coffers are overflowing, but using the money in different ways is a touchy point at Justice."
Not even appeals from Louis Sullivan, secretary of Health and Human Services, compel a change. During an interview in Pittsburgh last week, Sullivan said he has asked that forfeiture funds go partially toward drug rehab but Justice turned him down repeatedly.
Justice recently turned down a proposal from Jackson Memorial Hospital, a cash-poor public hospital in Miami, to use $6 million seized during a south Florida money-laundering case to build a new trauma center.
The hospital is known in the industry as a "knife-and-gun-club" because of the volume of shootings and stabbings it handles. Police investigate nearly 85 percent of the hospital's cases.
In its proposal, Jackson suggested training medical staff to spot injuries that are the result of a crime, adding on-call photographers who would specialize in taking pictures of victims for use during trials and improving preservation of damaged clothing, bullets and other pieces of evidence.
The idea had bipartisan support from Miami's congressional delegation, Metro-Dade police and the U.S. attorney's office in Miami.
The memorandum from Justice rejecting the idea came from Terwilliger, who wrote that seized money must go to official use which "typically, has included activities such as the purchase of vehicles and equipment," including guns and radios.
But, says Hughes, "if the purpose is to deal with the drug problem effectively, Justice's reluctance to consider new ideas - particularly when it comes to treatment programs - seems to me to undercut their ultimate goal."
The Justice Department, which champions forfeiture as the law enforcement tool of the '90s, declines to talk about where the law is headed.
"I don't think it's appropriate in the context of a press interview to discuss potential policy and legislative issues," says Terwilliger.
But in not talking, the government "masks that details of the total emasculation of the Bill of Rights," says John Rion, a Columbus, Ohio lawyer.
"The taxpayer thinks this forfeiture stuff is wonderful, until he's the one who loses something. Then, he realizes that it's not just the criminal's rights that have been taken away, it's everybody's."
Drug-fighting sheriff puts compassion before forfeitures
Robert Ficano says his Detroit-area drug team gives warning before seizing property
In Detroit, Wayne County Sheriff Robert Ficano is an unabashed supporter of grabbing the spoils of the war on drugs, but he tempers his fervor for forfeiture with controls.
Fïcano appears to be running precisely the type of drug interdiction program authors of forfeiture and seizure legislation envisioned.
It aggressively pursues drug criminals. it has procedures that protect innocent citizens, and it shows compassion - right down to the teddy bears narcotics agents carry to drug raids on homes where children live. In addition, it turns forfeited money right back into more drug investigations. It can do that, because the confiscated money has allowed it to create a new interdiction team devoted to stopping narcotics.
"We started with two officers out of the Wayne County Jail and we wanted to see if they would be able to seize enough in their raids, for them to pay for their own salaries," he says.
That first year, in 1984, they seized $250,000.
"Last year we seized over $4 million. And we've been able to completely fund the narcotic unit out of these
forfeited funds," Ficano says. Today he has 35 officers. 3 drug dogs and all the weapons. surveillance and communication gear needed to equip a modern drug team, with a $22 million budget.
"There isn't a dime of it from taxpayers' money that's used. So in essence, you have the crooks paying for their own busts," he says.
The public's fear of drugs helps win support for forfeiture. "However, we in law enforcement have to ensure that a balance is always kept. You can't violate people's rights.
"Whenever you push a law, a tool, as far as you can go and get up toward the edge, it becomes a difficult balance. There's a responsibility that goes with it.
Teddy bears that police in Detroit area give to children present during drug raids
In the area of forfeiture and seizure, I think we've probably gone as far as, we can and still be accepted by the public and by the courts. I think we're near that edge," the sheriff says.
To maintain balance. Ficano instituted a series of steps that had some of his 900 deputies grumbling at first that he was going soft.
One of his major targets,. he says, is closing crack houses, shooting galleries and other residential drug operations.
"We want these properties cleaned up and under the law we can seize them, but a surprising number of owners of drug houses have no idea of the activity, so we make sure they know what's going on," the sheriff says.
Ficano sends owners two written warnings that illegal activities are occurring on their property and that repeated arrests have been made.
"The first time we do it, we tell them what we found on their property and some of the things they can legally do to get these drug traffickers out," Ficano says. "We'll warn them a second time. The third time, we move to seize the house."
He admits he could make more money if he grabbed the property at the first violation, as many other departments do.
"But the motivation shouldn't be just seizing property. If we can get the public, the owners, to stop the trafficking, then we've accomplished an important goal," he says. "The warnings are needed because you just shouldn't wipe someone out, someone who may be innocent, without giving them a chance."
He also gives warning to drug buyers driving into the county.
In some crack areas, he says, neighborhood streets that in the middle of the afternoon should be peaceful and tranquil look like the parking lots at the University of Michigan stadium on a football Saturday.
In conjunction with local police departments, Ficano took out newspaper ads cautioning: "Buyers of Illegal Drugs, Take Notice." The ads listed descriptions of some of the 210 cars that have been seized from recreational drug users - and the neighborhoods of their owners -- and warned drug buyers to stay out of Wayne County or risk losing their vehicles.
Similarly, he gives a couple of chances to innocent owners of cars used by someone else in drug trafficking: After the first warning, they can claim innocence. that they didn't know that someone else was using the car to buy drugs. The second time the car is stopped it costs owners $750 to get it back If there's a third time, it's a seizure.
"A lot of these people need the cars to go to work or school, so we give them every chance we can, but it's got to stop."
He bristles when asked if he's soft on drug traffickers.
"Look at our arrest records - over 300 raids and 1,000 arrests last yearwe're not soft at all," Ficano says. "We can enforce the law and be aggressive about it. but we can also do it with some compassion and the common sense that is supposed to come with the badge."
Safeguards and tight controls are a must, he insists.
"We do not want cowboys. We do not want officers who follow the typical stereotype drug cop from 'Miami Vice' and other sews. Seizure is an important tool, but we'll lose it unless we keep a heavy emphasis on respecting individual rights."
Sitting atop the TV set in his office is a very un-"Miami Vice" prop: an 18inch, black-and-white speckled teddy bear.
"The biggest deputies we have can be distressed watching a child react to a parent or both parents being arrested after a drug raid. It eats away at you," the sheriff says.
The bears are kept in the trunk of the unit's cars and vans, he says.
"If there is a raid or property is being seized and there are children involved, our deputies can pull the bears out to, hopefully, calm down the children," . Ficano says.
It's difficult to envision a brawny SWAT officer, decked out in a helmet and bullet proof vest, carrying a gun in one hand and a teddy bear m the other. But the narcotic unit's weekly search warrant and arrest report has a column headed "Number of Bears."
The reports for the first two weeks of May show that two of nine bears given out were given as officers seized property.
"If there's something that can be done to reduce the pain that accompanies some of the things we have to do, why not do it?" Ficano asks.
The one area Ficano was hesitant to discuss in detail was the activity of his men as part of the Drug Enforcement Administration's joint task force at Detroit's Metro airport.
Some lawyers, including the American Civil Liberties Union. have criticized the DEA team for being overzealous in seizing cash from suspected drug dealers.
The sheriff did say safeguards exist to prevent improper stops, but added that DEA directed him not to discuss his airport work
While his drug unit is among the biggest moneymakers in the country, and the forfeited funds are key to financing that unit, he says there is a "very clear limit" on how far he will go.
"These new laws open all sorts of new areas for seizing the assets of drug traffickers. We'll use accountants, people with business and banking expertise - all sorts of nontraditional police skills to try to track and forfeit every dollar these dealers are making.
"But there's a line that we won't cross," Ficano says.

PRESUMED GUILTYThe Law's Victims in the War on Drugs
Pittsburgh Press, Aug 11, 1991 By Andrew Schneider and Mary Pat Flaherty
Part one:
THE OVERVIEW
Part two:
THE WAY YOU LOOK
Part three:
INNOCENT OWNERS
Part four:
THE INFORMANTS
Part five:
CRIME AND PUNISHMENT
Part six:
REFORMS
First published in the Pittsburgh Press August 11-16, 1991
It's a strange twist of justice in the land of freedom. A law designed to give cops the right to confiscate and keep the luxurious possessions of major drug dealers mostly ensnares the modest homes, cars and cash of ordinary, law-abiding people. They step off a plane or answer their front door and suddenly lose everything they've worked for. They are not arrested or tried for any crime. But there is punishment, and it's severe.
This six-day series chronicles a frightening turn in the war on drugs. Ten months of research across the country reveals that seizure and forfeiture, the legal weapons meant to eradicate the enemy, have done enormous collateral damage to the innocent. The reporters reviewed 25,000 seizures made by the Drug Enforcement Administration. they interviewed 1,600 prosecutors, defense lawyers, cops, federal agents, and victims. They examined court documents from 510 cases. What they found defines a new standard of justice in America: You are presumed guilty.
About the Authors
Mary Pat Flaherty, 36, is a graduate of Northwestern Univer sity who has worked for 14 years at The Pittsburgh Press where she currently is a special editor/news and a Sunday columnist.
In 1986, she won a Pulitzer Prize for specialized reporting for a series she wrote with Andrew Schneider on the international market in human kidneys. She was the first recipient of the Distinguished Writing Award given by the Pennsylvania Newspaper Publishers Association; twice has won writer of the year awards from Scripps Howard and has received numerous state and regional reporting awards.
Her assignments at The Press have included coverage of the 1988 Olympics in Seoul and a 5week trip through refugee camps in Africa.
Andrew Schneider, 48, be gan reporting for The Pittsburgh Press in 1984. Since that time, he has won two consecutive Pulitzer Prizes; in 1985 for the series he co-wrote with Mary Pat Flaherty on abuses in the organ transplant system, and in 1986, for a series, with Matthew Brelis, on airline safety, which also won the Roy W. Howard public service award.
His other work includes a series with reporters Lee Bowman and Thomas Buell on safety problems of the nation's railroads and a series with Bowman, exposing deficiencies in Red Cross disaster services.
Before joining The Press, he worked for UPI, the Associated Press and Newsweek. He is the founder of the National Institute of Advanced Reporting at Indiana University.
Part one:
THE OVERVIEW
Part two:
THE WAY YOU LOOK
Part three:
INNOCENT OWNERS
Part four:
THE INFORMANTS
Part five:
CRIME AND PUNISHMENT
Part six:
REFORMS

DRUGS, PROBATION AND COURT ORDERS
by Danny Kushlick.
Joe has missed another appointment with me. I have just called his probation officer to let him know and Joe will be returning to the court for breach of his probation order.
This does not sound like the caring, sharing drugs worker of days gone by. Is this the new school of enforced abstinence and the end of voluntarism in drugs work?
Joe is on a probation order with a 1A condition under the 1991 Criminal Justice Act (CJA) to seek treatment for his drug misuse. As the result of a scheme set up in March 1994 Joe and his court were given a new option for high tariff offenders. In 1994 Avon Probation Service funded a partnership scheme with Bristol Drugs Project (BDP) for offenders who were expected to receive a custodial sentence. Now they could opt for three months weekly counselling as part of their probation order. It is Hobson's choice, however, as individuals have to agree to attend the BDP and they can be deemed to have breached their probation order for non-attendance.
To date 45 clients have started on the programme and half have successfully completed the three months (the other half have breached). The vast majority of people referred to the project have committed acquisitive crime in order to support their habit. Most are young, male opiate users, shoplifting, burglary, cheque book fraud and the like.
Although the BDP always had close links with the criminal justice system, the move into a formal partnership with probation and the courts brought up a whole number of new practice issues and concerns.
Confidentiality
This had always been sacrosanct. Now I would have to report on individual's attendance and potentially be slandered in local prisons as "the guy who stitched me up", and so change the clients' views negatively regarding the project.
In practice the protocol we set up means that clients are very clear what will happen if they are given a condition to attend the project. Probation, likewise, are clear what information they will receive. Most clients build up a level of trust such that they can talk, for instance about drug dealing, that they would never speak about with their probation officer. The fact that, although we are in partnership with the criminal justice system, we are one or two steps removed, often gives people the confidence to speak openly.
Coercion
Would the fact that people were under a court order affect the nature of the relationship with the drug worker? The answer is yes, it does. Some, a minority, of people never really trust the confidentiality agreement, and I do not ever really get the full story. For others there is an element of resentment at having to attend and a constant fear of being breached. These added issues are obviously not present for voluntary users of the project.
Some have agreed to the condition purely to avoid a prison sentence and if they do attend subsequently, they are more interested in getting away than talking about themselves.
On the positive side for those people who are chaotic and who want help, the boundaries set by the court order can be extremely useful in providing a structure by which individuals feel supported. The bottom line is that anyone who decides, having been given the condition, that they don't want to come just stops coming. Individuals vote with their feet ultimately. Those who are breached and returned to court are, at worst, likely to receive the sentence they would have got if the scheme hadn't existed in the first place.
Although attendance may as the result of some coercion for many clients it is the first time they have been in contact with a drugs service. They at least know where to go for help should they feel they need it.
Measuring Success
As a partnership worker I have a number of masters whom I serve: my client, probation, the court and BDP.
Success for one will not necessarily be important for another. Convincing someone to regularly use the needle exchange will not necessarily be a Crown Court judge's first priority. Probation and the courts want to know the underlying issues that lead people to offend are being addressed in a way that can be reported back successfully. The courts also want there to be consequences for non-co-operation. Probation also want protocol that enables them to liaise, at the very least, about clients' attendance. Clients want a confidential drugs service that provides everything from support to referral to other agencies. BDP want me first and foremost to provide a service to clients and secondly to develop the service.
In order to meet all these needs we have developed a monitoring system that takes into account drug use, offending, client evaluation and harm minimisation issues. The fact is that although some people will improve on all key performance indicators, some will continue to offend and continue to use drugs. (Indeed, some will continue to offend even if they stop using drugs having been offending before they started to use). Completion of the condition itself is a measure of success for some clients who have never completed a court order.
Additional Bonuses
As a result of the partnership post being developed, liaison between the criminal justice system and BDP has improved greatly. There are many more opportunities for BDP to have a consultative role for probation and opportunities to educate magistrates through their meetings as to the nature of drug use and misuse and the type of people they are dealing with.
The Way Forward
Anecdotal evidence suggests that upwards of 70 per cent of probation clients are misusing drugs and a majority of them are offending because of their habit. This is a huge number of people and will require a multi-agency strategy and a large increase in resources to meet their needs.
Conditions of treatment have an important part to play as an option the court can use and that probation can offer to clients. Avon's experience is that they are immediately useful for about half of those who receive counselling as part of an order. Clients who would otherwise spend anything from three months to three years in prison can now opt for a community sentence during which they can address a number of different issues from a specialist service, which will be monitored by the court. It is, for those who are ready for a change, an opportunity that did not exist before 1994.
It will not, however, meet the needs of the vast majority of probation clients. Not until there is a recognition and strategic response to drug misuse in probation will things fundamentally shift. This also needs to include an analysis at a policy level of why so many people on probation misuse drugs.
Currently Avon Probation Service is working on a strategic response to drug and alcohol misuse amongst probation clients. There are now two partnership workers in the drugs field in Avon. We still cannot provide for anywhere near the needs of all drug using clients on probation. What is needed now is a strategic plan including training, consultation and support for probation officers, training and consultation for magistrates and judges, specialist probation workers and excellent links between probation and the statutory drugs team.
Conclusion
Court ordered drug treatment can work under conditions where probation and the courts support their partner. Just the same as in any other field some clients will get better, some worse and some remain the same. That said, the majority experience some benefit from the contact.
For people like Joe court ordered treatment has given him the opportunity in the community to stay away from a ram raiding œ1,000 a day crack habit and settle down with his girlfriend - as long as he turns up for the next appointment.
Danny Kushlick is a probation partner worker at BDP.
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THE ADDICTED OFFENDER:
Developments in Probation Policy,
Practice and Partnerships
by Dr Judith Rumgay.
Probation services have faced a number of thorny issues in recent attempts to develop practice with substance misusing offenders under their supervision. First among these has been the growing recognition of the sheer volume of clients on probation caseloads with substance misuse problems (Advisory Council on the Misuse of Drugs (ACMD) 1991). The consequent pressure to show a coherent and effective response to this group has forced an appreciation of the fact that many probation officers feel inadequate to the task. Adding to this uncertainty, encouragement to prioritise harm minimisation policies (ACMD 1991; Home Office Inspectorate 1993), while welcomed in principle, spawned an anxious debate about the practical implications of such an approach for a statutory agency in the criminal justice system. Finally, the requirement to develop financial partnerships in the non-statutory sector (Home Office 1990; 1992) has prompted some probation services to consider whether these issues might best be resolved by funding specialist agencies to provide services for substance misusing offenders.
A research project funded by the Mental Health Foundation has been studying local responses to this cluster of dilemmas. Beginning in 1994 and now nearing completion, the study aimed to examine the range of projects for substance misusing offenders provided under the auspices of probation services, to compare 'in-house' projects with those involved in partnership, and to explore professional issues emerging in the development of partnerships. The research has been conducted in three phases: a mail and telephone survey of all probation services in England and Wales; face-to-face interviews with probation and voluntary agency practitioners involved in both in-house and partnership projects; and detailed case studies of three successful projects.
A curious aspect to this research has been the question of the boundary between policy and operational statements. The study opened by approaching probation services with a request for policy documents concerning both substance misuse and partnerships. In respect of the latter, the documents received, almost without exception, comprised the 'partnership plans' required by the Home Office. These plans essentially account for action both taken and proposed to reach the required target of a minimum expenditure of five per cent of services' budget on partnerships. Such operational statements do not in themselves constitute policy, but ought in fact to be guided by policy. It is fair to say that plans offered accounts of priorities for selecting partnerships, but these were set out in broad terms. Moreover, it seems for some, at least, of our subsequent contacts with probation staff that the partnership plans were regarded as strategic documents designed to satisfy official expectations while preserving as much independence as possible. Certainly, the closeness with which they echoed Home Office guidance, with little elaboration or diversion into 'unmarked territory', was notable. If this tactical approach to the drafting of the plans is so, one is even more strongly driven to ask the question: what, and where is partnership policy?
Is this concern for the substance of policy in reality an esoteric concern of academic researchers? Substance misuse policies for the most part endorsed harm reduction, acknowledging the dilemmas that such an approach could create for workers in a statutory criminal justice agency. Concrete guidance on dealing with tensions arising in admittedly sensitive areas such as confidentiality and enforcement, however, appeared to be relatively thin overall. During the second phase interviews, probation officers almost invariably answered the question "How does your service's policy on substance misuse help you?", with an admission of ignorance as to its contents.
In any event, the apparently dominant concerns at policy level tend not to be a strong guide to the pressing issues for practitioners. For example, enforcement was frequently cited as a likely problem in terms of the bal-ancing of the expectations of National Standards (Home Office 1995) and the perceived unreliability of the client group. Very few practitioners, however, could actually recall the last occasion on which an offender was breached for not co-operating with the programme. In practice, enforcement seemed to play little part in their experience. Similarly, anticipated conflict between probation services and partner agencies over issues of confidentiality seemed to have materialised infrequently. Rather ironically, one project where such conflict had arisen was run in-house, involving disagreements between a specialist officer and colleagues as to the level of confidentiality to be preserved.
At practitioner level, perhaps the most sensitive issue, and one which could profoundly affect the quality of practice, was the anxiety of many probation officers for the future, both of their profession in general and their jobs in particular. The financial constraints of probation services following the introduction of cash limiting was necessitating hard decisions at management level which were keenly felt by main grade officers. The resultant insecurity affected both in-house and partnership projects, but in rather different ways.
For some in-house projects, there was anxiety as to the future resourcing of the programme. For example, in some areas probation officers were facing redeployment, as a result of the service's constricted capacity for recruitment. Such redeployment tended to affect officers with specialist roles, such as substance misuse, who were required to undertake a broader range of commitments. This was experienced as a dilution in the quality of the service offered through the substance misuse project, or as a hard choice between preservation of quality and work overload.
In the case of partnerships, however, the strain of professional insecurity frequently surfaced in the quality of inter-agency relationships. To the extent that probation officers perceived their professional roles to be threatened by partnership arrangements, their inter-actions with voluntary agency workers were defensive, and even in some cases apparently hostile. This was related not only to unease about financial constraints on staffing, but more deeply to fears of professional devaluation and marginalisation. A vital ingredient of successful partnerships thus seemed to be the perception at practitioner level of substance misuse partners as providers of a service which complemented rather than substituted for the probation officer's involvement. That the security of one's own professional identity fund-amentally underpins the capacity to appreciate the worth of others may not be a profound revelation. Nevertheless, it seemed clear that management had in many areas failed either to communicate to staff, or to convince them of the view expressed repeatedly in the partnership plans that partnerships should not substitute for the existing work of the probation service.
At a practical level, also, partnerships seemed vulnerable to disruption by the movement of officers who had been instrumental in their development. It was noticeable that successful partnerships enjoyed the attention and commitment of one or two probation officers who invested time and effort in establishing projects, linking colleagues to the substance misuse workers, offering guidance and bridging gaps in communication. Without such a champion, substance misuse workers tended to find themselves isolated, and experienced difficulties in generating referrals. This stemmed from a combination of overt or tacit resistance and simple neglect on the part of probation officers, the ratio of each being dependent on the overall quality of relationships between partners. Substance misuse workers frequently reported spending much of their time engaged in public relations exercise to attract the attention of probation officers to their service, and where necessary to ease resistance to their involvement. Probation officers involved in in-house specialist projects enjoyed a natural advantage here by virtue of their natural presence in probation offices. Where substance misuse workers from partner agencies were able to dedicate time to probation offices on a regular basis, they also benefited from an improvement in the referral rate.
The case studies this research is concluding with involved three contrasting projects which, though very different in their structures, all demonstrate successful practice. Two are partnership projects: one offering an open access outreach and counselling service; the other providing a structured, time-limited programme of counselling as a special requirement of probation supervision. These projects together illustrate different answers to a recurrent policy dilemma over the desirability of targeting offenders as a distinct group within the substance misusing population. This question was raised by many people at earlier stages of the research. It was argued on the one hand that offenders should enjoy and exercise the same rights of access to services as other citizens; but on the other hand that their particular vulnerability and difficulty as a group made special targeting a prerequisite of successful intervention. The third, in-house project found a different solution to this issue, by seconding probation officers on a part-time basis to local community drug and alcohol teams, where they dealt on a voluntary basis with all clients referred through the criminal justice system. It also enables the probation service to capitalise on its investment in the development of specialised knowledge and skills among certain of its staff.
For successful projects, irrespective of their structure, the price of success seemed to be overload. Probation officers' individualistic, protective approaches to their work, once overcome, apparently rapidly turns into enthusiasm for the offer of specialist involvement. Specialist substance misuse workers tended to view this as dependency, stemming from lack of confidence, which is certainly a more flattering interpretation than the alternative possibility that they had become a means of workload management for over-pressed officers. Specialists in substance misuse in such situations altered their approach from seeking referrals to promoting self-reliance, adopting a more consultative role aimed at increasing probation officers' capacity to deal directly with drug problems. This represents a somewhat ironic outcome to the enterprise of importing specialist skills to release officers' time for other activities. Moreover, it drives home the point that, whatever might have been intended or anticipated in terms substitution for their role, practitioner grade probation officers continue to constitute the main vehicle for the delivery of services to offenders under supervision. It will take more than five per cent of probation services' budgets to alter this framework. Nor is this simply a matter of funding, but of the fierce protectiveness of probation officers for their professional identity.
Written at a time of intense anxiety and demoralisation within the probation service, which perceives itself under attack on multiple fronts, these observations acquire an acute poignancy. It is increasingly clear that the problems in delivering high quality services to substance misusing offenders encountered in this study cannot be described simply as deficiencies in practice. Rather, those activities are permeated by, and reflect, the wider professional and organisational difficulties with which the probation service is currently struggling. It is a further tragedy of this situation that it is the least conducive environment imaginable for fostering creative involvement of the skills and dedication of partner agencies.
Judith Rumgay is a lecturer in social policy at the London School of Economics.
References
Advisory Council on the Misuse of Drugs (1991) Drug Misusers and the Criminal Justice System. Part 1: Community Resources and the Probation Service, HMSO.
HM Inspectorate of Probation (1993) Offenders who Misuse Drugs: the Probation Service Response, Home Office.
Home Office (1990) Partnership in Dealing with Offenders in the Community, Home Office.
Home Office (1992) Partnership in Dealing with Offenders in the Community: A Decision Document, Home Office.
Home Office (1995) National Standards for the Supervision of Offenders in the Community, Home Office.
html 1995 drugtext web-lab

As published in The International Journal of the Addictions, 25(12A), 1409-1419, 1990~91
What Works in Addiction Treatment and What Doesn't:
Is the Best Therapy No Therapy.
Stanton Peele, PhD
27 West Lake Blvd.
Morristown, NJ 07960
Abstract
The current trend toward treating drug and alcohol (and other) addictions in disease oriented, 12-step programs has had less success than most people believe. Treatments that teach coping skills, mobilize community forces, and instill values toward prosocial behavior have had success rates far superior to therapies that instruct individuals that they take drugs or drink excessively because they have a disease or because drugs are inherently addictive. Successful treatments instead deal with addicts' interactions with their environments and help them develop beliefs in their self-efficacy. Nonetheless, even addiction treatments which have demonstrated success face limitations in their ability to confront individual intentions and values, community standards, and environmental pressures and opportunities. At the same time, more individuals have quit addictions on their own than have been successfully treated by even the best therapies. Put simply, no therapy will ever be able in itself to make a substantial impact on our drug and alcohol or other addictive problems. in the meantime, addiction treatment is becoming more pervasive and coercive, and today holds out the possibility of corrupting our society and the self-conceptions of its members. [Translations are provided in the international Abstracts section of this issue.]
WHAT WORKS IN PREVENTING AND TREATING ADDICTION/SUBSTANCE ABUSE?
An expanding body of research has identified which therapies for addiction substance abuse succeed and which do not. Indeed, the American National Institute on Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA) have begun major programs to study the efficacy and outcomes of treatment and prevention programs for alcohol and drug abuse, while the National Academy of Sciences has received a mandate from the U.S. Congress to do like-wise. However, there is already a considerable body of data on these issues-data that show strong consistencies both within individual problem areas and across the range of addiction and substance abuse problems. Nonetheless, the United States government and professional treatment organizations and individual treatment facilities have shown no inclination to make use of the ample data that already exist on these topics, forcing us to wonder what good more such research or compilations of research will accomplish.
Exhaustively surveying the literature on comparative or controlled research on alcoholism treatment, Miller and Hester (1986) noted
Not only is the volume of research large, but it is gratifyingly consistent. The results of well-controlled studies in this area have seldom contradicted one another.... Certain methods have a very good track record, working well across a wide range of populations and settings. Others seem to have little therapeutic value, and are rather consistently found to yield little impact on drinking behavior when subjected to controlled evaluation ... As we constructed a list of treatment approaches most clearly supported as effective, based on current research, it was apparent they all had one thing in common...: they were very rarely used in American treatment programs. The list of elements that are typically included in alcoholism treatment in the United States likewise evidenced a commonality: virtually all of them lacked adequate scientific evidence of effectiveness. (p.122)
Miller and Hester constructed a table summarizing effective and much-utilized therapies (which, as they point out, are mutually exclusive sets) in Table 1. The following elements characterize the successful therapies Miller and Hester list:
1. (+) They reduce the reward value of the addictive/substance involvement (aversion therapies, self-control training).
(+) They enhance clients' coping skills so as to reduce the anxiety involved in real-world coping and enhance success at achieving real-world rewards (community reinforcement approach, stress management, family therapy, social skills training).
(-) They do not characterize the alcoholic as having a disease or life-long malady, provide putative information about the Nature of alcoholism, or dwell on putative reasons for alcoholics' drinking (Alcoholics Anonymous, alcoholism education, group therapy, individual counseling).
(-) They do not assail clients' self-concepts (confrontation) or bypass clients conscious coping mechanisms (disulfiram).
Table 1a
Supported Versus Standard Alcoholism Treatment Methods
Treatment methods currently supprted by controlled outcome research
Treatment methods currently employed as standard practice in alcoholism programs
Aversion therapies
Alcoholics Anonymous
Behavioral self-control training
Alcoholism training
Community reinforcement approach b
Confrontation
Marital and family therapy
Disulfiram
Social skills training
Group therapy
Stress management
Individual counseling
a. Miller and Hester (1986)
b. The community reinforcement approach combines marital and family therapy, job interventions, and self-control training using a time-out procedure under conditions of high likelihood of relapse.
Compare Miller and Hester's list of effective alcoholism therapies with a summary of the therapeutic community (TC) concept. Dc Leon (1987) describes the addicted person and the aims of the therapeutic community ()'C) as follows:
Rather than drug use patterns, individuals are distinguished along dimensions of psychological dysfunction and social deflcits. Many clients have never established conventional lifestyle Vocational and educational problems are marked; middle-class mainstream values are either missing or unachievable. Usually these clients emerged from a socially disadvantaged sector, where drug abuse is more a social response than a psycho-logical disturbance. Their TC experience is better termed habilitation, the development of a socially productive, conventional lifestyle for the first time in their lives.
Among clients from mote advantaged backgrounds, drug abuse is more directly expressive of psychological disorder or existential rnalaise, and the word rehabilitation is more suitable...
in the TC's view of recovery, the aim of rehabilitation is global. The primary psychological goal is to change the negative patterns of behavior, thinking and feeling that predispose drug use. .. Healthy behavioral alternatives to drug use are reinforced by commitment to the values of abstinence; acquiring vocational or educational skills and social productivity is motivated by the values of achievement and self-reliance. Behavioral change is unstable without insight, and insight is insufficient without felt experience. (p.8)
Charles Winick, a pioneering addiction/drug use researcher, examined all of the therapeutic communities in operation for heroin addicts in New York City. He found therapeutic communities retrained their clients in fundamental living skills, including attaining a high school diploma, developing basic competencies (like managing a bank account), graded assignments to work, and even training in personal hygiene. The TCs Winick studied were geared toward success outside the TC-that is, toward allowing the client to function in the real world For example, all the communities emphasized occupational training and job placement. TCs, such as Phoenix House, downplay the disease model of addiction/drug use. Instead of being recipients of a medical treatment, as the director of the London branch of Phoenix House makes clear, TCs place the responsibility for change with the addict:
We believe it is essential the addict be given ample opportunity to help himself in his own recovery and to assume responsibility for his life. Treatment of the ex-addict as helpless and incapable deprives him of this opportunity and panders to his manipulative and irresponsible behavior. (Warner-Holland, 1978)
Dc Leon's and Winick's evaluations offer solid evidence of success through TC programs. Winick's research examined clients before and after treatment, finding substantial improvement in terms of avoiding prison, working, and staying away from drugs. Dc Leon's research compared those who stay in TC treatment through graduation versus those who drop out, and found that graduates do far better. The problem with comparing dropouts with perseverers in the therapeutic community is that treatment failures become the comparison point for the treatment, an especially acute problem since this research reveals a high dropout rate in therapeutic communities.)
One drawback to TCS is their often coercive nature, the worst example of which was Synanon, whose founder and director-Charles Dederich, an AA graduate-hired a goon squad to attack internal and external critics (Weppner, 1983). At least one student of TCs has noted that they all share this tendency t~ ward totalitarianism: originally a great booster of TCs, Weppner (1983) eventually concluded that most Synanon techniques, including "immediate, harsh criticism for lapses in expected behavior or work performance, authoritarian rule by 'old-timers,' and emotional growth by conforming to the unrelenting twenty-four-hour surveillance in the organization, have been adopted by most therapeutic communities in the United States. .....In retrospect.... I must emphasize my belief that therapeutic communities are not the panacea, the easy answer to drug-abuse treatment ..... - have seen them to be.... Abuses are so eminently possible because of the inherently authoritarian nature of therapeutic communities" (pp.38, 213).
On the other hand, the successful aspects of TCs as revealed in Winick's and Dc Leon's work are:
1. They reject the disease model of drug use and do not consider addiction a life-time characteristic of the individual
2. They demand responsible behavior from the addict/user and require positive contributions to the community from residents.
3. They teach addict/users specific skills geared toward coping outside the community.
4. The goal of therapy is to graduate from the TC into the broader world
5. TCs explicitly inculcate values toward prosocial activity to replace the immature acting out that characterizes addict/user lifestyles.
An entirely different focus on drug abuse from that of the TC is provided by programs aimed at preventing (and to a lesser extent, treating) adolescent substance abuse. Newcomb and Bentler (1989), who have for some time studied the longitudinal development of drug use problems in the young, evaluated prevention programs in light of various risk populations. The authors in the first place identified the risk factors for drug abuse as the following:
1. Social-structural-factors:
Peer influences
Disadvantaged socioeconomic status
Disturbed families and adult models of drug abuse
2. Psychological factors:
Need for excitement
Psychopathologies such as depression and anxiety
3. Value factors:
Lack of religious commitment
Lower achievement orientation and poor school performance
Greater tolerance for deviance and a history of deviant behavior
Newcomb and Bentler divided prevention programs into the following groups:
1. Informational of knowledge programs, which provide so-called objective in-formation about drugs and alcohol, including programs that rely heavily on scare tactics (as in the standard lecture by ex-addicts or David Toma; cf. Peele,
1989).
2. Peer programs that focus on social skills involved in rejecting negative peer influences. These programs follow the notion of "Just Say No," although the realistic ones build in behavioral and social skill training and strive to enhance self-esteem.
3. Affective programs aimed at psychological growth.
4. Alternatives programs that focus on community, leisure, and physical activities and on remedial training such as job skills or one-on-one tutoring.
5. Combined affective/informational programs.
Evaluating the success of these programs with reference to different groups, Newcomb and Bender(1989) noted that "Scare tactics ... have not been effective" and, more generally, "knowledge, affective, and knowledge/affective approaches had little effect ... (and sometimes increased drug use)-" The authors found these approaches don't work because they ignore environmental factors. Peer programs, on the other hand, have often shown strong benefits, primarily for the "typical teenager," who finds it easier to resist invitations to drug and alcohol use. However, the authors noted, the effectiveness of this approach is limited primarily to those groups which already show the fewest risk factors for drug use.
The peer modality can help the teenager at a party, who is wavering about whether to try the marijuana joint being passed around, to decline the of..... -. [Such) peer approaches reduce the use of drugs but have less impact on abuse of drugs. ... The typical teenager who experiments with beer or shares a joint at a party is unlikely to be the one who will have severe problems with drugs later in life Labeling this person as a "druggy," sick, screwed up, or in need of treatment is liable to be more destructive than the use of the drug itself. (Newcomb and Bender, p.246)
Looking beyond this group for whom treatment is contraindicated, Newcomb and Bender (1989) declared, "It is misleading to bask in the success of some peer programs that have reduced the number of youngsters who experiment with drugs (0ut would probably never become regular users, let alone abusers) and ignore the tougher problems of those youngsters who are at high risk for drug abuse as well as other serious difficulties." Newcomb and Bender concluded: "For those most vulnerable to abusing drugs, prevention aimed at promoting alternative activities, building confidence and social competence, and providing broadened experiences was most effective" (p.246).
To summarize the Newcomb and Bender meta-analysis of drug use prevention and treatment programs:
1 Most prevention and treatment programs for adolescents are ineffective and they may be counterproductive, particularly when treatment programs mislabel drug use as a pathology for ordinary children who are likely to achieve normal life resolutions on their own
2. Help for the most susceptible groups of young people involves teaching children real skills and enabling them to broaden their horizons and to achieve wider opportunities.
WHAT SHOULD WE DO-ELIMINATE THERAPY?
All three of these surveys of effective treatments, so divergent in their methodologies and subject populations, point in the same crucial directions All three make clear that:
1. Treatment along medical-model lines that identifies drug use or alcohol misuse or addiction as an internal, individual problem is misguided and doomed to failure.
2. Most treatment in the United States assumes such an individual-deficit, medical model. Although all data contraindicate this approach, it is actually growing and being applied to broader and younger populations than those for which it was designed, meaning that a failed system is expanding into areas where its failures will be even more costly.
The reasons for this persistence in the face of contravening data, of course, have to do with American social history, the economics of treatment, and successful proselytizing by ex-addict/users and alcoholics who have undergone conversion experiences along the lines of the AA model (which actually follows the format of the earlier, Temperance model) Peele, 1989).
in a positive direction, what these summaries show about effective therapy is that:
It teaches people real skills for dealing with the world, dealing with other people, dealing with work, and dealing with themselves.
It confronts without apology the negative value system of the addict/users and their worlds.
It concentrates on broader social units-families, social groups, and communities-both as causes of and as resolutions for addiction
But all of these things-skills, values, and community-are best approached in natural settings and not in the treatment setting. Teaching people prosocial values and how to work or to deal with their families is something that can only be approached in the most stop-gap and expensive manner outside of the contexts in which these things have traditionally been taught-in families, in schools, in religious and civic organizations, and in communities.
The word community occurs constantly in these summaries. By far the most effective program reviewed by Miller and Hester (1986) was the Community Reinforcement Approach (CRA). Hunt and Azrin (1973) found that with chronic addicted inpatient alcoholics, CRA patients drank on 14% of days (compared with 79% of those in a standard hospital program involving AA and lectures), were unemployed one-twelfth as much, and spent one-fifteenth the time in institutions. Obviously, therapeutic communities involve communities-both in terms of the therapy intervention and in terms of the stated goal of successful TCs of reintroducing the resident into the broader community.
What, then, about therapies that rely directly on the community as a therapeutic resource? Mulford (1988) described such a community program as it operated in Iowa. The Iowa program hired a community coordinator in each town to deal with alcoholics. The University of Iowa trained coordinators and monitored the results in each town, providing the coordinators with feedback to help them learn from and build on their own and others' experiences." Coordinators were not required to have any special background or training. It was simply expected that they would care about alcoholics, and draw upon their common sense, experience, intuition, and empathy to contact people with drinking problems and lend them a helping hand Their [coordinators'] approach to clients varies depending upon the nature of the case. No two are treated alike."
[The coordinator] explains to alcoholics that there is no solution for their problem that anyone can give or sell them They must get it the old-fashioned way-work for it. Any benefit they get from others' efforts to help them is in proportion to the effort they themselves put into the process. He does nothing to alcoholics, and he does nothing for them that he can get them to do for themselves. Nor is his office a place for the community to dump its responsibilities to alcoholics. To encourage widespread community responsibility, he seeks to involve as many other citizens in the alcoholic's recovery as possible.
Serving as a catalyst for natural rehabilitation forces, the coordinator helps alcoholics restore and strengthen social relationships- through job, family, Alcoholics Anonymous, church and social activities. He also helps them use appropriate community services and resources to resolve their medical, legal, financial, religious, or other problems. (Mulford, 1988, cited in Peele, [989, p.267)
In 1975, however, the Iowa program was centralized under a State Alcoholism Authority, funded by federal and state funds and directed through federal guidelines according to the orthodox medical model (before that, communities were responsible for paying the coordinator and whatever office rent and expenses he needed themselves). The immediate result was that costs rose at least twofold for each community, while the State Authority's budget increased by a factor of ten. Yet, more alcoholics fell through the cracks, and in the first two years of operation, the new federally and state organized community programs served half as many new alcoholics as had the old community programs Mulford explains the cost differential:
The great cost-effectiveness advantage of the coordinator approach lies in the vastly greater number of persons served at minimal ~ The Washington County center [the one community coordinator program remaining in Iowa-this county declined to participate in the federally funded program] has annually been serving about 250 alcoholics on an annual budget of less than $45,000. That would treat only three or four cases in a nearby hospital-based center, and only one or two in an expensive private clinic. (Mulford, 1988, cited in Peele, 1989, p.268)
The alcoholism and addiction treatment movement always calls for more money to be spent on alcoholism-this is taken as a measure of America's commitment to combating alcoholism and drug addiction, and of its own success. Mulford, in contrast, here describes an actual program, growing out of real community re spouses, that costs a fraction of the typical medically-based programs and that would plow money directly into American communities. However, even under a Republican, Reagan-Bush Administration-one that gives lip service to returning power to communities and cost-effective government expenditure-America simply has continued to build up its costly and ineffective alcoholism and addiction bureaucracy.
In good part, this is due to American's delusion that great progress can be made-has already been made-through identifying the medical basis of alcoholic misbehavior. Mulford (1988) describes how this delusion actually works against us as communities and as a nation:
The alcoholism-disease way of thinking leads us to disown our responsibilities to keep each other reasonably sober as a part of the process of keeping each other human Instead, it encourages us to relinquish our authority for informally constraining each other's drinking behavior to designated "experts" who are all too eager to assume the task- (Mulford, 1988, cited in Peele, 1989, pp.268-269)
CONCLUSION
There is more and more treatment in economically advanced nations, which costs more and more and becomes increasingly entrenched, while social outcomes spiral downward. The NIAAA epidemiology research center, the Berkeley Alcohol Research Group (ARG), studies community responses to drinking problems in societies round the world. Robin Room (1988), director of ARO, noted that, "we were struck with how much more responsibility.,. [those in developing nations] gave to family and friends in dealing with alcohol problems, and how ready…..
[those in technological societies] were to cede responsibility for these human problems to official agencies or to professionals" (p.43). Yet, antlrropologist Dwight Heath (1982) has noted that drinking problems-especially the isolated, compulsive drinking that is an integral definition of alcoholism-are "virtually unknown inmost of the world's cultures," particularly preindustrial cultures (p 436). The major exception to this, of course, is when indigenous communities are destroyed by outside forces, as has occurred with Native American and Eskimo societies in the United States.
Room (1988) summarized the Alcohol Research Group's cross-cultural findings:
Studying the period since 1950 in seven industrialized countries [including California in the US] . . we were struck by the concomitant growth of treatment provisions in all of these countries, The provision of treatment, we felt, became a societal alibi for the dismantling of long-standing structures of control of drinking behavior, both formal and informal. (p. 43)
It seems, then, that the institution of a modem medical and social services system for dealing with problems like alcoholism corresponds exactly with the removal of the forces most effective in curtailing these problems in the first place. The entire alcoholism and addiction/drug abuse treatment movement is a giant subterfuge for avoiding the tealizations, responsibilities, and means required to deal with addictive/substance misuse problems in industrial nations around the world, As the community resources in these nations are eroded, they may and all too often seek escape in an orgy of drug addiction/abuse treatment because they cannot conceive of how to reverse the process of community deterioration, This social process can reasonably be described and defined as "addictive."
REFERENCES
DE LEON, 0(1985). The therapeutic community: Status and evaluationInternational Journal 0f the Addictions 20, 823-844.
DE LEON, G. (1987). The therapeutic community for substance abuse: Perspective and approach '[IG. DC Leori and 3.T. Ziegenltss, 3r. (Eds.), Therapeutic communities far addictions (pp. 5-1 8).
Springfield, IL Claries C. ThomaL
HEATh, D.B. (1982). SociocuItural variants in alcoholism In ~M. Patoon and ~ Kaufman (Eds.), Encyclopedic Handbook of alcoholism (pp. 416~4O). New York: Gardner Peas.
HUNt', G.M., and AZRIN, N.H. (1973). A community reinforcement approach to alcoholism Behavior Research and Therapy, 13, 1115-1123
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MILLER, and HESTER. R.K. (1986). The effectiveness of alcoholism treatment: What research reveal In W.FL Miller and N.K. Heather (EdL), Treating addictive behaviors; Processes of change (pp.121-173). New York: Plenum
MULFORD, H. (February, 1988). Enhancing the natural control of drinking behavior. Paper presented at conference' Evaluating recovery Outcoms', University of California, San Diego.
NEWCOMB, M.D., and BEP~ P.M. (1989). Substance use and abuse among children and teenagers. American Psychologist, 44,242-248.
PEELE, 5(1989).Diseasing of America: Addiction treatment outof control Lexington, MA: Lexington BOOKS
ROOM, ~ (1988). Closing statement, Evaluating recovery outcomes. Proceedings of conference published by Program on Alcohol Issues, University Extension, University of California, San Diego.
WARNER-HOLLAND. (1978). The development of 'concept houses' in Great Britain and Southem Ireland, 1967-1976. In DI. West (EdL), Problems 0f drug abuse."' in Britain' (pp.125-132).
Cambridge: Instimte of Criminology.
WEPPNER, R.S. (1983). The untherapeutic communiy. Lincoln' NE: University of Nebraska Press".
W'INICK, C. (1980). An empirical assesment of therapeutic communities in New York City. InL Brill
and C. winick (Eds), The yearbook of substance use and abuse' (VoL 2' pp.251-285). New York: Human Sciences Prees.
THE AUTHOR
Stanton Peele, PM), a social psychologist, published his first book, Love and Addiction (written with Archie Brodsky), in 1975. More recently, Dr. Peele has pointed out the inherent contradiction between therapies that tell people they are born addicts and the encouragement of self-efficacy needed for people to cope effectively and permanently to overcome addiction. His most recent books are Diseasing of America: Addiction Treatment Out of Control (1989) and (with Archie Brocisky and Mary Arnold) The Truth About Addiction and Recovery: The Life Process Program for Outgrowing Destructive Habits (1991).

Misdemeanours ... unclassified and otherwise (IJDP 9.4)

By Pat O’Hare

Ken Vail is a regular at the International Conference on the Reduction of Drug Related Harm. He is founder and Executive Director of the Xchange Point, Cleveland's second needle exchange program. If you have been to the Harm Reduction conference you will know who he is because he is extremely tall and wears his hair in a pony tail. He is one of the world's nice people. He is also one of the world of harm reduction's unsung heroes. A few days ago he spent six and a half hours in jail in Cleveland, Ohio for doing his job.

He was arrested on Tuesday 28th April and charged with an 'unclassified misdemeanour', the equivalent of a parking violation. Bail was set at $10000. He was arrested for violating the City's health emergency order on syringe exchange which was revised earlier this year. The revised regulations had asked the programmes to desist from syringe exchange until they demonstrated widespread community support through a variety of mechanisms such as community forums. Ken has been working on increasing the community support but has been vocal in criticising the 'desist' component of the order. A warrant was issued for his arrest and he turned himself in.

As in many of these things there was an element of farce in that the original summons was sent out on 23rd February to a 57-year-old man at a different address. The warrant for his arrest was issued on 20th April. Ken and his lawyers were told that it was an 'in-out process' at jail. Suddenly the bail bond was $10000 (later dropped to a personal bond) and he sat in jail for six and a half hours. At his hearing he pleaded not guilty.

On 19th May he appeared in court with his lawyer. The City Prosecutor informed his lawyer that undercover police saw him 'give a needle away without receiving one in exchange'. This was not true and in the words of his lawyer it was I more weak evidence to go with an already weak case'. Quite what undercover police are doing spying on outreach workers is another matter. His lawyer waived the right to a speedy trial and they decided to sit down with the City of Cleveland for a final time to resolve the problem.

On Ist June they met with city officials at the Health Department. Among those present were the City Health Director, HIV/AIDS Co-ordinator, Attorney and Prosecutor. William Patmon, the Council member that represents the district where the drop-in centre needle exchange site is located and who opposes the practice was not present. Eventually Ken met with him and arranged an appointment to sort things out. One meeting was postponed and Patman failed to turn up for the re-scheduled meeting.

As I have commented in the past, it is difficult to imagine that needle exchange, a public health strategy to reduce the spread of HIV and other infections, with proven results in doing so without increasing the prevalence of injecting drug use, can be so contentious that the city of Cleveland would risk more infections by calling a halt, however temporary, for their own political reasons. That someone can be arrested and spend time in jail because his public duty will not allow him to stop is beyond belief.

The situation in the USA, a country in which 35% of all new HIV cases are due to drug injection with unclean needles, is eccentric, to say the least. After many years of delay, the Clinton Administration announced recently that needle exchange programs are effective at reducing the spread of HIV and do not encourage drug use but refused to allow federal funding to be used for them. Health Secretary Donna Shalala urged state and local governments to implement their own programs because it is an effective public health strategy. Meanwhile one local government not only tells a project to suspend operations but it arrests a worker who is doing what the government has advised should be done.

Needle exchange programs are supported by the American Medical Association, the National Academy of Sciences, the Centers for Disease Control and Prevention, the American Nurses Association and American Public Health. In addition, the American Bar Association and the USA Conference of Mayors have urged the federal government to allow states and local governments to use federal HIV prevention funds to implement needle exchange programs.
Ken Vail was arrested for doing good public health. In Italy, harm reduction projects are harassed by police and sabotage attempts are made by staff who disagree with the policy. In Russia, a mobile needle exchange is raided by police and workers beaten up. People who are doing their jobs and being punished for it. As workers and policy makers in those countries where needle exchange is not a disputed strategy it is very easy to become complacent. Every now and then stories like this one come along to remind us that in many parts of the world this is a job that can only be done by brave and committed people. Ken Vail is one such person who doesn't want to go to jail and doesn't really want to appear in court. He is prepared to do so because of what he believes. He deserves our commendations and support.

Addiction: brain mechanisms and their treatment implications David J NuttUniversity of Bristol Psychopharmacology UnitSchool of Medical SciencesUniversity Walk, Bristol BS81TD, UK (D J Nutt FRCPsych)
The Lancet 1996; 347: 31-36
Drug addiction, or as it is also called, drug dependence, is a serious health problem; in addition to the huge direct health costs (psychiatric and physical), there are massive costs in terms of crime, loss of earnings and productivity, and social damage. The drugs of primary concern are the opioids, stimulants (amphetamines, cocaine), and alcohol, although nicotine addiction (smoking) is also an important health issue. Reducing the extent of drug dependence is one of the major goals of medicine.
The processes of addiction involve alterations in brain function because misused drugs are neuroactive substances that alter brain transmitter function. Then is an impressive and rapidly growing research base that is giving important insights into the neurochemical and molecular actions of drugs of misuse--the processes that are likely to determine such misuse in human beings. Exciting new developments in neuroimaging with both PET (positron emission tomography) and SPELT (single photon emission computed tomography) provide, for the first time, the possibility of testing in human beings theories of drug addiction derived from preclinical studies. Key concepts of addiction are shown in the panel.
Panel: Key concepts
Drug dependence Because addiction is an imprecise and potentially pejorative term. the WHO recommended In 1969 that It should be replaced by the term drug dependence. Dependence is a continuous variable; for any Individual Its extent is determined by a range of factors such as amount and frequency of drug use, development of tolerance and withdrawal, inability to abstain, and degree of physical, personal, and social damage. The dependence spectrum thus ranges from simple physical dependence, as for example in some long-term therapeutic-dose benzodiezepine users, to the complete disintegration of personal and social functioning found in end-stage alcoholics and 'hard drug' users. Physical dependence is caused by alterations in brain function that lead to the experiences of withdrawal. Psychological dependence describes repeated drug seeking and taking in the absence of withdrawal. Both can occur independently and contribute differing amounts to dependence on different drugs.
Tolerance This is the state in which drug actions diminish on repeated administration. Tolerance means that the addict needs more drug per dose; this increase in cost drives criminal activities. Tolerance often develops at a different rate for different actions of the drug. The respiratory depression caused by opioids reduces faster than the euphoric actions; this explains why addicts can use doses of heroin that would be lethal to non-addicts (several grams a day). A person becomes tolerant to the euphoric actions of cocaine faster than to its cardlostimulant actions, so on binge use, cardlotoxic concentrations are frequently reached.
Withdrawal Withdrawal Is signified by signs and symptoms that occur when a drug Is stopped or an antagonist (eg, naloxone for opiolds) Is given. Both physiological and psychological (conditioning) processes contribute. Because withdrawal Is almost invariably unpleasant (eg, morning shakes with alcohol) I Is a common reason for reuse of a drug. Moreover, withdrawal may also cause secondary problems. Examples are excitotoxic brain damage in the case of alcohol, and depression and anxiety in the case of cocaine. Withdrawal from some drugs (eg. methadone) may be long lived, and can be associated with continued craving.
Sensitisation This Is the opposite of tolerance ie. an increase In some actions of a drug on repeated administration--and tends to be seen with the stimulating actions of drug states. One example Is the increased locomotor activating effects of cocaine and amphetamine; a clinical corollary of this may be the psychotic state seen during stimulant binges. Both probably reflect dopamine receptor supersensitivity. Sensitisation to the excitatory changes found in withdrawal also occurs and this explains the long-established clinical observations that alcohol withdrawal progressively worsens. Sensitisation may also be the process of reinstatement, in which as an addiction 'career' progresses, relapses escalate much more rapidly to a state of decompensatlon.
Craving Craving, the desire to get (more of) the drug, Is difficult to define because It has several subcomponents. which differ between drug and between Individuals. For instance, with stimulants and alcohol, the first dose of drug can lead to a euphoric priming that drives repeated consumption: In many opioid addicts and alcoholics, craving is associated with withdrawal symptoms that seem to be conditioned to significant aspects of previous drug use-eg, needles and syringes or bars. Craving often leads to the addict's behaviour becoming highly focused on getting the drug with a narrowing of the normal behavioural repertoire. For example, an alcoholic will spend more and more time thinking about and engaging in drinking, and this leads to a progressive reduction In participation in work and family activities.
Euphoria Known by mart' synonyms (eg, rush, high, buzz) euphoria Is the state of pleasure produced by a drug. This state is closely linked to the reinforcing effects of the drug (is, how likely It is to lead to continued use). Euphoria is thought to relate to endogenous dopamine and or endogenous opiod release and is determined by both pharmacodynarnic and pharmecokinetic factors. Euphoria is not the sole reason for the use of drugs. Many addicts start drug use to deal with psychiatric difficulties, especially anxiety, which sedatives, opioids, and even stimulants can reduce.
Maintenance therapy In this therapeutic approach, the need for Illicit drug use is removed because the addict Is prescribed a drug whose actions substitute for the drug of misuse. Maintenance therapy Is an important component of harm reduction programmes, which seek to reduce the personal and social cost of drug addiction when abstinence Is not an option. The best example Is with oplold addiction, in which methadone reduces HIV infection and crime as well as engages the addict in treatment. Methadone has the disadvantage of the need for daily prescription and a high diversion potential into street (black market) use. Longer acting alternatives under investigation are buprenorphine and LRAM (bawetylmethadol); these can be given every 2-3 days, have lower street value, and are safer In overdose. Mcotine gums and patches are a safer route for nicotine self-administration than Is smoking. It is likely that maintenance therapy can be used for most drugs of dependence although clinical trials would be needed. Examples would be use of methylphenidate for cocaine or amphetamine dependence and long-acting benzodiazepines for intravenous temazepam users.

Pharmacological aspects
Drugs of misuse were traditionally classified into groups according to their physiological or psychological actions (eg, stimulants, sedatives). This classification is unsatisfactory because a single drug may have several actions; alcohol often acts as a stimulant in the early (rising) phase of intoxication, but as brain concentrations increase sedation ensues. The molecular sites of action of most drugs of misuse have been well characterised in recent years (see table) so it is preferable to classify drugs according to their pharmacodynamic actions.
Generally, the more efficacious the drug is at producing its pharmacological effect, the greater is the addiction potential and street value (figure 1). Drugs with lower efficacy are called partial agonists (eg, buprenorphine for opioid receptors) bretazenil for benzodiazepine receptors2). The pharmacological profile of partial agonists is such that they are useful in maintenance treatment since they provide some reinforcement; thus, buprenorphine will keep opioid addicts in treatment. Nonetheless, because partial agonists attenuate the actions of full agonists, buprenorphine should diminish intravenous street heroin use. Moreover, the lower efficacy means that it is much safer in overdose.
Antagonists have zero efficacy (eg, naltrexone for opioid receptors, 3 flumazenil for benzodiazepine receptors4). They are very effective blockers of agonists. Their limitations are that they can precipitate withdrawal in physically dependent addicts and, because they do not provide any reinforcement, there is little incentive for addicts to stay on them. Naltrexone is useful in highly motivated individuals in whom relapse to opioid use could portend the end of their career (eg, doctors and pharmacists). This antagonist is also used in some countries under probation orders when non-compliance with treatment will then lead to prison.
For most drugs of misuse, the molecular sites of action are receptors or transporter sites; many of these have been cloned and sequenced, discoveries which in themselves are important advances for molecular biology. The dopamine transporter was cloned to expedite the understanding of cocaine's action;5 all three of the opioid receptors and the multiple subunits of the γ-aminobutyric acid agonist A-type (GABA A) receptor have also been cloned. Such discoveries help direct research towards a more rational design of treatment, and help develop theories of the brain mechanisms underlying addiction. There is a large research effort being directed towards finding a drug that will bind to the dopamine transporter and prevent the binding, and hence the actions, of cocaine without interfering with dopamine uptake.6
New μ opioid receptor drugs with potential treatment use such as antagonists (clocinnamox)7 or partial agonists (buprenorphine) have been designed. The knowledge that alcohol acts through GABA and excitatory aminoacid receptors is leading to the study of drugs acting at these receptors (eg, acamprosate)8 as treatments.
Pharmacokinetic factors are also important in determining the misuse potential of drugs; in general the faster the drug enters the brain the more reinforcing it is. Many of the developments in drug misuse reflect efforts by addicts to speed up the rate of drug delivery. Perhaps the best example is cocaine; when chewed in the form of coca leaves it has little misuse potential. Progressively it has been refined so that entry to the brain is accelerated, from paste to powder and finally the lipophilic free-base (crack). In parallel, the route of administration has changed from oral through nasal to intravenous or smoking; the latter two result in brain concentrations that peak within minutes of drug taking.9 Addicts prefer heroin to morphine because it is more lipophilic and so enters the brain faster. The quest for immediate reinforcement fuelled the epidemic of intravenous drug use that is now the major cause of HIV and hepatitis C virus spread. Reducing this behaviour is one of the most important goals in addiction treatment programmes.

Brain transmitters involved in addiction
Drugs are used because they produce alterations in brain function that result is positive changes in mood; this can be an elevation in mood from normal (euphoria) or the reduction of a negative dysphoric mood as in withdrawal. These changes are effected by interactions with neurochemical processes, usually by mimicking or increasing the action of endogenous transmitters.
DopamineMost drugs that produce elevations of mood or euphoria, including nicotine and alcohol, release dopamine in either the nucleus accumbens or the prefrontal cortex in animals, as demonstrated by brain dialysis.10 Dopamine release can be either direct (for example, the stimulants cocaine and amphetamines release dopamine), or indirect (opioids switch off the firing of GABA neurons that tonically inhibit dopamine cell firing). Several studies have shown that blockade of either D1 or D2 dopamine receptors attenuates the reinforcing actions of both these classes of drugs, which argues for a central mediating role of dopamine receptor activation in the initiation of addiction.11 Of clinical relevance is the suggestion that a genetic polymorphism of the D2 receptor is strongly Baked to drug misuse but this is still controversial.12
Homoeostatic adaptation occurs to the dopamine-increasing actions of drugs, so that when the drug is stopped dopamine release is decreased below normal; this explains the "crash" after stimulant discontinuation 9 and some aspects of nicotine, opioid, and alcohol withdrawal. Drugs that block dopamine reuptake (eg, desiptramine and mazindol, which are used to treat cocaine withdrawal) presumably work by increasing dopamine concentrations.9 Dopamine overactivity probably underlies alcoholic delirium tremens and the need to treat with dopamine-D2-receptor blocking agents such as haloperidol.13 Chronic dysregulation of dopamine function in detoxified alcoholics as revealed by a decreased number of uptake sites in SPECT studies with 123I-βCIT14 may explain the new finding that the low potency neuroleptic tiapride reduces relapse.' ,
It is now possible to measure both D1 and D2 dopamine receptors and the dopamine uptake site in human beings with neuroimaging techniques (figure 2). Cocaine has been shown with PET to bind predominantly to the dopamine-rich areas of the basal ganglia;16 11C-RTI, an isopropyl derivative of cocaine, is a newer and better marker of these dopamine uptake sites. Now that D2 receptors (with 11C-raclopride) and Dl receptors (with 11C-SCH-23390) can be visualised, alterations in function in addicts could be studied.16 Dopamine metabolism can also be monitored in vivo with 18F-dopa. Similarly, the local metabolic effects of cocaine can be studied with 16F-deoxyglucose uptake. These studies have shown that cocaine globally decreases brain metabolic activity.17 An exciting potential development of PET/SPELT technology is to measure endogenous dopamine release; if cocaine and amphetamine do act by releasing dopamine this should be seen as a displacement of radiolabelled receptor ligand.
Endogenous agonist opioids The brain makes a complex mixture of peptides that as as endogenous transmitters at opioid receptors-the β-endorphins and encephalins; these are involved in appetite, pain, and response to stress.17 Misused opioids such as heroin act at the same receptors as the natural opioid system. However, because they have much higher efficacy than the endogenous transmitter they "high jack" the natural system by producing a much exaggerated response. Endogenous opioids are thought to be involved in the actions of other misused drugs such as alcohol and stimulants. For example, alcohol may cause dependence because it releases endogenous opioids; this could explain the therapeutic benefit of opioid antagonists such as naltrexone.18
There are three types of opioid receptors (μ, κ and δ) that are distinguished by selective agonists and in some cases antagonists. μ and/or δ receptors mediate the euphoric actions of opioids,19 with δ being possibly more important for alcohol.20 Activation of κ receptors is aversive and could explain some aspects of opioid actions including the dysphoria of withdrawal 21 Many misused opioids have activity at all three receptor types so adaptive changes in each may be important in the process of addiction.
Brain opioid receptors can be imaged in PET with 11C-labelled diprenorphine (non-selective antagonist) (figure 3) or carfentanyl (μ agonist).16 Diprenorphine has been used to show the release of endogenous opioids in some forms of seizures22 and so could potentially be used to reveal whether non-opioid drugs cause their release also. Diprenorphine could also be used to determine the degree of receptor occupation required for optimum therapy with the various maintenance treatments such as methadone and naltrexone. Neuroimaging techniques not only offer the opportunity to test directly theories of drug dependence developed from animal studies in human beings; they can also be used to understand and optimise current treatments and develop new ones. For instance, the proportion of brain opioid receptors occupied during maintenance therapy with methadone could be determined and related to degree of dependence, craving, and treatment outcome. The linking of the clinical effects of partial agonists and their brain binding should lead to the more rational design of new compounds.
Another interesting possibility would be to explore the role of endogenous opioids in craving once reliable methods of inducing this state have been developed. One major future need for opioid receptor neuro-imaging is the development of subtype-selective antagonist ligands to unravel the role of μ, δ and κ receptors in the actions of the various drugs of misuse.
Noradrenaline The activity of noradrenergic neurons is decreased by opioids, and withdrawal is thought to be due in part to the unopposed expression of compensatory processes. This explains why clonidine 23 or lofecidine, 24 α2-adrenoceptor agonists that inhibit noradrenergic neuronal activity, are effective treatments of opioid withdrawal. A similar hyperadrenergic state accounts for many features of alcohol withdrawal, especially anxiety, tremor, sweating, and hypertension,25 although clonidine is not a recommended treatment for this condition because it does not protect against seizures. Some clinical data suggest that longer-term reduction in noradrenaline activity may predispose alcoholics to relapse and that drugs that selectively reverse this process may have clinical use.26 Complex time-dependent alteration in noradrenaline function has recently been reported in patients withdrawing from stimulants27 which may open new therapeutic avenues. Recent animal data suggest that noradrenaline/dopamine interactions in the nucleus accumbens and frontal cortex may be important in the actions of stimulant drugs, contributing to features such as sensitisation..26 As yet neuroimaging of brain noradrenaline systems is not possible, although a potential α2-adrenoceptor ligand has been identified.26
Serotonin (5-HT) 5-HT is an amine transmitter secreted by cells whose bodies are found in the raphe nuclei of the brain stem and whose axons arborise and diffusely innervate higher brain structures, as is the case for noradrenaline. 5-HT has many roles in brain function, but in relation to addiction the main ones relate to appetite, impulsivity and craving. Early-onset (type II) alcoholics with a history of violent crime have low brain 5-HT turnover,30 perhaps due to a polymorphism in their gene for the synthetic enzyme tryptophan hydroxylase. This subgroup of alcoholics also shows altered 5-HT receptor sensitivity in that administration of the 5-HT 2 receptor agonist mCPP produced craving rather than anxiety.31 In this context it is intriguing that in rodents trained to self-administer alcohol, 5-HT receptor antagonists such as ritanserin and amperozide reduce intake.32 Clinical trials of these drugs an now continuing. Increasing brain 5-HT function by blocking its reuptake with selective serotonin reuptake inhibitors (SSRIs) reduces voluntary alcohol consumption in heavy social drinkers.33 The 5-HT receptor agonist buspirone reduces relapse in detoxified alcoholics with comorbid anxiety disorders.34 Neuroimaging of 5-HT is in its infancy but one of the newer PET dopamine uptake site tracers RTI 55 also labels the 5-HT transporter. Considerable progress is also being made towards producing an 10F-labelled precursor for turnover studies. 5-HT, receptors have been imaged with 11C-ritauserin,16 although not yet in addicts, and a PET ligand for 5-HT1A receptors ( 11C-WAY 100635) is under development.35
Aminoacid receptors The major excitatory and inhibitory transmitters in the brain are the closely related aminoacids GABA (inhibitory) and glutamate (excitatory). The GABA receptor complex contains a binding site for the bemodiazepines, which is their sole site of action. Alcohol(s) and the barbiturates also enhance GABA function but in addition block some glutamate receptors.37 This dual action probably explains their added toxicity and dependence liability. Children at bid risk of becoming alcoholics seem to have altered benzodiaepine receptor sensitivity.36 On repeated use of the alcohol(s) and barbiturates, there is a compensatory increase in the number of brain glutamate receptors which contributes to the hyperexcitable state found in withdrawal. Since excessive glutamate activity can be neurotoxic, one suggestion is that repeated withdrawal, as seen nightly in alcoholics, may explain the brain damage in heavy drinkers.37 Brain excitatory , aminoacid receptors are involved in dependence on other drugs; thus, tolerance to opioids can be attenuated by co-treatment with dizocilpine, a blocker of the N-methyl-D-aspartate (NMDA) class of glutamate receptor.38 Because NMDA receptors are very important in processes such as learning and memory, this suggests that drugs of this class could be used to treat some aspects of addiction, especially conditioned responses. Acam-prosate has been suggested to act in this way in alcoholics. The benzodiazepine site on the GABA-A receptor can be well visualised by PET with 11C-flumazenil39 or SPECT with 123I- iomazenil,40 which are both antagonists. Recent studies have revealed that intoxicating doses of benzodiazepine agonists occupy only about 30% of brain receptors (figure 4) 41 It would be of interest to determine whether this fraction is altered after chronic use, especially high-dose intravenous use as found with many addicts. The brain circuits involved in benzodiazepine withdrawal in animals are parts of the limbic system and thalamus;42 these studies used the deoxyglucose technique which is applicable to PET. ' As yet there are no satisfactory neuroimaging ligands for excitatory receptors, although ketanmine can be used to block NMDA receptor function in patients and could be used in imaging studies of brain metabolism
Other transmitters There are at least 80 other brain neurotransmitters, some of which are likely to be involved in addiction. One good candidate is CCK (cholecystokinin), which is found in larger amounts in the brain than in the gut. There are two subtypes of brain CCK receptors (A and B), and selective antagonists for each are now available. CCKB-receptor activation seems to be involved in withdrawal from a range of drugs including benzodiazepines, alcohol, and cocaine since antagonists (such as PD 134308) block several aspects of this syndrome. 43 CCK antagonists also moderate tolerance development to opioid analgesia so might have some use in opioid addiction. Recently, receptors for cannabis have been discovered; one is found predominantly in the brain and the other in peripheral tissues, especially spleen. Both are members of the family of receptors that are coupled to G-proteins which includes the receptors for dopamine, noradrenaline, and many 5-HT receptors. Intriguingly the cannabis receptor in the brain is by far the most abundant of these which suggests an important role in brain function .44 Several possible endogenous transmitters for these receptors have been suggested, with anadamide being the best candidate at present.45 The role of endogenous cannabinoids in addiction can now be tested since a selective antagonist to this receptor has been synthesised. 46
Calcium channels The regulation of intracellular calcium homoeostasis is critical to all cells and several different calcium channels control the passage of this ion across cell membranes. One of these, the L- type channel, is substantially altered by alcohol and some other misused drugs. Alcohol administration reduces calcium entry through these channels; this results in an adaptive increase in their number so that in withdrawal calcium flux is excessive. Calcium-channel antagonists of the dihydropyridine type (eg, nitrendipine) block some aspects of alcohol withdrawal and when given with the alcohol prevent the increase in channel number.47 The clinical implications of such findings are potentially very important and should be investigated especially since increased calcium flux could also contribute to neuronal death.
Brain circuits of addiction
Such brain circuits are beginning to be understood in animals, though there are little supporting data from human beings. The primary circuit seems to be the dopamine pathway that runs from the ventral tegmental area (VTA) through the nucleus accumbens to the prefrontal cortex (figure 5).19 Dopamine release in either the nucleus accumbens, prefrontal cortex, or both is produced by all misused drugs apart from the benzodiazepines.10 Some (eg, cocaine) act on the dopamine terminals, whereas others (eg, opioids) increase cell firing at the level of the cell bodies. Direct injection of drugs into these brain regions is reinforcing since animals will self-administer opioids and cocaine directly into them. Moreover drug withdrawal is associated with reduced dopamine transmission in these regions and aversive drugs (eg, κ agonists) inhibit dopamine release there. 10 ,21 Paradoxically some other aversive experiences such as pain cause dopamine release, and some argue that changes in this transmitter reflect not simply the reinforcing actions of drugs but their salience as a conditioned cue. The feasiblity of measuring dopamine release in human brain by displacement of radioligands has already been mentioned and requires exploration.
Other brain regions important in addiction are the globes pallidus and the amygdala (both of which receive projections from the nucleus accumbens), and the monoaminergic nuclei of locus coeruleus and raphe." Significant changes in transmitter function in these regions have been found with opioids and stimulants in rodents. The pathways have been mapped with markers for altered metabolism (deoxyglucose) and expression of gene products after neuronal activation (eg, cFOS, cJUN). Although many of these brain areas are small in human beings, it is possible to detect alterations in brain metabolism by measuring changes in regional blood flow in some areas (eg, frontal cortex) using PET (15O-water or 18F-dtoxyglucose) or SPELT (99mTc HMPAO). These procedures can also be applied to explore the brain regions that' are activated or shut off during other drugrelated states such as craving and withdrawal. New techniques of image analysis (correlation and spectral analysis) and improved PET camera technology should allow regions such as the nucleus accumbens, and even brainstem structures such as the VTA and the locus coeruleus, to be imaged in future.
Conclusions
Major advances in the science of addiction have been made in the past two decades. We now have a good understanding of the molecular pharmacology of most drugs of. misuse, the only exception being inhaled solvents. The neurobiology of addiction in animals is becoming clearer with the use of new techniques such as drug self-administration. The growth of neuroimaging techniques offers the exciting possibility that the hypotheses developed from the preclinical studies could, and hopefully will, be tested in human beings.
I thank Prof JLewis and Dr A Malizia for their help with this article.
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Drug Dependence, a Chronic Medical Illness
Implications for Treatment, Insurance and Outcomes Evaluation
Thomas McLellan, PhD, David C. Lewis, MD, Charles P. O'Brien, MD, PhD Herbert D. Kleber, MD
Author Affiliations: The Treatment Research Insti­tute, Philadelphia, Pa (DrMcLellan); The Penn/VA cen­ter for Studies of Addiction at the Veterans Affairs Medical Center and the University of Pennsylvania, Philadelphia (Drs McLellan and O'Brien); The Brown University Center for Alcohol and Addiction Studies, Providence, RI (Dr Lewis); and The National Center on Addiction and Substance Abuse at Columbia Uni­versity, New York, NY (Dr Kieffer).
Corresponding Author: A. Thomas McLellan, PhD, The Treatment Research Institute,150 S Independence Mall W, Suite 600, Philadelphia, PA 19106-3475
(e-mail: tmclellan@research.org)

Many expensive and disturbing social problems can be traced directly to drug dependence. Re-cent studies(1-4) estimated that drug de­pendence costs the United States ap­proximately $67 billion annually in crime, lost work productivity, foster care, and other social problems.(2-4) These expensive effects of drugs on all social systems have been important in shap­ing the public view that drug depen­dence is primarily a social problem that requires interdiction and law enforcement rather than a health problem that requires prevention and treatment.
This view is apparently shared by many physicians. Few medical schools or residency programs have an ad-equate required course in addiction. Most physicians fail to screen for alco­hol or drug dependence during rou­tine examinations.(5) Many health pro­fessionals view such screening efforts as a waste of time. A survey (6) of general practice physicians and nurses indi­cated that most believed no available medical or health care interventions would be "appropriate or effective in treating addiction." In fact, 40% to 60% of patients treated for alcohol or other drug dependencies return to active substance use within a year following treatment discharge.(7-9) One implication is that these disappointing results con-firm the suspicion that drug depen­dence is not a medical illness and thus is not significantly affected by health care interventions. Another possibil­ity is that current treatment strategies and outcome expectations view drug dependence as a curable, acute condi­tion. If drug dependence is more like a chronic illness, the appropriate stan­dards for treatment and outcome expectations would be found among other chronic illnesses.
To explore this possibility, we un­dertook a literature review comparing drug dependence with 3 chronic ill­nesses: type 2 diabetes mellitus, hyper-tension, and asthma. These examples were selected because they have been well studied and are widely believed to have effective treatments, although they are not yet curable. Our review searched all English-language medical and health journals in MEDLINE from 1980 to the present using the following key words: heritability, pathophysiology, diagno­sis, course, treatment, compliance, adherence, relapse, and reoccurrence. Im­portantly, our definition of drug and our review criteria included all over-the-counter (alcohol and nicotine), pre­scription (benzodiazepines, amphet­amines, opiates), and illegal (heroin, marijuana, cocaine) drugs.
The review is presented in 2 parts. The first part considers some charac­teristic aspects of chronic illness, such as diagnosis, heritability, etiology, and pathophysiology. The second part re-views recent advances in the medical treatment of drug dependence and con­siders treatment response, particu­larly medication adherence and re-lapse or recurrence. Although we are aware that arguments by analogy are limited, we believe this comparative analysis of drug dependence with other chronic illnesses offers some instruc­tive and provocative implications.

DIAGNOSIS, HERITABILITY, ETIOLOGY, AND PATHOPHYSIOLOGY

Diagnosis
Most adults have used alcohol and/or other drugs, sometimes heavily to the point of abuse but rarely to the point where that use could reasonably be called an illness. There is no labora­tory test for dependence, but the diag­nostic differentiation of use, abuse, and dependence has been operationally re-fined and repeatedly shown to be reli­able and valid.(10,11)
Dependence or what is commonly called addiction is operationally defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition(10) as a pathologic condition manifested by 3 or more of 7 criteria. Two of these cri­teria, tolerance and withdrawal, indi­cate neurologic adaptation or so-called physiologic dependence. However, as has been pointed out,(12) physiologic adaptation (tolerance or withdrawal) by itself is neither neces­sary nor sufficient for a diagnosis of sub-stance dependence. Indeed, those receiving a dependence diagnosis are required to show a "compulsive desire for and use of the drug(s) despite seri­ous adverse consequences" such as "use instead of or while performing impor­tant responsibilities"(10,11)
There are several short (<5 min­utes of patient or practitioner time) questionnaires that can screen for al­cohol and other drug dependence disorders with high rates of sensitivity and specificity.(13) Following a positive screening result, standardized diagnos­tic checklists can be applied during the medical evaluation. Diagnoses that result from these standardized and eas­ily applied criteria have been reliable and valid across a range of clinical and nonclinical populations.(11)

Genetic Heritability
One of the best methods for estimat­ing the level of genetic contribution is to compare the rates of a disorder in monozygotic and dizygotic twins. Heri­tability estimates from twin studies(14,15) of hypertension range from 0.25 to 0.50, depending on the sample and the diagnostic criteria used. Twin stud­ies of diabetes offer heritability esti­mates of approximately 0.80 for type 2(16) and 0.30 to 0.55 for type 1 diabetes mellitus." Finally, twin studies(18,19) of adult-onset asthma have produced a somewhat broader range of heritabil­ity estimates, ranging from 0.36 to 0.70.
Several twin studies(20-23) have been published in the substance depen­dence field, all showing significantly higher rates of dependence among twins than among nontwin siblings and higher rates among monozygotic than dizygotic twins. Published heritability estimates include 0.34 for males de-pendent on heroin, 0.55 for males de-pendent on alcohol, 0.52 for females dependent on marijuana, and 0.61 for cigarette-dependent twins of both sexes.(20-23) More studies of heritability are needed across drug types and sexes, but the evidence suggests significant ge­netic contribution to the risk of addic­tion comparable to that seen in other chronic illnesses.

Role of Personal Responsibility
Since the use of any drug is a volun­tary action, behavioral control or will-power is important in the onset of dependence. Thus, at some level an addicted individual is at fault for initi­ating the behaviors that lead to a de­pendence disorder. Doesn't this volun­tary initiation of the disease process set drug dependence apart, etiologically, from other medical illnesses?
There are many illnesses in which voluntary choice affects initiation and maintenance, especially when these vol­untary behaviors interact with genetic and cultural factors. For example, among males, salt sensitivity is a ge­netically transmitted risk factor for the eventual development of one form of hypertension.(24,25) However, not all of those who inherit salt sensitivity de­velop hypertension. This is because the use of salt is determined by familial salt use patterns and individual choice. Similarly, risk factors such as obesity, stress level, and inactivity are prod­ucts of familial, cultural, and personal choice factors.(24,25) Thus, even among those with demonstrated genetic risk, a significant part of the total risk for de­veloping hypertension can be traced to individual behaviors.
There are also involuntary compo­nents embedded within seemingly vo­litional choices. For example, al-though the choice to try a drug may be voluntary, the effects of the drug can be influenced profoundly by genetic fac­tors. Those whose initial, involuntary physiologic responses to alcohol or other drugs are extremely pleasurable will be more likely to repeat the drug taking than those whose reaction is neu­tral or negative. Work by Schuckit(26) and Schuckit and Smith(27) has shown that sons of alcohol-dependent fathers in­herit more tolerance to alcohol's ef­fects and are less likely to experience hangovers than sons of non–alcohol-dependent fathers. In contrast, the in­herited presence of an aldehyde dehy­drogenase genotype (associated with alcohol metabolism) causes an invol­untary skin "flushing" response to alcohol.(28-30) Individuals who are homo­zygous for this allele (approximately 35% of the Chinese population, and 20% of Jewish males in Israel) have an especially unpleasant initial reaction to voluntary alcohol use to the point where there are virtually no alcoholics found with this genotype.(28-30)

Pathophysiology
The acute effects of alcohol and other drugs have been well characterized. However, even a complete understand­ing of these acute effects cannot ex-plain how repeated doses of alcohol and other drugs produce paradoxically in-creasing tolerance to the effects of those drugs concurrent with decreasing vo­litional ability to forgo the drug. As sug­gested by Koob and Blooms(31) the chal­lenge is to find an internally consistent sequence by which molecular events modify cellular events and in turn pro-duce profound and lasting changes in cognition, motivation, and behavior. Research on the neurochemical, neu­roendocrine, and cellular changes as­sociated with drug dependence has led to remarkable findings during the past decade, as summarized in the recent lit­erature.(32-35) Herein, we summarize just 3 areas of investigation.
Addictive drugs have well-specified ef­fects on the brain circuitry involved in the control of motivated and learned behaviors.(31-36) Anatomically, the brain cir­cuitry involved in most of the actions of addictive drugs is the ventral tegmental area connecting the limbic cortex through the midbrain to the nucleus accumbens.(35-36) Neurochemically, alco­hol, opiates, cocaine, and nicotine have significant effects on the dopamine sys­tem, although through different mecha­nisms. Cocaine increases synaptic do­pamine by blocking reuptake into presynaptic neurons; amphetamine produces increased presynaptic release of dopamine, whereas opiates and alco­hol disinhibit dopamine neurons, pro­ducing increased firing rates. Opiates and alcohol also have direct effects on the en­dogenous opioid and possibly the y-ami­nobutyric acid systems.(31-36)
Significantly, the ventral tegmental area and the dopamine system have been associated with feelings of euphoria,(31-36) Animals that receive mild elec­trical stimulation of the dopamine sys­tem contingent on a lever press will rapidly learn to press that lever thou-sands of times, ignoring normal needs for water, food, or rest.(36) Cocaine, opi­ates, and several other addictive drugs produce supranormal stimulation of this reward circuitry.(31-36)
Given the fundamental neuro-anatomy and neuropharmacology of this system, it is understandable that ad­dictive drugs could produce immedi­ate and profound desire for their read-ministration. Less clear is why simply preventing the administration of these drugs for some period would not cor­rect the situation, return the system to normal, and lead to a "sadder but wiser" individual who would be less instead of more likely to reuse those drugs.
It is known that use of these drugs at some dose, frequency, and chronic­ity will reliably produce enduring and possibly permanent pathophysiologic changes in the reward circuitry, in the normal levels of many neurochemi­cals, and in the stress response system.(31,35,37-41) Volkow et al (37-42) found impairments in the dopamine system of abstinent former cocaine users 3 months after their last use. Otherstudies(39,40) have documented sustained changes in the stress response system following abstinence from opiate or co­caine dependence. Researchers do not know how much drug use is required to create these changes or whether these effects ever return to normal. Somatic signs of withdrawal last several days, motivational and cognitive impair­ments may last several months(33) but the learned aspects of tolerance to the drug may never return to normal.(35,36,41)
A second explanation for the endur­ing pathology seen among drug-dependent persons and their ten­dency to relapse lies in the integration of the reward circuitry with the moti­vational, emotional, and memory cen­ters that are colocated within the lim­bic system. These interconnected regions allow the organism not only to experience the pleasure of rewards but also to learn the signals for them and to respond in an anticipatory manner.(36,41,43) Repeated pairing of a person (drug-using friend), place (corner bar), thing (paycheck), or even an emo­tional state (anger, depression) with drug use can lead to rapid and en-trenched learning or conditioning. Thus, previously drug-dependent in­dividuals who have been abstinent for long periods may encounter a person, place, or thing that previously was as­sociated with their drug use, produc­ing significant, conditioned physi­ologic reactions, such as withdrawal-like symptoms and profound subjective desire or craving for the drug.(43,44) These responses can combine to fuel the "loss of control" that is considered a hall-mark of drug dependence.(10)
These conditioned physiologic responses have been shown in labora­tory studies(41,45,46) of currently abstinent former opiate, cocaine, and alcohol—dependent individuals. Childress et al,(43) using positron emission tomography, examined limbic and control brain regions of detoxified, male, cocaine-dependent subjects and cocaine-naive controls during videos of cocaine-related scenes. During the video, these currently abstinent former cocaine-dependent subjects experienced in-creased craving and showed a pattern of limbic increases and basal ganglia decreases in regional cerebral blood flow that mimicked the effects of the drug itself. This pattern did not occur in cocaine-naive controls or among the for­merly cocaine-dependent patients in response to a neutral video.(43) Thus, even artificial video scenes of cocaine-related stimuli, presented in the sterile context of a positron emission tomog­raphy laboratory, produced excitation of brain reward regions and triggered drug craving.

TREATMENT RESPONSE
A central question in the comparison of drug dependence with other ill­nesses is whether dependence will de-crease without treatment and whether it will respond to medications and other interventions. There is a large re-search literature on drug dependence treatment outcomes.(7-9,34,35,47-49) The treatment of addiction has been de-scribed in a manual(50) and 2 detailed volumes (51,52) Space permits only a few ex­amples from that literature, addressing questions of particular import to phy­sicians.

Untreated Persons
Examinations of untreated, dependent persons offer some indication of the natural course of addiction. For example, Metzger et al(53) measured drug use, needle-sharing practices, and human immunodeficiency virus (HIV) infec­tion rates of 2 large samples of opiate-dependent persons in Philadelphia, Pa. The in-treatment (IT) group included 152 patients randomly selected at admis­sion to a methadone maintenance pro-gram. Out-of-treatment (OT) subjects were also heroin-dependent individuals matched to the IT group by age, race, sex, neighborhood, and other relevant background factors, although none of the 103 OT subjects had received treatment. Both groups were interviewed and tested for HIV status every 6 months for 7 years. At the initial assessment, 13% of the IT sample and 21% of the OT sample were HIV positive. By 7 years, 51% of the OT group but only 21% of the IT group tested HIV positive.53 Of course, even this substantial between-group difference does not prove that treatment participation was the causal agent. It is likely that the OT subjects lacked the motivation for change found among the treated patients. Thus, lack of desire for personal change, rather than the effects of the treatment itself, could have produced the differences seen.
One way to separate the effects of drug dependence treatment from the effects of motivation is to compare treated and untreated substance-dependent indi­viduals who were explicitly not inter­ested in treatment. Booth and col­leagues50 studied 4000 intravenous drug users seeking HIV testing as part of a multisite acquired immunodeficiency syndrome initiative in 15 cities. Sub­jects were randomly assigned to either standard HIV testing alone or to stan­dard testing plus 3 sessions of motiva­tional counseling from a health educa­tor. At 6-month follow-up, those who received additional counseling showed half the rate of drug injection (20% vs 45%), 4 times the likelihood of absti­nence (confirmed by urinalysis), and sig­nificantly lower arrest rates (14% vs 24%) than those randomly assigned to receive just HIV testing.(54) Studies of other illnesses show that screening and brief advice from physicians can affect the motivation for change among pa­tients and the longer-term course of their health. The data of Booth et al suggest this is true even for seriously addicted individuals.
Svikis et al(55) studied drug abuse treatment in pregnant, cocaine-dependent women who did not originally apply for treatment. All women had simply ap­plied for prenatal care and were found to be positive for cocaine use on a rou­tine drug screen. They were compared with 46 pregnant, demographically matched women who tested positive for cocaine use and received standard pre-natal care during the year before the op­ening of the experimental treatment program. Drug dependence treatment consisted of 1. week of residential care followed by twice-weekly addiction counseling in the context of the sched­uled prenatal visits.
At delivery, 37% of the treated patients tested positive for cocaine use compared with 63% of the untreated women. Infants of the treated women averaged higher birth weights (2934 vs 2539 g) and longer gestational periods (39 vs 34 weeks) than those of the com­parison group. Following delivery, 10% of infants in the treated group required care in the neonatal intensive care unit (mean, 7 days). In comparison, 26% of infants in the untreated group required intensive care (mean, 39 days). Aver-age costs of care were $14500 for the treated group and $46 700 for the com­parison group. These data indicate that drug-dependent women can be screened and motivated during prenatal care and that drug dependence treatment can be combined with traditional prenatal care in an extremely cost-effective manner.

Medications
In addition to medications for nico­tine dependence, such as nicotine gum and patch and bupropion hydrochlo­ride, medications for alcohol and opi­ate addiction have been developed under Food and Drug Administration guidelines, have been researched in ran­domized clinical trials, and have reached the market. Herein, we discuss a few recent developments, but a complete review has been published by the Institute of Medicine.(35)
Opioid Dependence.
Opioid ago­nists, partial agonists, and antagonists are the 3 primary types of medications available for the treatment of opioid de­pendence, all acting directly on opioid receptors, particularly µ-receptors.(35) Agonist medications, such as metha­done hydrochloride, are prescribed in the short-term as part of an opioid de­toxification protocol or in the long-term as a maintenance regimen. Double-blind, placebo-controlled tri­als(56,57) have shown methadone to be ef­fective in both inpatient and outpa­tient detoxification, although the long-term effects of detoxification alone, without continuing treatment, have been uniformly poor. As a mainte­nance medication, methadone's oral route of administration, slow onset of action, and long half-life have been ef­fective in reducing opiate use, crime, and the spread of infectious diseases, as was recently validated by a Na­tional Institutes of Health Consensus Conference.(58)
The partial agonist buprenorphine hydrochloride is administered sublin­gually and is active for approximately 24 to 36 hours.(59) Large double-blind, placebo-controlled trials of buprenorphine have shown reductions in opi­ate use comparable with methadone but with fewer withdrawal symptoms on discontinuation.(60) Importantly, the combination of buprenorphine plus nal­oxone hydrochloride, designed to reduce injection use, will soon be released for prescription in primary care settings.(61)
Opioid antagonists such as naltrex­one block the actions of heroin through competitive binding for 48 to 72 hours, producing neither euphoria nor dys­phoria in abstinent patients (62,63) Naltrexone is used as a maintenance medi­cation, designed as an "insurance policy" in situations where the patient is likely to be confronted with relapse risks. Naltrexone in combination with social or criminal justice sanctions is routinely used in the monitored treatment of physicians, nurses, and other professionals (63) In a recent controlled trial, Cornish and colleagues(64) showed that naltrexone added to standard fed­eral probation produced 70% less opi­ate use and 50% less reincarceration than standard probation alone.
Alcohol Dependence.
Naltrexone has been found effective at 50 mg/d for re­ducing drinking among alcohol-dependent patients (65,66) It works by blocking at least some of the "high" pro­duced by alcohol's effects on µ-opiate receptors. More recently, European re-searchers have found encouraging re­sults using the 'γ-aminobutyric add ago­nist acamprosate to block craving and relapse to alcohol abuse.967) Alcohol-dependent patients prescribed acam­prosate showed 30% higher absti­nence rates at 6-month follow-up than those randomized to placebo. Further-more, those who returned to drinking while receiving acamprosate reported less heavy drinking (≥5 drinks per day) than those receiving placebo."
Stimulant Dependence.
Although there are not yet effective medications for the treatment of cocaine or amphet­amine dependence,(35) there are proven behavioral treatments.(66-71) There also are promising animal studies of a potential vaccine that binds to and inacti­vates metabolites of cocaine,(72) but clini­cal trials will not be scheduled for several years.

Comparing Treatments for Drug Dependence With Treatments for Other Chronic Diseases
There is no reliable cure for drug de­pendence. Dependent patients who comply with the recommended regimen of education, counseling, and medication have favorable outcomes during and usually for at least 6 to 12 months following treatment.(47-50) Fa­vorable outcomes typically continue in patients who remain in methadone maintenance or in abstinence mainte­nance through participation in Alco­holics Anonymous (AA) or other self-help programs.(48,50-52) However, because of insurance restrictions, many pa­tients receive only detoxification or acute stabilization with no continuing care.(3,6,9) Others drop out of rehabilita­tion-oriented treatment and/or they ig­nore physician advice to continue tak­ing medications and participating in AA. Thus, 1-year, postdischarge follow-up studies(47,52,73) have typically shown that only about 40% to 60% of discharged patients are continuously abstinent, al-though an additional 15% to 30% have not resumed dependent use during this period. Problems of low socioeco­nomic status, comorbid psychiatric con­ditions, and lack of family and social supports are among the most impor­tant predictors of poor adherence dur­ing addiction treatment and of relapse following treatment.(47-52.74)
Hypertension, diabetes, and asthma are also chronic disorders, requiring continuing care throughout a patient's life. Treatments for these illnesses are effective but heavily dependent on adherence to the medical regimen for that effectiveness. Unfortunately, stud­ies have shown that less than 60% of adult patients with type 1 diabetes melli­tus fully adhere to with their medica­tion schedule(75) and less than 40% of patients with hypertension or asthma adhere fully to their medication regi­mens(76,77) The problem is even worse for the behavioral and diet changes that are so important for the maintenance of gains in these chronic illnesses. Again, studies indicate that less than 30% of patients with adult-onset asthma, hyper-tension, or diabetes adhere to pre-scribed diet and/or behavioral changes that are designed to increase func­tional status and to reduce risk factors for recurrence of the disorders(75-78) Across all 3 of these chronic medical ill­nesses, adherence and ultimately out-come are poorest among patients with low socioeconomic status, lack of fam­ily and social supports, or significant psychiatric comorbidity.(75-79) Perhaps because of the similarity in treatment adherence, there are also similar relapse rates across these disorders. Outcome studies indicate that 30% to 50% of adult patients with type 1 diabetes and approximately 50% to 70% of adult patients with hyperten­sion or asthma experience recurrence of symptoms each year to the point where they require additional medical care to reestablish symptom remission (75,80)

COMMENT
Few persons who try drugs or regu­larly use drugs become dependent. However, once initiated, there is a pre­dictable pathogenesis to dependence marked by significant and persistent changes in brain chemistry and func­tion. It is not yet possible to explain the physiologic and psychological pro­cesses that transform controlled, vol­untary use of alcohol and other drugs into uncontrolled, involuntary depen­dence. Twin studies indicate a definite role for genetic heritability. Nonethe­less, personal choice and environmen­tal factors are clearly involved in the expression of dependence. In terms of vulnerability, onset, and course, drug dependence is similar to other chronic illnesses, such as type 2 diabetes, hyper-tension, and asthma.
Our review of treatment response found more than 100 randomized controlled trials of addiction treatments, most showing significant reductions in drug use, improved personal health, and reduced social pathology but not cure.(7-9,34,35,47-52,81,82) Recent treatment advances include potent, well-tolerated medications for nicotine, alco­hol, and opioid dependence(35,58,61,65-67) but not marijuana or stimulant depen­dence. There is little evidence of effec­tiveness from detoxification or short-term stabilization alone without maintenance or monitoring such as in methadone maintenance or AA.(47-52.57) However, as in treatments for other chronic disorders, we found major prob­lems of medication adherence, early drop-out, and relapse among drug-dependent patients. In fact, problems of poverty, lack of family support, and psychiatric comorbidity were major and approximately equal predictors of non-compliance and relapse across all chronic illnesses examined.(74-83)
Thus, our review suggests that drug dependence shares many features with other chronic illnesses. We are aware that arguments by analogy are lim­ited, and even marked similarities to other illnesses are not proof that drug dependence is a chronic illness. None­theless, these similarities in heritabil­ity, course, and particularly response to treatment raise the question of why medical treatments are not seen as ap­propriate or effective when applied to alcohol and drug dependence. One pos­sibility is the way drug dependence treatments have traditionally been delivered and evaluated.
Many drug dependence treatments are delivered in a manner that is more appropriate for acute care disorders. Many patients receive detoxification only.(3-35,48,49) Others are admitted to spe­cialty treatment programs, where the goal has been to rehabilitate and discharge them as one might rehabilitate a surgical patient following a joint re-placement (47)Outcome evaluations are typically conducted 6 to 12 months following treatment discharge. The usual outcome evaluated is whether the pa­tient has been continuously abstinent after leaving treatment.
Imagine this same strategy applied to the treatment of hypertension. Hyper­tensive patients would be admitted to a 28-day hypertension rehabilitation program, where they would receive group and individual counseling regarding be­havioral control of diet, exercise, and life-style. Very few would be prescribed medications, since the prevailing insur­ance restrictions would discourage main­tenance medications. Patients complet­ing the program would be discharged to community resources, typically with-out continued medical monitoring. An evaluation of these patients 6 to 12 months following discharge would count as successes only those who had remained continuously normotensive for the entire postdischarge period. In this regard, it is interesting that relapse among patients with diabetes, hypertension, and asthma following ces­sation of treatment has been consid­ered evidence of the effectiveness of those treatments and the need to retain patients in medical monitoring. In contrast, relapse to drug or alcohol use following discharge from addiction treatment has been considered evidence of treatment failure. The best outcomes from treat­ments of drug dependence have been seen among patients in long-term metha­done maintenance programs(49,50,58,83) and among the many who have continued participating in AA support groups.(84,85)

IMPLICATIONS
For primary care physicians, this re-view suggests that addiction screening, diagnosis, brief interventions, medica­tion management, and referral criteria should be taught as part of medical school and residency curricula and rou­tinely incorporated into clinical prac­tice(86.87) For those in health policy, our review offers support for recent insur­ance parity initiatives.(88) Like other chronic illnesses, the effects of drug de­pendence treatment are optimized when patients remain in continuing care and monitoring without limits or restric­tions on the number of days or visits cov­ered. Although it is unknown whether care delivered in a specialty program or coordinated through primary care will provide the maximal benefits for pa­tients and society, it is essential that prac­titioners adapt the care and medical monitoring strategies currently used in the treatment of other chronic illnesses to the treatment of drug dependence.

Funding/Support
This review was supported by grants from the Department of Veterans Affairs, the Na­tional Institute on Drug Abuse, the Center for Sub-stance Abuse Treatment, The Robert Wood Johnson Foundation, and the Office of National Drug Control Policy.

Acknowledgment
The manuscript was reviewed (but not supported financially) by the Physician Leadership for National Drug Policy before submission, and Dr Lewis is a member of that organization.

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JAMA October 4, 2000 vol 284 no 13

PSYCHOPATHOLOGY IN DRUG DEPENDENT INDIVIDUALS: A CLINICAL REVIEW
Gerald J. McKenna* There has long been an effort to develop a single unifying theory to explain the phenomenon of drug dependence. Some of these efforts have focused on psychoanalytic theory, various aspects of ego functioning, socio-economic factors, and physiological effects of drugs. Most investigators, however, have focused on character pathology in addicts and have considered addiction as representing one form of character disorder. There has been a lack of emphasis on various psychiatric conditions which could predispose and accompany drug dependence. This author considers drug dependence as a multi-etiological phenomenon. This paper explores various psychiatric problems identified in drug dependent individuals and how they interact with the drug dependence. The use of psychotropic agents in the treatment of drug dependent persons is also explored.
*Gerald J. McKenna, M.D., is Instructor in Psychiatry at the Harvard Medical School at The Cambridge Hospital. He is former Director of Drug Treatment Services for The CambridgeSomerville Mental Health & Retardation Center. He is currently Project Director and Principal Investigator, National Institute on Drug Abuse Research Grant *R18-DA01896-02: Treatment of Depression in Drug Abusers: Doxepin vs. Placebo. IntroductionDrug us e and drug dependence is a multi-etiological phenomenon which includes social, economic, psychological, and physiological factors. Included in this opinion is the belief that there is a high incidence of psychiatric problems in drug dependent individuals and that specific psychiatric syndromes may lead an individual to become drug dependent. Historically, most of the medical profession has viewed addiction in terms of character pathology, with only little attention paid to other contributing factors. The aim of this paper is to expand on the multi-etiological theory of drug dependence, viewing addiction (especially narcotics addiction) as it relates to various psychotic states, depression, borderline personality, character pathology, and situational stress with time-limited addiction. I will also briefly examine the use of various psychotropic agents in the treatment of certain drug dependent individuals. A key point is that careful individual evaluation must be made of each drug dependent person in order to develop an adequate treatment plan.
Historical PerspectiveIn the past fifty years there has been a steady progression and shift in our understanding of the nature of addiction and its contributing factors. Until recently, much of the work in this area was generated by a few individuals whose primary interest was formulating a single theoretical network for understanding addiction. Investigators focused on one or more of the theoretical areas in which addiction was viewed, including the intrapsychic (psychoanalytic and other psychological factors), the social (including socio-economic factors), and the physiological (effects of drugs on the biological organism). A brief review of some of the major literature in this area will help familiarize the reader with the theoretical trends in the addictions and will also serve to highlight some of the major public and scientific controversies regarding the etiology of addiction and methods for treatment of the drug dependent individual.
Early psychoanalytic work is scanty and focuses mainly on the libidinal aspects of drug use relating to instinctual drives and object relations. Kolb (1927) suggested that personality characteristics of the user determined both the pattern of drug use and the subjective effects of the drug. Though his terminology is moralistic and was undoubtedly influenced by the prevailing notion that use was ipso facto evidence of deviance, Kolb was careful in his sampling and thorough in reporting on a variety of influencing factors in his subjects. In 1933, Rado identified the presence of depression in many of the addicts he studied, yet he tended to emphasize the regressive function which drugs had for the user. In the early 1950's, Glover emphasized the ego defensive role of drugs in protecting against paranoid thinking and overt psychosis.
After the establishment of the Federal prison for narcotic addicts at Lexington, Kentucky, a new and intensive effort was undertaken to understand narcotic addiction. While initial efforts focused on the physiological aspects, later efforts were directed toward the psychological characteristics of the narcotic addict. Wikler (1952, 1953) focused on addicts' anxieties related to aggression and sexuality and the manner in which drugs were used to relieve these anxieties. In subsequent decades, Vaillant (1966) and Wishnie (1974) pointed out that depression was often an underlying syndrome in the addict and that the narcotic served to defend against and mask depression.
In a review by Treece (1977) various psychological profiles of drug dependent individuals as measured on the MMPI show no consistency and suggest that the profiles are strongly influenced by the setting in which the test is given, the sampling technique, and the treatment status of the individual.
Gerard and Kornetsky (1954) and Chein, Gerard, Lee, and Rosenfeld (1964) were the first to look at the phenomenon of adolescent addiction in a ghetto setting and the first to attempt to synthesize the theoretical formulations up to that point. They understood both the specific effects of the drugs and their role in the psychological economy of the individual.
Subsequent works by Krystal and Raskin (1970), Wurmser (1974), and Khantzian (1974) have focused on the adaptive use of drugs in maintaining ego stability, managing painful and sometimes overwhelming affects, tolerating narcissistic injury, and defending against certain affects, particularly rage and aggression.
A number of recent studies illustrate the presence and variety of psychopathology in drug dependent individuals presenting for treatment. Reports by Benvenuto and Bourne (1975), Wesson, Smith, and Lerner (1975), McKenna (1978), and Stauss, Ousley, and Carlin (1977) stress the high degree of psychopathology among polydrug users. A report by McKenna and Khantzian (1979) compares a group of polydrug and narcotics users according to ego functions and psychopathology. The data in that report compares scores on the Psychiatric Status Schedule of Spitzer and Endicott among narcotics users, polydrug users, and combination narcotics and polydrug users. The results indicated a degree of psychopathology in all these groups to be similar to or greater than that for a group of psychiatric inpatients. Furthermore, there were no significant differences among the various drug dependent groups. Since all the patients in the drug dependent sample were entering a drug detoxification unit, they could be expected to be experiencing more symptomatic distress, thus somewhat skewing the results. Even taking this into account, we feel the results point to significant disturbance in drug dependent individuals entering drug treatment. Khantzian (1978) develops the theory that addicts have deficiencies in those component ego functions related to "self care and selfregulation," hypothesizing that these deficiencies or defects in self care occur as a " . . . result of failures to adopt and internalize these functions from the caring parents in early and subsequent phases of development."
Thus we can see that during the last 50 years there has been a continual expansion of efforts to understand the psychological factors underlying drug dependence. Much of the current work is aimed at further examining the various aspects of psychopathology seen in drug dependent individuals. CLINICAL CONSIDERATIONSPsychosis in Drug Dependent Individuals
Psychic distress often precedes and usually accompanies drug dependence. Nowhere is this more evident than in those individuals with incipient or already present psychotic states who seek relief from their symptoms by attempting self-treatment with narcotics. In at least two separate methadone maintenance programs we have found a history of psychosis predating addiction to narcotics in approximately 10% of the patients in treatment. (Since there are fewer narcotic dependent persons in treatment than in the general population, this figure may indicate that those with a history of psychosis are overrepresented in methadone maintenance programs.) These individuals are generally unfamiliar with mental health resources, are not particularly psychologically-minded, yet are aware that something is seriously wrong. They frequently give a history of searching for a substance to relieve their symptoms, typically stopping their search when they begin using opiates, particularly heroin. This is not surprising since heroin is an extremely potent psychotropic agent and, as seen in the histories of some of our patients, has an effective antipsychotic action. They have discovered a psychotropic drug that is effective in alleviating the thought and affective disturbances commonly found in psychotic states such as schizophrenia or bipolar affective illness. (This use of narcotics by psychotic persons is pharmacologically reasonable, since narcotics, particularly morphine, were used as a common treatment to control acute psychotic symptoms prior to the discovery of phenothiazines.)
In 1973 McKenna, Fisch, Levine et al. reported on three individuals on methadone maintenance who had histories of psychosis (diagnosed as paranoid schizophrenic, manic depressive illness, and psychotic depression). In each case the psychotic symptoms were controlled with methadone (at doses ranging from 60 to 150 mg). The three patients had repeatedly attempted detoxification and experienced a return of their symptoms when their dose of methadone was decreased below 20 mg. Each attempted to remain drug free and invariably returned to drug use; eventually, each returned to the methadone maintenance program. When it became apparent that the methadone was acting as an antipsychotic agent, we attempted to alter their treatment regimen.
The first patient, who had symptoms of bipolar affective illness, was successfully switched to a regimen of lithium carbonate plus continued individual and group therapy. He remained symptom free and off narcotics for one year, was stabilized on lithium, and subsequently left the region and was lost to follow-up.
The second patient, who developed a psychotic depression when drug free, eventually stabilized on a daily regimen of methadone (56 mg), amitryptyline (150 mg), and diazepam (40 mg). Though he tried to remain narcotics free following detoxification, he returned to narcotic use and ultimately chose to remain on methadone.
The third patient detoxified for the second time in June, 1972. Nearing completion of detoxification, he began experiencing auditory hallucinations, left the program, and continued to experience symptoms of a paranoid schizophrenic reaction which continued until December, 1972, when he reapplied for methadone maintenance. He refused treatment with phenothiazines and was induced onto 60 mg per day methadone maintenance on the general psychiatry unit. Following stabilization on methadone and the diminution of his psychotic symptoms, he was transferred to the methadone maintenance clinic where he preferred to be treated.
Berken, Stone, and Stone (1978) have reported a case in which methadone was used to control schizophrenic rage in a nineteen-year-old woman. They noted a history of heavy street drug use, including heroin, typical schizophrenic symptoms, lack of response during 13 hospitalizations to usual psychotropic drugs (including lithium carbonate, tricyclic antidepressants, major and minor tranquilizers). Methadone, as well as other narcotics which the woman used on the street, calmed her periods of rage and significantly improved her self image so that she was able to work successfully in psychotherapy while remaining on methadone maintenance.
For these people who attempt to self-medicate psychotic symptoms, problems occur because 1) narcotics are illegal; 2) these individuals are thus forced into a lifestyle and subculture not necessarily of their own choosing; 3) they are viewed by the public and institutions in our society as deviant and criminal rather than as individuals in need of mental health services; 4) they usually suffer from problems with self esteem associated with addiction.
Normally, we would expect such a population to be treated in the traditional mental health system. Instead, they end up in drug treatment programs, are often on methadone maintenance, and they experience the attendant stigma associated with these programs. This situation presents a dilemma for patients, drug treatment program staff, and psychiatric program staff. Psychiatric outpatient (and inpatient) programs are reluctant to treat drug dependent individuals; staff frequently feel they lack the pharmacology background necessary to detoxify drug dependent persons and also the skills needed for follow-up treatment of persons they consider to have character disorders. On the other hand, drug dependent individuals with histories of psychiatric disorders frequently prefer the identity of "drug addict" to that of "psychiatric patient." We have not found a solution to this problem and currently have certain patients on combinations of methadone and antipsychotic drugs (phenothiazines, butyrophenones) and use our inpatient psychiatric service if hospitalization is required. Depression
Another major psychiatric syndrome that we see repeatedly in patients on methadone maintenance is depression. This finding has been noted as well in other drug treatment programs. Weissman, Slobetz, Prusoff, et al. (1976) and Senay (1977) report at least moderate depression in approximately one-third of two separate groups of patients on methadone maintenance. In a study we are currently conducting,2 we have found a 51% rate of moderate depression in 35 patients tested to date. This rate has held constant for patients entering the program (tested 3 weeks after beginning methadone) and those in the program for variable lengths of time. (This percentage may decrease as our sample size increases.)
These findings raise a number of interesting and important questions. Why is there such a high incidence of depression in patients on methadone maintenance? Does the depression precede or do symptoms follow addiction to heroin or other opiates? It is difficult to answer either of these with much certainty. Some individuals report depressive symptoms (though they rarely use the term depression) prior to using narcotics. For these people, the narcotic use may be an attempt at self-treatment, a use similar to that by the previously described individuals with psychotic symptoms. More often, though, patients describe the onset of depressive symptoms after they have become addicted. They relate the symptoms to their feelings about themselves as "addicts" and the ostracization they feel from the rest of society. The consequent lowering of self esteem is, of course, a central feature of depression. Whether the symptoms precede or follow addiction, they play an important role in the life of the patient and need attending to in a drug treatment program as they would in any psychiatric setting. Character PathologyThe question of character pathology invariably arises in any discussion of addiction. In the older terminology, addiction of any sort was considered a specific character and behavior disorder. It was categorized along with antisocial personality, passive aggressive personality, and so on. In the newer proposed classification (DSM III), various addictions are separated and classified under Organic Mental Disorders and Substance Use Disorders. There is an association made, however, between Substance Use Disorders and Antisocial Personality, which is listed as a Personality Disorder. In any case, there is still the strongly held belief in both professional and public circles that individuals who are drug dependent are character disordered.
In our patient population, there is little doubt that character pathology is present in many drug dependent individuals. The point is that if clinicians think only of character pathology when they evaluate drug dependent individuals, they will miss the diagnoses so far discussed, thus doing a disservice to their patients and themselves. In this context, only a careful clinical evaluation of each patient can lead to an appropriate treatment plan. Borderline PersonalityConsideration of so-called "Borderline Personality" has received considerable attention in the past decade. We see a number of individuals in our drug treatment program who fall into this category, though, admittedly, it is a poorly defined term. The following is a partial description of Borderline Personality from the proposed DSM 111: 3
"The essential feature is instability in a variety of areas, including interpersonal relationships, behavior, mood, and self-image. No single feature is invariably present. Interpersonal relationships are often intense and unstable with marked shifts of attitude over time. Frequently there is impulsive and unpredictable behavior that is potentially physically selfdamaging. Mood is often unstable with marked shifts from normal mood to some dysphoric mood or with inappropriate intense anger or lack of control of anger. A profound identity disturbance may be manifested by uncertainty about several issues relating to identity, such as self-image, gender identity, long-term goals or values. There may be problems tolerating being alone, and chronic feelings of emptiness or boredom" (p. K20-21).
This adequately describes many of the features in patients we would term as having a "Borderline Personality."
Their lives are frequently in turmoil, and they present difficult treatment problems in drug treatment programs as well as in more traditional psychiatric settings. With time, I believe that the drug treatment field will add further depth to our understanding of these very troubled individuals. Situational Stress with Time-Limited Addiction
It is increasingly clear that individuals can use and become dependent on substances for timelimited periods, especially during periods involving stress. The experience of the Southeast Asian War demonstrated that thousands of American servicemen could become physically dependent on heroin during their tour of duty and stop their use of this powerful drug prior to their return to the United States. A report by Robbins (1973) showed that relatively few of these individuals continued their heroin use once they returned to the U.S. Among other things, this shattered the commonly held belief that heroin was such a powerful substance that use and addiction were synonymous. This also demonstrated that addiction to heroin need not be permanent and that the drug, though powerful and both physically and psychologically addicting, might not necessarily be more dangerous than many other drugs in common use (especially drugs in the sedative hypnotic category). Use of Psychotropic Drugs in Treatment of Drug Dependent Individuals
The question of whether or not to use psychotropic drugs as an adjunct in the overall treatment of drug dependent individuals is controversial. One argument frequently put forth is that it seems contradictory to use drugs to treat individuals who have clearly demonstrated an inability to control their drug use. Corollary to this argument is that the goal of treatment for drug dependent individuals should be attaining a drug free state. It is probable that for some individuals, becoming drug free is the best solution; for others, treatment with both addicting and non-addicting drugs appears appropriate.
Methadone, for example, has only reluctantly been accepted as one drug in the clinical armamentarium for treating heroin and other narcotic addiction. I also feel that the judicious use of other psychotropic agents can be beneficial for certain drug dependent individuals. It has already been pointed out that antipsychotic drugs can be useful, either by themselves or in combination with methadone, in treating those drug dependent individuals with a history of psychosis. Similarly, we may find that tricyclic antidepressants are useful in alleviating the depression that is frequently present in patients addicted to narcotics and other drugs (most patients who present for treatment in our program are using several drugs and can be considered polydrug dependent). More data from the several depression studies currently being conducted should give valuable information on this issue. In a pilot study, Woody, O'Brien, and Rickels (1975) reported success in using doxepin HCl in treating a group of individuals on methadone maintenance. They discovered that individuals treated with doxepin HCI tended to need less methadone and also used fewer other drugs. We are currently conducting a similar double blind study2 to test the effectiveness of doxepin HCI in a group of moderately to severely depressed patients on methadone maintenance. We hope to present the results of this study later this year.
We have not used the various drugs in the sedative hypnotic category and don't at this time feel these would be useful, primarily because of their addictive potential. Nonetheless, many patients in our program regularly supplement their daily dose of methadone with diazepam, propoxyphene, alcohol, and other drugs to a lesser extent. We are hoping that the antianxiety effects of doxepin HCI will result in less sedative hypnotic drug use among subjects in the doxepin group in the depression study. SUMMARY
We have attempted to present data and clinical experiences from our work with drug dependent individuals to demonstrate that there are many etiologies of drug dependence. This demands that clinicians in the field carefully assess each patient to determine if there are underlying psychiatric causes for their drug use and subsequent dependence and to develop a treatment approach which addresses such causes. A rationale is presented for the use of psychotropic drugs as an adjunct in the treatment of certain drug dependent persons. The notion that drug dependence is related only to character pathology is rejected.
NOTES 1. 'Me work in this report was supported by Grant No. 5-H81-DA01509-03 from the National Institute on Drug Abuse.
2. "Treatment of Depression in Drug Abusers: Doxepin vs. Placebo." Grant No. RI 8-DAO1 89602 from the National Institute on Drug Abuse.
3. Diagnostic and Statistical Manual of Mental Disorders III, Second Draft, prepared by The Task Force on Nomenclature and Statistics of the American Psychiatric Association. Washington, D.C., 1978. REFERENCES
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Glover, E. 1956 "On the Etiology of Drug Addiction." In, On the Early Development of Mind. New York, International Universities Press.
Khantzian, E. J. 1974 "Opiate Addiction: A Critique of Theory and . Some Implications for Treatment." Am. J. Psychotherapy. 28:59-70.Khantzian, E. J. 1978 "The Ego, the Self and Opiate Addiction: Theoretical and Treatment Considerations." Int. Review Psychoanalysis. 5:189-198.
Kolb, L. 1927 "Clinical Contributions to Drug Addiction: The Struggle for Cures and the Conscious Reasons for Relapse. J. Nerv. Ment. Dis. 66:22-43.
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McKenna, G. J., Fisch, A., Levine, M., Patch, V. and anyes, A. 1973 "The Use of Methadone as a Psychotropic Agent." Proceedings of the Fifth National Methadone Conference. Washington, D.C.
McKenna, G. J., and Khantzian, E. J. 1979 "Ego Functions and Psychopathology in Narcotics and Polydrug Users." Int. J. Addictions. 14, No. 2.
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Robins, L. N. 1973 "The Vietnam Drug User Returns." Special Action Office Monograph, Series A., No. 2. Washington, D.C. U.S. Government Printing Office.Senay, E. C., Dorus, W. and Yufit, R. 1977 "Depression in Drug Abusers." Paper presented at the American Psychiatric Association Convention. Toronto.
Stauss, F. F., Ousley, N. and Carlin, A. 1977 "Psychopathology and Drug Abuse: An MMPI Comparison of Polydrug Abuse Patients with Psychiatric Inpatients and Outpatients." Addictive Behaviors. 2:75-78.
Treece, C. J. 1977 "Narcotic Use in Relation to Selected Ego Functions among Incarcerated Women." Unpublished doctoral dissertation. Boston University.
Vaillant, G. E. 1966 "A 12-Year Follow-Up of New York Narcotic Addicts, III: Some Social and Psychiatric Characteristics. Arch. General Psychiatry. 15:599-609.
Weissman, M., Slobetz, F., Prusoff, B., Mezritz, M. and Howard, P. 1976 "Clinical Depression among Narcotics Addicts Maintained on Methadone in the Community." Am. J. Psychiatry. 133:1434-1438.
Wesson, D. R., Smith, E. and Lerner, S. 1975 "Streetwise and Nonstreetwise Polydrug Typology." J. Psychedelic Drugs. 7:121134.
Wikler, A. 1952 "A Psychodynamic Study of a Patient During Experimental SelfRegulated Readdiction to Morphine. Psych. Q. 26:270.
Wikler, A. and Rasor, R. W. 1953 "Psychiatric Aspects of Drug Addiction." Am. J. Med. 14:556-570.
Wishnie, H. 1974 "Opioid Addiction: A Marked Depression. In Lesse, S. (Ed.), Masked Depression. New York. J. Aronson, Inc.Woody, G. E., O'Brien, C. P. and Rickels, K.1975 " Depression and Anxiety in Heroin Addicts: A Placebo-Controlled Study of Doxepin in Combination with Methadone." Am. J. Psych. 132:447-450.
Wurmser, L. 1974 "Psychoanalytic Considerations of the Etiology of Compulsive Drug Use." J. Am. Psych. Assoc. 22:820-843.

Drug Dependence, a Chronic Medical Illness
Implications for Treatment, Insurance and Outcomes Evaluation
Thomas McLellan, PhD, David C. Lewis, MD, Charles P. O'Brien, MD, PhD Herbert D. Kleber, MD
Author Affiliations: The Treatment Research Insti­tute, Philadelphia, Pa (DrMcLellan); The Penn/VA cen­ter for Studies of Addiction at the Veterans Affairs Medical Center and the University of Pennsylvania, Philadelphia (Drs McLellan and O'Brien); The Brown University Center for Alcohol and Addiction Studies, Providence, RI (Dr Lewis); and The National Center on Addiction and Substance Abuse at Columbia Uni­versity, New York, NY (Dr Kieffer).
Corresponding Author: A. Thomas McLellan, PhD, The Treatment Research Institute,150 S Independence Mall W, Suite 600, Philadelphia, PA 19106-3475
(e-mail: tmclellan@research.org)

Many expensive and disturbing social problems can be traced directly to drug dependence. Re-cent studies(1-4) estimated that drug de­pendence costs the United States ap­proximately $67 billion annually in crime, lost work productivity, foster care, and other social problems.(2-4) These expensive effects of drugs on all social systems have been important in shap­ing the public view that drug depen­dence is primarily a social problem that requires interdiction and law enforcement rather than a health problem that requires prevention and treatment.
This view is apparently shared by many physicians. Few medical schools or residency programs have an ad-equate required course in addiction. Most physicians fail to screen for alco­hol or drug dependence during rou­tine examinations.(5) Many health pro­fessionals view such screening efforts as a waste of time. A survey (6) of general practice physicians and nurses indi­cated that most believed no available medical or health care interventions would be "appropriate or effective in treating addiction." In fact, 40% to 60% of patients treated for alcohol or other drug dependencies return to active substance use within a year following treatment discharge.(7-9) One implication is that these disappointing results con-firm the suspicion that drug depen­dence is not a medical illness and thus is not significantly affected by health care interventions. Another possibil­ity is that current treatment strategies and outcome expectations view drug dependence as a curable, acute condi­tion. If drug dependence is more like a chronic illness, the appropriate stan­dards for treatment and outcome expectations would be found among other chronic illnesses.
To explore this possibility, we un­dertook a literature review comparing drug dependence with 3 chronic ill­nesses: type 2 diabetes mellitus, hyper-tension, and asthma. These examples were selected because they have been well studied and are widely believed to have effective treatments, although they are not yet curable. Our review searched all English-language medical and health journals in MEDLINE from 1980 to the present using the following key words: heritability, pathophysiology, diagno­sis, course, treatment, compliance, adherence, relapse, and reoccurrence. Im­portantly, our definition of drug and our review criteria included all over-the-counter (alcohol and nicotine), pre­scription (benzodiazepines, amphet­amines, opiates), and illegal (heroin, marijuana, cocaine) drugs.
The review is presented in 2 parts. The first part considers some charac­teristic aspects of chronic illness, such as diagnosis, heritability, etiology, and pathophysiology. The second part re-views recent advances in the medical treatment of drug dependence and con­siders treatment response, particu­larly medication adherence and re-lapse or recurrence. Although we are aware that arguments by analogy are limited, we believe this comparative analysis of drug dependence with other chronic illnesses offers some instruc­tive and provocative implications.

DIAGNOSIS, HERITABILITY, ETIOLOGY, AND PATHOPHYSIOLOGY

Diagnosis
Most adults have used alcohol and/or other drugs, sometimes heavily to the point of abuse but rarely to the point where that use could reasonably be called an illness. There is no labora­tory test for dependence, but the diag­nostic differentiation of use, abuse, and dependence has been operationally re-fined and repeatedly shown to be reli­able and valid.(10,11)
Dependence or what is commonly called addiction is operationally defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition(10) as a pathologic condition manifested by 3 or more of 7 criteria. Two of these cri­teria, tolerance and withdrawal, indi­cate neurologic adaptation or so-called physiologic dependence. However, as has been pointed out,(12) physiologic adaptation (tolerance or withdrawal) by itself is neither neces­sary nor sufficient for a diagnosis of sub-stance dependence. Indeed, those receiving a dependence diagnosis are required to show a "compulsive desire for and use of the drug(s) despite seri­ous adverse consequences" such as "use instead of or while performing impor­tant responsibilities"(10,11)
There are several short (<5 min­utes of patient or practitioner time) questionnaires that can screen for al­cohol and other drug dependence disorders with high rates of sensitivity and specificity.(13) Following a positive screening result, standardized diagnos­tic checklists can be applied during the medical evaluation. Diagnoses that result from these standardized and eas­ily applied criteria have been reliable and valid across a range of clinical and nonclinical populations.(11)

Genetic Heritability
One of the best methods for estimat­ing the level of genetic contribution is to compare the rates of a disorder in monozygotic and dizygotic twins. Heri­tability estimates from twin studies(14,15) of hypertension range from 0.25 to 0.50, depending on the sample and the diagnostic criteria used. Twin stud­ies of diabetes offer heritability esti­mates of approximately 0.80 for type 2(16) and 0.30 to 0.55 for type 1 diabetes mellitus." Finally, twin studies(18,19) of adult-onset asthma have produced a somewhat broader range of heritabil­ity estimates, ranging from 0.36 to 0.70.
Several twin studies(20-23) have been published in the substance depen­dence field, all showing significantly higher rates of dependence among twins than among nontwin siblings and higher rates among monozygotic than dizygotic twins. Published heritability estimates include 0.34 for males de-pendent on heroin, 0.55 for males de-pendent on alcohol, 0.52 for females dependent on marijuana, and 0.61 for cigarette-dependent twins of both sexes.(20-23) More studies of heritability are needed across drug types and sexes, but the evidence suggests significant ge­netic contribution to the risk of addic­tion comparable to that seen in other chronic illnesses.

Role of Personal Responsibility
Since the use of any drug is a volun­tary action, behavioral control or will-power is important in the onset of dependence. Thus, at some level an addicted individual is at fault for initi­ating the behaviors that lead to a de­pendence disorder. Doesn't this volun­tary initiation of the disease process set drug dependence apart, etiologically, from other medical illnesses?
There are many illnesses in which voluntary choice affects initiation and maintenance, especially when these vol­untary behaviors interact with genetic and cultural factors. For example, among males, salt sensitivity is a ge­netically transmitted risk factor for the eventual development of one form of hypertension.(24,25) However, not all of those who inherit salt sensitivity de­velop hypertension. This is because the use of salt is determined by familial salt use patterns and individual choice. Similarly, risk factors such as obesity, stress level, and inactivity are prod­ucts of familial, cultural, and personal choice factors.(24,25) Thus, even among those with demonstrated genetic risk, a significant part of the total risk for de­veloping hypertension can be traced to individual behaviors.
There are also involuntary compo­nents embedded within seemingly vo­litional choices. For example, al-though the choice to try a drug may be voluntary, the effects of the drug can be influenced profoundly by genetic fac­tors. Those whose initial, involuntary physiologic responses to alcohol or other drugs are extremely pleasurable will be more likely to repeat the drug taking than those whose reaction is neu­tral or negative. Work by Schuckit(26) and Schuckit and Smith(27) has shown that sons of alcohol-dependent fathers in­herit more tolerance to alcohol's ef­fects and are less likely to experience hangovers than sons of non–alcohol-dependent fathers. In contrast, the in­herited presence of an aldehyde dehy­drogenase genotype (associated with alcohol metabolism) causes an invol­untary skin "flushing" response to alcohol.(28-30) Individuals who are homo­zygous for this allele (approximately 35% of the Chinese population, and 20% of Jewish males in Israel) have an especially unpleasant initial reaction to voluntary alcohol use to the point where there are virtually no alcoholics found with this genotype.(28-30)

Pathophysiology
The acute effects of alcohol and other drugs have been well characterized. However, even a complete understand­ing of these acute effects cannot ex-plain how repeated doses of alcohol and other drugs produce paradoxically in-creasing tolerance to the effects of those drugs concurrent with decreasing vo­litional ability to forgo the drug. As sug­gested by Koob and Blooms(31) the chal­lenge is to find an internally consistent sequence by which molecular events modify cellular events and in turn pro-duce profound and lasting changes in cognition, motivation, and behavior. Research on the neurochemical, neu­roendocrine, and cellular changes as­sociated with drug dependence has led to remarkable findings during the past decade, as summarized in the recent lit­erature.(32-35) Herein, we summarize just 3 areas of investigation.
Addictive drugs have well-specified ef­fects on the brain circuitry involved in the control of motivated and learned behaviors.(31-36) Anatomically, the brain cir­cuitry involved in most of the actions of addictive drugs is the ventral tegmental area connecting the limbic cortex through the midbrain to the nucleus accumbens.(35-36) Neurochemically, alco­hol, opiates, cocaine, and nicotine have significant effects on the dopamine sys­tem, although through different mecha­nisms. Cocaine increases synaptic do­pamine by blocking reuptake into presynaptic neurons; amphetamine produces increased presynaptic release of dopamine, whereas opiates and alco­hol disinhibit dopamine neurons, pro­ducing increased firing rates. Opiates and alcohol also have direct effects on the en­dogenous opioid and possibly the y-ami­nobutyric acid systems.(31-36)
Significantly, the ventral tegmental area and the dopamine system have been associated with feelings of euphoria,(31-36) Animals that receive mild elec­trical stimulation of the dopamine sys­tem contingent on a lever press will rapidly learn to press that lever thou-sands of times, ignoring normal needs for water, food, or rest.(36) Cocaine, opi­ates, and several other addictive drugs produce supranormal stimulation of this reward circuitry.(31-36)
Given the fundamental neuro-anatomy and neuropharmacology of this system, it is understandable that ad­dictive drugs could produce immedi­ate and profound desire for their read-ministration. Less clear is why simply preventing the administration of these drugs for some period would not cor­rect the situation, return the system to normal, and lead to a "sadder but wiser" individual who would be less instead of more likely to reuse those drugs.
It is known that use of these drugs at some dose, frequency, and chronic­ity will reliably produce enduring and possibly permanent pathophysiologic changes in the reward circuitry, in the normal levels of many neurochemi­cals, and in the stress response system.(31,35,37-41) Volkow et al (37-42) found impairments in the dopamine system of abstinent former cocaine users 3 months after their last use. Otherstudies(39,40) have documented sustained changes in the stress response system following abstinence from opiate or co­caine dependence. Researchers do not know how much drug use is required to create these changes or whether these effects ever return to normal. Somatic signs of withdrawal last several days, motivational and cognitive impair­ments may last several months(33) but the learned aspects of tolerance to the drug may never return to normal.(35,36,41)
A second explanation for the endur­ing pathology seen among drug-dependent persons and their ten­dency to relapse lies in the integration of the reward circuitry with the moti­vational, emotional, and memory cen­ters that are colocated within the lim­bic system. These interconnected regions allow the organism not only to experience the pleasure of rewards but also to learn the signals for them and to respond in an anticipatory manner.(36,41,43) Repeated pairing of a person (drug-using friend), place (corner bar), thing (paycheck), or even an emo­tional state (anger, depression) with drug use can lead to rapid and en-trenched learning or conditioning. Thus, previously drug-dependent in­dividuals who have been abstinent for long periods may encounter a person, place, or thing that previously was as­sociated with their drug use, produc­ing significant, conditioned physi­ologic reactions, such as withdrawal-like symptoms and profound subjective desire or craving for the drug.(43,44) These responses can combine to fuel the "loss of control" that is considered a hall-mark of drug dependence.(10)
These conditioned physiologic responses have been shown in labora­tory studies(41,45,46) of currently abstinent former opiate, cocaine, and alcohol—dependent individuals. Childress et al,(43) using positron emission tomography, examined limbic and control brain regions of detoxified, male, cocaine-dependent subjects and cocaine-naive controls during videos of cocaine-related scenes. During the video, these currently abstinent former cocaine-dependent subjects experienced in-creased craving and showed a pattern of limbic increases and basal ganglia decreases in regional cerebral blood flow that mimicked the effects of the drug itself. This pattern did not occur in cocaine-naive controls or among the for­merly cocaine-dependent patients in response to a neutral video.(43) Thus, even artificial video scenes of cocaine-related stimuli, presented in the sterile context of a positron emission tomog­raphy laboratory, produced excitation of brain reward regions and triggered drug craving.

TREATMENT RESPONSE
A central question in the comparison of drug dependence with other ill­nesses is whether dependence will de-crease without treatment and whether it will respond to medications and other interventions. There is a large re-search literature on drug dependence treatment outcomes.(7-9,34,35,47-49) The treatment of addiction has been de-scribed in a manual(50) and 2 detailed volumes (51,52) Space permits only a few ex­amples from that literature, addressing questions of particular import to phy­sicians.

Untreated Persons
Examinations of untreated, dependent persons offer some indication of the natural course of addiction. For example, Metzger et al(53) measured drug use, needle-sharing practices, and human immunodeficiency virus (HIV) infec­tion rates of 2 large samples of opiate-dependent persons in Philadelphia, Pa. The in-treatment (IT) group included 152 patients randomly selected at admis­sion to a methadone maintenance pro-gram. Out-of-treatment (OT) subjects were also heroin-dependent individuals matched to the IT group by age, race, sex, neighborhood, and other relevant background factors, although none of the 103 OT subjects had received treatment. Both groups were interviewed and tested for HIV status every 6 months for 7 years. At the initial assessment, 13% of the IT sample and 21% of the OT sample were HIV positive. By 7 years, 51% of the OT group but only 21% of the IT group tested HIV positive.53 Of course, even this substantial between-group difference does not prove that treatment participation was the causal agent. It is likely that the OT subjects lacked the motivation for change found among the treated patients. Thus, lack of desire for personal change, rather than the effects of the treatment itself, could have produced the differences seen.
One way to separate the effects of drug dependence treatment from the effects of motivation is to compare treated and untreated substance-dependent indi­viduals who were explicitly not inter­ested in treatment. Booth and col­leagues50 studied 4000 intravenous drug users seeking HIV testing as part of a multisite acquired immunodeficiency syndrome initiative in 15 cities. Sub­jects were randomly assigned to either standard HIV testing alone or to stan­dard testing plus 3 sessions of motiva­tional counseling from a health educa­tor. At 6-month follow-up, those who received additional counseling showed half the rate of drug injection (20% vs 45%), 4 times the likelihood of absti­nence (confirmed by urinalysis), and sig­nificantly lower arrest rates (14% vs 24%) than those randomly assigned to receive just HIV testing.(54) Studies of other illnesses show that screening and brief advice from physicians can affect the motivation for change among pa­tients and the longer-term course of their health. The data of Booth et al suggest this is true even for seriously addicted individuals.
Svikis et al(55) studied drug abuse treatment in pregnant, cocaine-dependent women who did not originally apply for treatment. All women had simply ap­plied for prenatal care and were found to be positive for cocaine use on a rou­tine drug screen. They were compared with 46 pregnant, demographically matched women who tested positive for cocaine use and received standard pre-natal care during the year before the op­ening of the experimental treatment program. Drug dependence treatment consisted of 1. week of residential care followed by twice-weekly addiction counseling in the context of the sched­uled prenatal visits.
At delivery, 37% of the treated patients tested positive for cocaine use compared with 63% of the untreated women. Infants of the treated women averaged higher birth weights (2934 vs 2539 g) and longer gestational periods (39 vs 34 weeks) than those of the com­parison group. Following delivery, 10% of infants in the treated group required care in the neonatal intensive care unit (mean, 7 days). In comparison, 26% of infants in the untreated group required intensive care (mean, 39 days). Aver-age costs of care were $14500 for the treated group and $46 700 for the com­parison group. These data indicate that drug-dependent women can be screened and motivated during prenatal care and that drug dependence treatment can be combined with traditional prenatal care in an extremely cost-effective manner.

Medications
In addition to medications for nico­tine dependence, such as nicotine gum and patch and bupropion hydrochlo­ride, medications for alcohol and opi­ate addiction have been developed under Food and Drug Administration guidelines, have been researched in ran­domized clinical trials, and have reached the market. Herein, we discuss a few recent developments, but a complete review has been published by the Institute of Medicine.(35)
Opioid Dependence.
Opioid ago­nists, partial agonists, and antagonists are the 3 primary types of medications available for the treatment of opioid de­pendence, all acting directly on opioid receptors, particularly µ-receptors.(35) Agonist medications, such as metha­done hydrochloride, are prescribed in the short-term as part of an opioid de­toxification protocol or in the long-term as a maintenance regimen. Double-blind, placebo-controlled tri­als(56,57) have shown methadone to be ef­fective in both inpatient and outpa­tient detoxification, although the long-term effects of detoxification alone, without continuing treatment, have been uniformly poor. As a mainte­nance medication, methadone's oral route of administration, slow onset of action, and long half-life have been ef­fective in reducing opiate use, crime, and the spread of infectious diseases, as was recently validated by a Na­tional Institutes of Health Consensus Conference.(58)
The partial agonist buprenorphine hydrochloride is administered sublin­gually and is active for approximately 24 to 36 hours.(59) Large double-blind, placebo-controlled trials of buprenorphine have shown reductions in opi­ate use comparable with methadone but with fewer withdrawal symptoms on discontinuation.(60) Importantly, the combination of buprenorphine plus nal­oxone hydrochloride, designed to reduce injection use, will soon be released for prescription in primary care settings.(61)
Opioid antagonists such as naltrex­one block the actions of heroin through competitive binding for 48 to 72 hours, producing neither euphoria nor dys­phoria in abstinent patients (62,63) Naltrexone is used as a maintenance medi­cation, designed as an "insurance policy" in situations where the patient is likely to be confronted with relapse risks. Naltrexone in combination with social or criminal justice sanctions is routinely used in the monitored treatment of physicians, nurses, and other professionals (63) In a recent controlled trial, Cornish and colleagues(64) showed that naltrexone added to standard fed­eral probation produced 70% less opi­ate use and 50% less reincarceration than standard probation alone.
Alcohol Dependence.
Naltrexone has been found effective at 50 mg/d for re­ducing drinking among alcohol-dependent patients (65,66) It works by blocking at least some of the "high" pro­duced by alcohol's effects on µ-opiate receptors. More recently, European re-searchers have found encouraging re­sults using the 'γ-aminobutyric add ago­nist acamprosate to block craving and relapse to alcohol abuse.967) Alcohol-dependent patients prescribed acam­prosate showed 30% higher absti­nence rates at 6-month follow-up than those randomized to placebo. Further-more, those who returned to drinking while receiving acamprosate reported less heavy drinking (≥5 drinks per day) than those receiving placebo."
Stimulant Dependence.
Although there are not yet effective medications for the treatment of cocaine or amphet­amine dependence,(35) there are proven behavioral treatments.(66-71) There also are promising animal studies of a potential vaccine that binds to and inacti­vates metabolites of cocaine,(72) but clini­cal trials will not be scheduled for several years.

Comparing Treatments for Drug Dependence With Treatments for Other Chronic Diseases
There is no reliable cure for drug de­pendence. Dependent patients who comply with the recommended regimen of education, counseling, and medication have favorable outcomes during and usually for at least 6 to 12 months following treatment.(47-50) Fa­vorable outcomes typically continue in patients who remain in methadone maintenance or in abstinence mainte­nance through participation in Alco­holics Anonymous (AA) or other self-help programs.(48,50-52) However, because of insurance restrictions, many pa­tients receive only detoxification or acute stabilization with no continuing care.(3,6,9) Others drop out of rehabilita­tion-oriented treatment and/or they ig­nore physician advice to continue tak­ing medications and participating in AA. Thus, 1-year, postdischarge follow-up studies(47,52,73) have typically shown that only about 40% to 60% of discharged patients are continuously abstinent, al-though an additional 15% to 30% have not resumed dependent use during this period. Problems of low socioeco­nomic status, comorbid psychiatric con­ditions, and lack of family and social supports are among the most impor­tant predictors of poor adherence dur­ing addiction treatment and of relapse following treatment.(47-52.74)
Hypertension, diabetes, and asthma are also chronic disorders, requiring continuing care throughout a patient's life. Treatments for these illnesses are effective but heavily dependent on adherence to the medical regimen for that effectiveness. Unfortunately, stud­ies have shown that less than 60% of adult patients with type 1 diabetes melli­tus fully adhere to with their medica­tion schedule(75) and less than 40% of patients with hypertension or asthma adhere fully to their medication regi­mens(76,77) The problem is even worse for the behavioral and diet changes that are so important for the maintenance of gains in these chronic illnesses. Again, studies indicate that less than 30% of patients with adult-onset asthma, hyper-tension, or diabetes adhere to pre-scribed diet and/or behavioral changes that are designed to increase func­tional status and to reduce risk factors for recurrence of the disorders(75-78) Across all 3 of these chronic medical ill­nesses, adherence and ultimately out-come are poorest among patients with low socioeconomic status, lack of fam­ily and social supports, or significant psychiatric comorbidity.(75-79) Perhaps because of the similarity in treatment adherence, there are also similar relapse rates across these disorders. Outcome studies indicate that 30% to 50% of adult patients with type 1 diabetes and approximately 50% to 70% of adult patients with hyperten­sion or asthma experience recurrence of symptoms each year to the point where they require additional medical care to reestablish symptom remission (75,80)

COMMENT
Few persons who try drugs or regu­larly use drugs become dependent. However, once initiated, there is a pre­dictable pathogenesis to dependence marked by significant and persistent changes in brain chemistry and func­tion. It is not yet possible to explain the physiologic and psychological pro­cesses that transform controlled, vol­untary use of alcohol and other drugs into uncontrolled, involuntary depen­dence. Twin studies indicate a definite role for genetic heritability. Nonethe­less, personal choice and environmen­tal factors are clearly involved in the expression of dependence. In terms of vulnerability, onset, and course, drug dependence is similar to other chronic illnesses, such as type 2 diabetes, hyper-tension, and asthma.
Our review of treatment response found more than 100 randomized controlled trials of addiction treatments, most showing significant reductions in drug use, improved personal health, and reduced social pathology but not cure.(7-9,34,35,47-52,81,82) Recent treatment advances include potent, well-tolerated medications for nicotine, alco­hol, and opioid dependence(35,58,61,65-67) but not marijuana or stimulant depen­dence. There is little evidence of effec­tiveness from detoxification or short-term stabilization alone without maintenance or monitoring such as in methadone maintenance or AA.(47-52.57) However, as in treatments for other chronic disorders, we found major prob­lems of medication adherence, early drop-out, and relapse among drug-dependent patients. In fact, problems of poverty, lack of family support, and psychiatric comorbidity were major and approximately equal predictors of non-compliance and relapse across all chronic illnesses examined.(74-83)
Thus, our review suggests that drug dependence shares many features with other chronic illnesses. We are aware that arguments by analogy are lim­ited, and even marked similarities to other illnesses are not proof that drug dependence is a chronic illness. None­theless, these similarities in heritabil­ity, course, and particularly response to treatment raise the question of why medical treatments are not seen as ap­propriate or effective when applied to alcohol and drug dependence. One pos­sibility is the way drug dependence treatments have traditionally been delivered and evaluated.
Many drug dependence treatments are delivered in a manner that is more appropriate for acute care disorders. Many patients receive detoxification only.(3-35,48,49) Others are admitted to spe­cialty treatment programs, where the goal has been to rehabilitate and discharge them as one might rehabilitate a surgical patient following a joint re-placement (47)Outcome evaluations are typically conducted 6 to 12 months following treatment discharge. The usual outcome evaluated is whether the pa­tient has been continuously abstinent after leaving treatment.
Imagine this same strategy applied to the treatment of hypertension. Hyper­tensive patients would be admitted to a 28-day hypertension rehabilitation program, where they would receive group and individual counseling regarding be­havioral control of diet, exercise, and life-style. Very few would be prescribed medications, since the prevailing insur­ance restrictions would discourage main­tenance medications. Patients complet­ing the program would be discharged to community resources, typically with-out continued medical monitoring. An evaluation of these patients 6 to 12 months following discharge would count as successes only those who had remained continuously normotensive for the entire postdischarge period. In this regard, it is interesting that relapse among patients with diabetes, hypertension, and asthma following ces­sation of treatment has been consid­ered evidence of the effectiveness of those treatments and the need to retain patients in medical monitoring. In contrast, relapse to drug or alcohol use following discharge from addiction treatment has been considered evidence of treatment failure. The best outcomes from treat­ments of drug dependence have been seen among patients in long-term metha­done maintenance programs(49,50,58,83) and among the many who have continued participating in AA support groups.(84,85)

IMPLICATIONS
For primary care physicians, this re-view suggests that addiction screening, diagnosis, brief interventions, medica­tion management, and referral criteria should be taught as part of medical school and residency curricula and rou­tinely incorporated into clinical prac­tice(86.87) For those in health policy, our review offers support for recent insur­ance parity initiatives.(88) Like other chronic illnesses, the effects of drug de­pendence treatment are optimized when patients remain in continuing care and monitoring without limits or restric­tions on the number of days or visits cov­ered. Although it is unknown whether care delivered in a specialty program or coordinated through primary care will provide the maximal benefits for pa­tients and society, it is essential that prac­titioners adapt the care and medical monitoring strategies currently used in the treatment of other chronic illnesses to the treatment of drug dependence.

Funding/Support
This review was supported by grants from the Department of Veterans Affairs, the Na­tional Institute on Drug Abuse, the Center for Sub-stance Abuse Treatment, The Robert Wood Johnson Foundation, and the Office of National Drug Control Policy.

Acknowledgment
The manuscript was reviewed (but not supported financially) by the Physician Leadership for National Drug Policy before submission, and Dr Lewis is a member of that organization.

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JAMA October 4, 2000 vol 284 no 13

DRUG USER RIGHTS:
Learning from Black Drug Users
by Cynthia Matthews
It's the age-old debate - we are fast approaching the Millennium, talking about the importance of 'freedom of choice', 'developments', 'progression' and yet drugs workers still haven't got it right when it comes to meeting the needs of black drug users.
It appears that many of the drug services provided by organisations touting slogans like 'we welcome crack users' and 'particularly people from ethnic minorities', remain in the dark when it comes to meeting the needs of black drug users and in particular those using crack. I don't believe that with the vast amount of available research or equal opportunity policies gathering dust on many shelves, that I need reinvent the wheel or cover old ground discussing many issues pertaining to the impact of crack cocaine on black communities.
The social, psychological and economic devastation it has caused, that continues to tear to shreds the social fabric that invisibly bonds together a group of people, whom in the absence of adequate levels of service provision are left with no other option but to dig deep within themselves and draw upon an inner strength - an experience known only to those who have been oppressed, generation upon generation, because of the colour of their skin.
There'd be no need for me to buy a lottery ticket every Saturday night, if I'd been paid for the number of times I've met, been approached by or often spoken to another black individual who had voiced complete dissatisfaction with a service they'd approached for help with their drug problem. Nor would I need to buy a lottery ticket for the amount of times the words 'racist', 'judgmental', or 'inaccessible' have been used to describe what's been met on their arrival.
Many black drug users complain that they believe it is not only their drug taking behaviour which is being challenged by white drugs workers. On admission, or when entering a service, they are more often than not met by a white, middle class, careerist, who is quite simply unable to recognise the diversity of black culture - or of black people as individuals who differ in many ways, just like any other race. Where these occasions arise after 'assessments', 'counselling sessions' or 'meetings', race becomes an issue. From the user's viewpoint it's the frustrating old dilemma of being confronted yet again, by yet another racist. As stereotypical responses flow with ease from their mouths, it becomes difficult for the individual not to send their eyes rolling to the back of their head in exasperation, thinking "not another one"! Faced with the enormity of the task ahead, it becomes clear that if anything is to be gleaned from this, it's the user's responsibility to try and educate the worker to a level of cultural awareness sufficient enough for the worker to begin to assess their client's true needs. Unfortunately, being forced to confront the worker's ignorance only serves to reinforce the racist stereotypes about black drug users.
This scenario is not hypothetical. It's familiar occurrence only serves to further alienate and marginalise the individual from the service, and society in general. This is important to realise when set against the fact that as experience has shown, black crack users only present themselves to services in desperation, in crisis - when all else has failed.
So we are talking about 'freedom of choice', 'development' and 'progression' - all important factors that are all too often ignored when considering the inclusion of a black agenda - that needs to be incorporated into all drugs services, if they are to be of any real use. There remains far too many black crack users floating around in sub-cultural pockets of activity, with little or no faith, or understanding of how the system works. As a consequence many black families struggle like cottage industries, trying against all odds to cope with the fallout. Clearly more initiatives of quality and substance need to be developed in order that variety will give rise to choice.
Initiatives need to be targeted at the heart of the community. A clear example of excellence was the launch of Newham Drugs Advice Project's (NDAP) black specific service RAW, which is delivered from an ethno-centric perspective. RAW's launch, which included 'edutainment', advice and support, recognised the struggles of black users and their families and acknowledged the impact of drug use on the black community - and delivered from an ethno-centric perspective with which black people could easily identify. NDAP's unique approach to launching RAW and raising awareness of its existence in the black community, was not only inspiring, it empowered in every possible way. NDAP recognise that crack users move from group to group, area to area, and that as a consequence crack sub-culture is fluid. Hence the objective of targeting direct to the heart of the community achieved its aim.
Learning from this example, it is of paramount importance to recognise and act on the obvious need for more initiatives of RAW's kind. Initiatives that offer black users accessibility, that are flexible and versatile in approach, if we are to talk about there being 'freedom of choice' for black clients when it comes to using services. Just as the Millennium is considered an important milestone in acknowledging change, I for one would like to see radical change in the ability of purchasers and providers of services to improve their ability to think. Think of meeting the needs of all users in the agenda for the next Millennium.
It's time to recognise that in the absence or want of a pharmaceutical alternative, there is no quick fix for crack users. There is no magic wand that can be waved to make users disappear as soon as things become too difficult. Work has to be done - real work. To date we have seen the funding and implementation of more than enough pseudo-initiatives, resulting in more than enough disenfranchised black workers and users who lack the overall organisational support required to get the job done or achieve realistic aims in terms of overcoming their drugs problems. Progress has passed its sell by date, services must take on board the full scope and intentions of black users' needs when touting black or ethnic minority slogans. It is time to ensure that all black clients receive counselling from a black, well-trained and where possible, qualified drugs worker, if they are to have any faith in the ability of the service.
On entering the service it is imperative that black users are not alienated by the workers' lack of cultural understanding or unfamiliarity with the service environment. (Sticking up a few Bob Marley posters will not suffice!) It's time to develop effective means of communication with black users. On a practical level all workers must be properly trained in the likely phases, lengths and modes of withdrawal from crack cocaine and the healing processes, and it must be supported with relevant literature and workshops.
It's time to ensure representation of black drug users at every level when considering development and progression. Those that have achieved abstinence should be invited to partake in the consultation process on future policy. As the saying goes "He who feels it, knows it". Experience shows the list of needs goes on, but the next time you see a black user, "Can you give one good reason why he or she should use your service?"

Cynthia Matthews is a freelance writer. For more information about RAW contact Abdul Rahman on 0171 474 2222.

(c) Cynthia Matthews - put copyright at end; with Peter McDermott.

probation

DRUGS, PROBATION AND COURT ORDERS
by Danny Kushlick.
Joe has missed another appointment with me. I have just called his probation officer to let him know and Joe will be returning to the court for breach of his probation order.
This does not sound like the caring, sharing drugs worker of days gone by. Is this the new school of enforced abstinence and the end of voluntarism in drugs work?
Joe is on a probation order with a 1A condition under the 1991 Criminal Justice Act (CJA) to seek treatment for his drug misuse. As the result of a scheme set up in March 1994 Joe and his court were given a new option for high tariff offenders. In 1994 Avon Probation Service funded a partnership scheme with Bristol Drugs Project (BDP) for offenders who were expected to receive a custodial sentence. Now they could opt for three months weekly counselling as part of their probation order. It is Hobson's choice, however, as individuals have to agree to attend the BDP and they can be deemed to have breached their probation order for non-attendance.
To date 45 clients have started on the programme and half have successfully completed the three months (the other half have breached). The vast majority of people referred to the project have committed acquisitive crime in order to support their habit. Most are young, male opiate users, shoplifting, burglary, cheque book fraud and the like.
Although the BDP always had close links with the criminal justice system, the move into a formal partnership with probation and the courts brought up a whole number of new practice issues and concerns.
Confidentiality
This had always been sacrosanct. Now I would have to report on individual's attendance and potentially be slandered in local prisons as "the guy who stitched me up", and so change the clients' views negatively regarding the project.
In practice the protocol we set up means that clients are very clear what will happen if they are given a condition to attend the project. Probation, likewise, are clear what information they will receive. Most clients build up a level of trust such that they can talk, for instance about drug dealing, that they would never speak about with their probation officer. The fact that, although we are in partnership with the criminal justice system, we are one or two steps removed, often gives people the confidence to speak openly.
Coercion
Would the fact that people were under a court order affect the nature of the relationship with the drug worker? The answer is yes, it does. Some, a minority, of people never really trust the confidentiality agreement, and I do not ever really get the full story. For others there is an element of resentment at having to attend and a constant fear of being breached. These added issues are obviously not present for voluntary users of the project.
Some have agreed to the condition purely to avoid a prison sentence and if they do attend subsequently, they are more interested in getting away than talking about themselves.
On the positive side for those people who are chaotic and who want help, the boundaries set by the court order can be extremely useful in providing a structure by which individuals feel supported. The bottom line is that anyone who decides, having been given the condition, that they don't want to come just stops coming. Individuals vote with their feet ultimately. Those who are breached and returned to court are, at worst, likely to receive the sentence they would have got if the scheme hadn't existed in the first place.
Although attendance may as the result of some coercion for many clients it is the first time they have been in contact with a drugs service. They at least know where to go for help should they feel they need it.
Measuring Success
As a partnership worker I have a number of masters whom I serve: my client, probation, the court and BDP.
Success for one will not necessarily be important for another. Convincing someone to regularly use the needle exchange will not necessarily be a Crown Court judge's first priority. Probation and the courts want to know the underlying issues that lead people to offend are being addressed in a way that can be reported back successfully. The courts also want there to be consequences for non-co-operation. Probation also want protocol that enables them to liaise, at the very least, about clients' attendance. Clients want a confidential drugs service that provides everything from support to referral to other agencies. BDP want me first and foremost to provide a service to clients and secondly to develop the service.
In order to meet all these needs we have developed a monitoring system that takes into account drug use, offending, client evaluation and harm minimisation issues. The fact is that although some people will improve on all key performance indicators, some will continue to offend and continue to use drugs. (Indeed, some will continue to offend even if they stop using drugs having been offending before they started to use). Completion of the condition itself is a measure of success for some clients who have never completed a court order.
Additional Bonuses
As a result of the partnership post being developed, liaison between the criminal justice system and BDP has improved greatly. There are many more opportunities for BDP to have a consultative role for probation and opportunities to educate magistrates through their meetings as to the nature of drug use and misuse and the type of people they are dealing with.
The Way Forward
Anecdotal evidence suggests that upwards of 70 per cent of probation clients are misusing drugs and a majority of them are offending because of their habit. This is a huge number of people and will require a multi-agency strategy and a large increase in resources to meet their needs.
Conditions of treatment have an important part to play as an option the court can use and that probation can offer to clients. Avon's experience is that they are immediately useful for about half of those who receive counselling as part of an order. Clients who would otherwise spend anything from three months to three years in prison can now opt for a community sentence during which they can address a number of different issues from a specialist service, which will be monitored by the court. It is, for those who are ready for a change, an opportunity that did not exist before 1994.
It will not, however, meet the needs of the vast majority of probation clients. Not until there is a recognition and strategic response to drug misuse in probation will things fundamentally shift. This also needs to include an analysis at a policy level of why so many people on probation misuse drugs.
Currently Avon Probation Service is working on a strategic response to drug and alcohol misuse amongst probation clients. There are now two partnership workers in the drugs field in Avon. We still cannot provide for anywhere near the needs of all drug using clients on probation. What is needed now is a strategic plan including training, consultation and support for probation officers, training and consultation for magistrates and judges, specialist probation workers and excellent links between probation and the statutory drugs team.
Conclusion
Court ordered drug treatment can work under conditions where probation and the courts support their partner. Just the same as in any other field some clients will get better, some worse and some remain the same. That said, the majority experience some benefit from the contact.
For people like Joe court ordered treatment has given him the opportunity in the community to stay away from a ram raiding œ1,000 a day crack habit and settle down with his girlfriend - as long as he turns up for the next appointment.
Danny Kushlick is a probation partner worker at BDP.
html 1995 drugtext web-lab

The concept of self-medication in the addictions: Implications for a model of clinical management within a secondary care serviceGianni Dianin
ABSTRACT
The split between primary and secondary care in the addiction field has brought about a redefinition of the way patient care is planned and in. the way addiction services interface with and complement each other.
In the addiction field this strategic re-configuration has far reaching implications for the organisational, managerial and the clinical level.
In this context the role of the Drug Dependency Unit becomes redefined as a Specialist Service whose main function is to offer a service to those problematic drug users whose needs could not be adequately met in the community at primary level, because of comorbidity and/or chronic polydrug use.
Within this framework the concept of drug use as self-medication has been found to provide a useful tool in the treatment of the secondary care sector clients group.
The advantages in employing such conceptualisation are related to a better differentiation of the caseload, an increased efficiency in devising the treatment plan, and finally in a better co-operation between primary and secondary care services.
This paper will describe the development of a secondary service, St. Clement's SDU. Finally the implication for research are considered.

THE DDU ROLE AND HARM REDUCTION
Historically the DDUs role was to provide pharmacological maintenance, in-patient detox or psychiatric treatment, to those who had already failed to become drug free in the primary services.
Recently the DDUs have assumed more of a specialist treatment role within the present configuration of drug services .(ie primary/ secondary/ tertiary tiers of treatment).
The role of the DDU has become therefore to offer a service to those so called "problematic drug users" who had already failed to comply with their treatment plan at primary level.
However in a climate of heavy cuts to the Health budgets, the limited resources of the DDU are almost completely used to provide the maintenance service rather than a specialist one. This is because maintenance services are seen as "Specialist", and theoretically no primary service should provide maintenance.
This results in a situation whereby the DDU just accumulates people on maintenance prescriptions, without having the possibility to refer them back to the primary services once stabilised.
One way to use better the D'DU resources would be to understand that maintenance treatment per se, like drug use per se is not pathological. So the resources of the DDU could be directed more effectively where they are most needed, that is where there is evidence of drug related pathology either physical or psychological,
At the Specialist Drug Unit (SDU) the DDU of Tower Hamlet, the staff has been experiencing the fact that many of its clients are now stabilised and could be managed in the community.
The client group the SDU should be actively targeting are those drug users who are unable to stabilise even on a maintenance prescription, or who have acute conditions which needs specialist care.
This paper will be concerned with the theory and practice related to those clients who, because of psychological difficulties, are not able to stabilise.
In particular this paper , using the concept of "Self-Medication", and Psychotic- non Psychotic continuum, will try to provide a therapeutic model of intervention for client with dual diagnosis, which now represent at least 30 per cent of the caseload.
SELF-MEDICATION and DUAL DIAGNOSIS
The concept of Self-medication goes back to the 1960s with Psychoanalysis. H. Rosenfeld in his influential book "Psychotic States" :introduces two papers on drug abuse. In these paper drug abuse is seen as a self-:medication: The drug users would use drugs as a manic defence from his/her psychotic suffering.
Drug abuse in the 60s was still seen as the symptoms of a deep psychopathology and considering that at the time the prevalence of drug abuse was just a few hundreds it is possible to assume that there was not enough experience in the drug field to know that drug use is infact not necessarily a sign of psychopathology.
Also mental illness was always, and still is unfortunately, seen as the result of drug abuse.
We now know that about 50 per cent of lifetime drug dependent people also had a lifetime psychiatric disorder. (Kessler 1994)
This means that a significant percentage of our client group is likely to need a service able to address such comorbidity at a specialist level and not just by referring to psychiatric services but by having staff trained in dealing with comorbidity from within the DDU.

DIFFERENTIATION OF CLIENTS NEEDS
After about 15 years of harm minimisation it seems obvious that it is possible to use drugs in a reasonably healthy way without having to destroy one's life, relationships, career.
One easy differentiation can be between the adolescent who uses recreationally at week-ends, and the polydrug user who is dependent, on several substances and seems to be unable to stabilise. However there is no clinical tool to help the clinician in making a differentiation which goes beyond the quantity of drug used and the psychosocial difficulties related to the abuse. (ie Addiction severity index).
For example one of the clients at the SDU, John 32 years old, was referred by his GP for his intractable drug problem which had created all this person problems. He had already failed 3 detoxes and until he was not drug free he could not have hoped to do anything with his life. But looking at John's history it cames out that he never knew whom his father was, his mother had a lifetime manic-depressive psychosis, and the brother was in prison for robbery. Also he has no qualifications, and was never able to hold down a job. At the age of 5, John was taken into care for neglect, and there he was bullied, and raped by the older boys. When at the age of 15 he left the Care home, he started to prostitute himself, and at 16 he was already using Heroin. The last time John attempted to detox he had a severe depression with suicidal ideations. Hence the referral to the SDU.
Unfortunately this case is not rare and a significant number of clients present with this kin of deprived and abused childhood.
It is therefore possible to hypothesize that John's drug use is based on an attempt to minimise internal impulses of a psychotic nature. This type of abuse is therefore self-medication, and it seems useless to attempt further detoxes without taking into account this person internal psychological resources.
So, in order to make the intervention more effective it is necessary to operate a distinction not only between frequency and quantity of drug abuse and its related problems, but above all it is imperative to assess whether the dynamics linked to the abuse have to do with selfmedication.
One way to differentiate the quality of drug use is to use a continuum between psychotic and non-psychotic use.
Psychotic and non-psychotic personality is not a psychiatric diagnosis, but is a terminology used by Dr. W.Bion, a Psychoanalyst. Dr Bion used this terms to understand how to engage, stimulate, the non-psychotic part of the person, in order to increase the person's internal resources and insight.
To clarify, the terms are not psychiatric, and are non judgemental or labelling, because they are applicable to every one of us, as we all have a psychotic and a non-psychotic part of our personality.
There would be no use in labelling clients already discriminated because of supposed selfinflicted problems.
NEUROBIOLOGY AND SELF-MEDICATION
There is evidence from neurobiological studies that drug use is affected, by the way our endogenous opiate system works. Research done on animals show that the environment, genetic factors, and emotional factors do affect the self-administration of opiates.
It is possible to hypothesise that an individual, for genetic, environmental, perinatal or emotional factors, may have such a dysfunction on his/her endogenous opiate system to induce the person to use the drugs that will be able to re-balance the neurochemical dysfunction, and bring about emotional relief.
TREATMENT IMPLICATIONS
In order to respond to the needs of the client with dual diagnosis it is necessary to have a clear clinical protocol.
At the SDU all clients receive a nurses assessment. When a dual diagnosis is identified the person will be then referred both to the Psychiatrist and to a Psychotherapist who will then liaise regarding the treatment plan, which will include Pharmacotherapy and Psychotherapy.
The nursing staff will also arrange the practical support the client may need.
The fact a Psychotherapist is involved has created some difficulties with the fact that there is still little knowledge of the difference between Advice, Counselling and Psychotherapy.
In the drug field unfortunately, psychological therapies have always been given little space. What the clients are able to receive in the drug service is "Drug Counselling", which is practised by anyone even without formal. qualifications. This is something that at the level of a DDU should be addressed, as complex clients such as those with dual diagnosis deserve to be offered a Specialist psychological intervention, as opposed to a generic one.
CONCLUSIONS
Starting from the role of the DDU this paper has tried to address the needs of clients with dual diagnosis.
In an harm minimisation environment, the concept of self-medication and of the Psychotic non-psychotic continuum has been used at the SDU to assess and provide treatment for the clients with dual diagnosis.
Given the limited resources available in the drug field to-day and the great demand put upon staff by the complexity of the clients' :problems, there is an urgent need to reconfigure services in the light of such considerations.
The drug problem becomes therefore secondary and the whole individual needs becomes more important. The medical model used in the DDU to-day is restrictive and in a way colludes with the clients irrational belief that everything is due to drugs and can only be treated with drugs.
The DDU should be able to provide the Medication needed, but should above all be able to address the causes of the self destructive use displayed by dual diagnosis client.
In conclusion, differentiating the client group will not only make a better use of our scarce resources, but will also respond adequately to the clients needs.
REFERENCES
1) H. Rosenfeld (1960) "On Drug Addiction"; and (1964) " The pathology of Alcoholism and Drug addiction: A critical review of the psychoanalytic literature". Both From: "Psychotic States" (1965). Karnac. London.
2) Pfeffer and Waldon. (1987) "Psychiatric differential diagnosis" London
3) Strang J.; Gossop M. Ed. (1994) "Heroin Addiction and drug policy: The British System". Oxford.
4) Bion. (1967) "Second Thoughts;Differentiation between the psychotic and non-psychotic personalities". Karnac. London.
5) Dworkin, Porrino and Smith. (1993) "Neurological substrates of Opioid abuse" Chapter 13 in "The neurology of opiates" R. Hammer Ed.CRC press USA.
6) Mirin S.,Weiss R. (1991) Chap.12 "Clinical Textbook of Addictive disorders" Ed. Frances R., Miller S. The guilford Press; New York, London.
7) Dodes M.; Khantzian E. (1991) Chap. 17 in " Clinical TextbooK of Addictive Disorders". Ed. Frances & Miller. The Guilford Press.
8) Kessler R.; (1995) Chap.7 in "Textbook in Psychiatric epidemiology" Ed. Tsuang, Tohen & Zahner. Wiley-Liss Inc.

The Addict and the Law
introduction 1 2 3 4 5 6 7 8 9 10 CHAPTER 10 THE PATTERN OF REFORM
Reform of present methods of handling addiction ought to take into consideration a number of objectives concerning which there should be relatively little controversy.. The controversy focuses on what are the best methods of reaching the objectives rather than on the objectives themselves. The goal of all drug control measures is, in a general way, the enhancement of the common or social good. When we say this, we should keep in mind that the drug addict is a member of society and that drug control measures ought to take his welfare into account.
Concerning the addiction problem as a whole, the following aims would probably be agreed upon as desirable by all parties in the current controversy:
1. Prevention of the spread of addiction and a resultant progressive reduction in the number of addicts.2. Curing current addicts of their habits insofar as this can be achieved by present techniques or by new ones which may be devised.3. Elimination of the exploitation of addicts for mercenary gain by smugglers or by anyone else.4. Reduction to a minimum of the crime committed by drug users as a consequence of their habits.5. Reducing to a minimum the availability of dangerous addicting drugs to all non addicts except when needed for medical purposes.6. Fair and just treatment of addicts in accordance with established legal and ethical precepts taking into account the special peculiarities of their behavior and at the same time preserving their individual dignity and self-respect.
Other aims and principles of an effective program which are of a more controversial nature but which are implied by the above are the following:
7. Antinarcotic laws should be so written that addicts do not have to violate them solely because they are addicts.8. Drug users are admittedly handicapped by their habits but they should nevertheless be encouraged to engage in productive labor even when they are using drugs.9. Cures should not be imposed upon narcotics victims by force but should be voluntary.10. Police officers should be prevented from exploiting drug addicts as stool pigeons solely because they- are addicts.11. Heroin and morphine addicts should be handled according to the same principles and moral precepts applied to barbiturate and alcohol addicts because these three forms of addiction are basically similar.
THE PROGRAM IN GENERAL
The most effective program for achieving these ends in Western nations seems to be one which gives the drug user regulated access to the medical profession with the physician determining the mode of treatment in accordance with the circumstances of the particular case. Characteristically, this type of program almost invariably involves, wherever it is used, some sort of supervision and regulation of medical practice with regard to addicts by public health officials. Police measures enter the picture only infrequently when medical controls fail.The British program has been described in detail because it is an outstanding example of this system which has been emulated by other nations. It is not suggested here that the United States ought to adopt the British or any other program, lock, stock, and barrel. What is suggested is that successful foreign programs, including the British, should be intensively studied and intelligently adapted to American needs and to special conditions existing in this country. Particular attention needs to be given to the manner in which a reform program is introduced into the United States because of the extraordinarily- large numbers of addicts in a relatively few large cities. Too precipitous change might well discredit a new program before it was given a real chance.
The final result or goal of the reform program which is implicit in this entire book is 2 situation in which most of the addicts in the United States would be in the hands of private physicians. The latter would be free to treat addicts in accordance with accepted medical standards without fear of prosecution. The Public Health Service might be the logical agency to exercise a supervisory and advisory control over practitioners with drug users under their care, but 2 matter of this sort is a detail that should be left to medical officials. The police and federal narcotics agents would be expected to inspect the records of drug stores, drug manufacturers, importers, and distributors as they do at present, and to apprehend persons engaging in the illicit traffic-including any addicts who might do so.
It is absolutely essential, if addiction is to be treated as a medical rather than as a police problem, that doctors be permitted to prescribe regular supplies of drugs to addicts when this is, in their judgment, indicated. If this is not permitted, addicts will continue to be exploited by the underworld as they now are. It should be realistically assumed that even under relatively favorable circumstances no large percentage of drug users will be permanently and immediately cured. Nevertheless, the regular administration of drugs to users should always continue to be regarded as a temporary expedient designed to protect the addict's reputation and to keep him out of underworld hands pending withdrawal and cure. It is assumed that physicians would keep the addict's daily dosage at a minimal level and minimize, as far as possible, the evil physical effects of addiction while they attempted to persuade him to undergo institutional withdrawal and to try to break his habit. Institutional facilities for withdrawal should obviously be provided in hospitals, not in jails, and medical authorities should, when necessary, be authorized to employ restraint upon the addict during withdrawal and for a brief period of time thereafter.' Many addicts currently ask to be committed to jail in order to break their habits. If humane and intelligently worked out plans and facilities, such as those at Lexington, were generally available, addicts would quickly learn of them and would present themselves for voluntary, cures much more frequently than now. Despite assertions to the contrary, there are very few addicts who do not desire to be freed of their habits. This is true also in countries where addiction is not a criminal matter.
It needs to be emphasized that the reforms suggested here do not include the establishment of narcotics clinics, like those of the 19zo's, where drugs are doled out or administered to addicts. The clinic plan has serious disadvantages as a general program, and there is no country in the world today which has such a program. On the other hand, the system of placing the narcotic addict in the hands of the private medical practitioner has been extensively used for many years in many countries throughout the world with uniformly satisfactory results.
It is much more practical to get at the addict through the doctor than it is to try to handle him at centrally located clinics. The clinic idea involves the danger of perpetuating the evils of congregate treatment by, bringing addicts together rather than keeping them separate. There are more doctors than addicts in the United States. Hence, theoretically if each doctor in-the country were to agree to accept one addict as a patient this would more than take care of all addicts. Such a program would be difficult to organize, but if anything could be done to encourage drug users now concentrated in large cities to move to smaller communities or rural areas, this would be a distinct gain which would make it easier to administer the program and also make it easier for addicts to refrain from relapse after being taken off drugs. An effect of this nature might be achieved by at first limiting the number of addicts who could be handled by any one physician in the larger cities where users are now most numerous.
TRANSFER OF AUTHORITY TO THE MEDICAL PROFESSION
If addiction is a medical problem and the addict is to be handled medically, it is necessary that the authority to determine what specific program will be applied to the user be placed in medical hands. This means that power now being exercised by legislators, lawyers, judges, prosecutors, and policemen must be transferred to the medical profession. This transfer of power will be resisted by some of those who will have to surrender it, but the issue is clear. It is absurd to call addiction a medical matter and then permit policemen, prosecutors, and legislators to specify how it shall be treated.2
The legal basis for putting doctors in charge of handling addiction already exists in the decisions of the Supreme Court. The basis in popular opinion also exists, for most Americans today are quite ready to accept the idea that drug addiction, like alcohol addiction, and perhaps like cigarette addiction, ought not be dealt with as a police matter. What is needed is an appropriate plan of action by administrative officials. The first point of attack should probably be the regulations of the Treasury Department which threaten the physician with criminal prosecution for prescribing drugs for users except under the two conditions: (a) terminal disease such as cancer, and (b) an aged and infirm user-who might die if the drug were withdrawn. The New York Academy of Medicine has already assailed these regulations and has forcibly pointed out how they have for many years put physicians in a straitjacket with regard to narcotic addiction.3
The first step in reform might therefore well be a conference sponsored by the A.M.A. perhaps with the New York Academy of Medicine at the invitation of the Secretary of the Treasury and the Attorney General, with a mandate to revise the existing regulations so as to bring them into conformity with the Supreme Court's doctrine that addiction is a proper subject of medical care. Delegates to such a conference should be predominantly medical practitioners with direct clinical experience with addicts, especially in private practice. There are, and have always been, sharp differences of opinion among medical practitioners concerning the proper treatment of addiction. A statement of standards formulated after a free and open discussion would presumably make allowances for such divergent views. Minority opinions held by substantial numbers within the profession should not be ruled out of court by majority vote. The limits of legitimate treatment for addiction should be determined, in short, in about the same way as they are for venereal disease or for tuberculosis.
A revision by medical men of Treasury Department regulations would certainly either remove entirely or greatly reduce the threat of criminal prosecution to conscientious physicians who undertook to care for addicts. This fact might make it feasible for the medical conference to accept another mandate, namely, that of surveying and bringing into the full light of public examination the facts concerning addicts who are now being handled as medical cases and shielded from the police and punitive action. Little is presently known of these users except that many are thought to be physicians and nurses and that Most are members of the upper social classes. Such a survey would facilitate more realistic planning and would serve to enlighten many members of the medical profession concerning the narcotics problem and existing medical techniques being applied to it.
Removal of the threat of prosecution would in all likelihood lead automatically to a gradual increase in the number of addicts under the care of physicians as the latter came to realize that medical judgment, rather than the police or the criminal law, had become the controlling factor. Such gradual expansion of a medical program would be highly desirable because of the large numbers of addicts in this country and because it would permit members of the medical profession to become acquainted with the problem over a period of time rather than having it thrust upon them abruptly. A sudden transition might well lead to chaos and confusion in the large narcotics centers.
The President's Advisory Commission recommended. in its report that "the definition of legitimate medical use of narcotic drugs and legitimate medical treatment of a narcotic addict are primarily to be determined by the medical profession."' The Commission completely ignored the 1963 report of the New York Academy of Medicine dealing directly with this matter. Instead, it asked the American Medical Association and the National Research Council of the National Academy of Sciences to make a statement on the issue. The result was a masterpiece of diplomacy and noncommittal doubletalk, and was published as part of the report of the Presidential Commission., It stipulated that it is the duty of doctors toobey all laws, rules and regulations at federal, state, and local levels, and simply reiterated the current regulations of the Treasury Department as the definition of proper medical treatment of addicts, without indicating that the definition was drawn from Treasury Department regulations.The Commission evidently assumed that the A.M.A.-N.R.C. report automatically made the view of the New York Academy unacceptable-and illegitimate. But proper medical treatment of diseased persons is not something which is settled by majority vote of A.M.A. officials. That body cannot and does not dictate to physicians how they are to treat diseases. Such questions, like scientific questions, are never settled by majority vote. If they were, and departures from sanctioned practice were prosecuted in the criminal courts as they are in this instance, there could be little progress. The President's Commission, despite its gesture to the medical profession, clearly did not accept the idea of full medical control as advocated by the New York Academy of Medicine. That was no doubt why it made no reference whatever to that organization's position, and why it summarily brushed aside any serious consideration of European programs.
The President's Commission, instead of proposing any plan which would have given physicians the authority they must have if addiction is not to be handled punitively, recommended a program of civil commitment, not as a substitute for imprisonment, but as an alternative to it in selected instances. The Attorney General and the Judiciary, it suggests, should make the "crucial determinations" at the federal level and the Bureau of Prisons, the Public Health Service, and the probation and parole services should manage the actual program.6 This program explicitly avoids giving any important authority to medical persons. It also leaves the addict's status under the criminal law unchanged, does nothing to remove the threat of prosecution for doctors, and leaves the hapless user in the hands of the illicit traffic. The Commission, in short, did not suggest any transfer of power to medicine, but envisaged the establishment of a rehabilitative medical program for drug addicts within the confines of prisons. Anyone acquainted with prisons knows that they are chronically understaffed, underfinanced, overcrowded, and generally ill equipped to undertake constructive programs of this sort even for inmates who are much less difficult and troublesome than narcotic addicts. Diseased persons are not ordinarily treated for their ailments in jails and penitentiaries.
MONITORING THE PROGRAM
As has been indicated, there are presently privileged addicts to whom the usual penalties and rules are not applied, who are given access to legal drugs and handled medically. Revision of the Treasury Department regulations, it has been suggested, would probably increase the number of addicts under medical care by encouraging doctors to treat users of humbler social status. As the number of users under such medical care increased it would probably be regarded as desirable that the program be monitored by an agency which would continuously collect statistical and other types of data concerning the operation of the plan, perform advisory and inspection services, and continuously evaluate the program. In European countries these functions are generally handled by the public health authorities and there seems to be no reason why the same procedure should not be followed here. In Britain the Ministry of Health uses medically trained inspectors for the job of consulting with and advising, doctors in cases where the use of narcotics is.. an issue.
The proposal advanced here assumes medical control of the program, with changes made in accordance with medical judgment on the basis of experience with the plan. It is therefore, in a sense, presumptuous or pointless to suggest in advance a detailed mode of operation or a specific plan for every contingency. Nevertheless, one may speculate that it might be deemed desirable to establish rules for the guidance of physicians in accepting addicts for medical treatment. The experience of Lady Frankau, as she reports it, suggests, for example, that addicts might be accepted only if they indicated willingness to take and hold 2 regular job and to maintain a stable residence, and if they gave some indication of a desire to rid themselves of their habits. An advantage of such rules might be to motivate addicts to meet these conditions, and also, conceivably, to prevent the medical practitioners in large cities with many addicts from being overwhelmed by them.Another conception is suggested by the 196 3 Report of the Neu, York Academy of Medicine which points out that there is a variety of medical situations for which the current Treasury Department regulations are inadequate and unduly restrictive.' The expansion of medical services to addicts might therefore begin with a gradual relaxation of these regulations, with the following types of addicts being admitted to the program in some sort of sequence:
1. Addicts with non-fatal diseases and chronic illnesses should be among the first to be included.2. Aged addicts who have been addicted for many years and taken many cures, and for whom cure seems cruel, pointless, and hopeless.3. Persons who have become addicted in the course of medical treatment. The addicted patient should continue to be a medical responsibility.4. Addicts who come from good families and cultural backgrounds, have no criminal records, and have regular jobs and stable places of residence.5. Persons who acquired their addiction in the military service.6. Any housewife who is a user. This would be for the purpose of making it unnecessary for her to be a prostitute or to help her escape from prostitution.
Ultimately if this scheme were carried out there would remain a residual group of addicts which would probably consist of thehopelessly degraded and demoralized criminal addicts unwilling to give up their illicit way of life, users not interested in quitting, and other hard-core types. For these, civil or criminal commitment would be appropriate and would serve the function of exerting pressure upon them to qualify for the medical program. There would be a residual illicit traffic catering to this remaining group of derelict and recalcitrant types which would be an appropriate object of police attention.
SOME ANTICIPATED EFFECTS
What the effects might be of a program such as that described in this chapter may be indirectly indicated by citing some of the conversations recorded in congressional hearings at which the advisability of subjecting barbiturates and amphetamines to penal controls was considered and rejected. In 195 1, for example, Mr. Anslinger commented as follows on the idea that his Bureau handle barbiturates in the same way as heroin:
"It would be worse than prohibition. It would rake us years finally to get that under control, and we do not have enough men right now.... It would take $5,000,000 and take five times as many men as we have, and then you would have conditions similar to prohibition. I think it would become a very unpopular bureau in this country.... Certainly it is not a peddling traffic like morphine, heroin and cocaine. It is in the hands of the doctors and druggists. I do not think we ought to take it out of their hands and put it in the hands of the underworld, and certainly it is not in the hands of the underworld today. . . ." Mr.-Simpson: "I would like to get clear on one thing. You would not want morphine and opium, and so forth, in the control of druggists and physicians? That would not suit your purposes, Would it?"Anslinger: "No, Sir."Simpson: "Then why would barbiturates be safe in their hands? Are they not as dangerous in their hands? That is what I cannot get."8In 1955, again before the Boggs subcommittee, the following exchanges took place:Mr. Anslinger: "When you are after 2 peddler he will not sell you barbiturates or amphetamines.''Mr. Boggs: "But there is no reason for him to."Mr. Anslinger: "That is true."if the theory that you can become addicted to barbiturates is true then it seems to me that in that field they are doing just what some of these doctors in New York [the New York Academy of Medicine] have advocated they do in the field of other narcotics, which is a proposal which does not appeal to you at all ......Mr. Karsten: "Do you have a history, Mr. Commissioner, of barbiturate users graduating, then, later on to narcotics? Do they follow a pattern like that?"Mr. Anslinger: "We have not seen that pattern, Congressman; that is something which you would think would follow, but they do not go in that direction. The marihuana user is usually the one."9 '
We see in these conversations a perfectly explicit awareness of the conditions that are needed to produce an illicit traffic and of the inconsistency of public policy concerning various types of drugs. Mr. Anslinger's reply to the suggestion that he was not consistent was that the punitive program was necessary with respect to opiates because they are more dangerous and destructive than barbiturates. However, Public Health Service experts had been showing the congressmen films on barbiturate withdrawal and gave them evidence which pointed to exactly the opposite conclusion. We have previously noted that in 1937, before the federal antimarihuana bill was passed, Mr. Anslinger also said that marihuana users did not go on to heroin.10 Perhaps if barbiturates were prohibited in the same manner that heroin now is its users would also graduate to the latter drug.
The former head of the Federal Bureau of Narcotics has provided other illuminating material concerning the advantages of a program of medical, rather than punitive, treatment for drug users. For example, speaking of the treatment of addicts, he had this to say:
There is no single set way to deal with those trapped in the tentacles. I personally have dealt with many of the individual cases. Each has been different. I am not, for instance, a believer in what doctors call "ambulatory treatment"-giving a patient withdrawal treatment in his office, with no check on what the patient may do, or how much he may use the addict, employed this method.
The addict in one case was a Washington society woman. I had known her personally for some years. She was a beautiful, and gracious lady. She had become so badly addicted to demerol that no doctor would prescribe for her; her demand was too great. Word of her case came to me through some of her friends. Was there any way I could help? The woman, I learned, was ready to kill herself. She would not deal with pushers nor would she take a cure or go voluntarily to a hospital herself. Moreover, if I made a case against her, it would destroy her completely-along with the unblemished reputation of one of the nation's most honored families. I agreed to help her, through a trusted physician to whom she appealed for drugs. She was not to know my role. I also learned that she was so afraid that pharmacists would try to cut the strength of her demerol, with sugar of milk or some other non-narcotic substance, that she insisted on receiving only unopened, sealed bottles of demerol from the druggist. That complicated the business but I called in a pharmaceutical manufacturer who agreed to work with us. Each bottle of demerol, specially packaged and sealed, delivered in routine fashion from the drug store, on the prescription of the physician, contained less actual demerol than the previous bottle. Within three months, without the woman realizing, she went from a large daily "ration" of demerol to none at all. What she was getting, in the bottles, was not demerol but sugar of milk." The woman was subsequently informed that she was cured of her addiction and "broke into tears of joy."
Another similar instance involved an addict who was described as one of the most influential members of the Congress of the United States. This man was completely "'intractable," refusing to consider medical treatment and defiant of anything that might be done to him by the police. In this case Mr. Anslinger offered the congressman the proposition that if he would agree not to go to underworld pushers his supply of morphine would be underwritten by the Bureau. It was stipulated that the man was to obtain his supplies from an "obscure druggist" on the outskirts of Washington. The lawmaker naturally accepted the offer and went on using legal morphine till he died with only Mr. Anslinger, the druggist, and the addict himself knowing what was going on.12
From the analysis of these two instances we can see that Anslinger had the following desirable effects in mind: (I) protection of the reputation of the addict and his family; (2) making it possible for the addict to escape exploitation by underworld drug peddlers; (3) breaking the habit in an effective and humane manner; (4) preventing suicide on the part of the user; (5) permitting the user to continue in a legitimate occupation and to be self-supporting; and (6) making it unnecessary for users to congregate with other users.
For the medical profession Mr. Anslinger has formulated rules which prevent the physician from handling addicts in this manner:
"Ambulatory treatment of drug addicts should not be tried. Institutional treatment is always required.""An addict should never be given drugs for self-administration."13
The questions raised by Mr. Anslinger's cases include the following: How many American addicts offered the same deal as that proposed to the congressman would accept and abide by it? How many users could be successfully taken off drugs by physicians using Mr. Anslinger's method, and others that medical men might devise? What percentage of American addicts might engage in productive labor, like the congressman, if they were handled in an equivalent manner' On what principles sh ould addicts of lesser status, who are not personally acquainted with prominent officials in Washington, be excluded from the opportunities offered these two?
In chapter 6 we have referred to a report from London on the fate, in that city, of forty Canadian drug users who sought refuge there from Canada's punitive program. 14 From this report one may infer: (I) that there is 2 probability that a significant percentage of addicts under medical care might work for a living even if they failed to break their habits; (2) that many persons who are addicts first and criminals secondarily would welcome the chance to be law abiding; (3) that an intelligently handled, voluntary program of medical treatment and withdrawal would attract the cooperation of a significant percentage of addicts; and finally (4) that even many addicts who are "criminal" in the genuine sense of the word are not entirely beyond redemption.
EFFECTS ON THE SPREAD OF THE HABIT
In earlier chapters it has been suggested that the spread of the drug habit in modern times has been closely linked with the prohibition system of control and its invariable accompaniment, the illicit traffic. The illicit traffic makes drugs available, but it does more than that. The very facts of illegality and expensiveness give drugs a symbolic significance and attractiveness to some segments of the population which they would not otherwise have. Taking drugs has become for some persons a group way of life, a means of protest, and a way of revolt against accepted values. Nowhere in the Western world are there as many young addicts as there are in the United States, and it is in this country that the so-called "addict subculture" and the drug-using juvenile gang have become especially prominent.
From a study of youthful Negro narcotics users in Chicago, Harold Finestone has provided an excellent analysis of the motivations of a relatively new type of drug user.15 The title of the article, "Cats, Kicks, and Color," suggests its themes. The Negro "cat," says Finestone, substitutes "hustle" for legitimate work, which he aristocratically disdains; the main purpose of his life is to experience the "kick" from performing acts tabooed by "squares" and beyond their comprehension. The use of drugs, from the standpoint of the cat's revolt against middle-class morality, is the supreme, the ultimate kick. It gives excitement to the cat's life and, in his own eyes at least, sets him off in an elite conspiratorial group:
It is this limited, esoteric character of heroin use which gives to the car the feeling of belonging to an elite. It is the restricted extent of the distribution of drug use, the scheming and intrigue associated with underground "connections" through which drugs are obtained, the secret lore of the appreciation of the drug's effects, which give the cat the exhilaration of participating in a conspiracy."
Finestone notes that the young Negro user of narcotics manifests a certain zest in his mode of life, particularly during the initial or honeymoon period. This zest is especially associated with the cat's adventurous and dangerous life on the city streets, with his contest against the whole world to maintain his supply of drugs, and with the game of hide-and-seek that he plays with the police. It is part of this adventurer's way of life to "play it cool" in crises such as those which are represented by withdrawal distress, jails, prisons, and the police.
It is this fact-that drug use in the United States has become a group way of life, a form of protest or revolt against the dominant conventional values of the society-that has contributed heavily to the epidemic character of the postwar drug problem. The meaning of drugs for the adolescent Negro cat is not unlike its significance for "beats" or for many jazz musicians.
Of special importance is the apparent fact that while there are adolescent groups in foreign countries which resemble the American "beats" and "cats," such as the "Teddy Boys'' of Britain and the "Bodgies" or "Wedgies" of Australia, the use of heroin seems not to have been taken up by these foreign groups. The reasons for this, one may speculate, are probably connected with the manner in which heroin addiction is handled in these countries. When it is dealt with as a medical problem, the use of heroin evidently does not serve as a symbol of protest or revolt nor does it become a group way of life. Addicts under the care of physicians have no special reasons or need for association with each other or with the underworld. While the direct effects of drugs obtained from physicians are the same as those from illicit supplies, the fact of being under the physician's care no doubt leads the drug user to think of himself more as a sick or diseased person than as a member of an underground conspiratorial group. At any rate, there does not appear to be a single instance of a country in which opiate addiction is handled medically where the use of opiates has acquired the status of a fad or become an epidemic as it has in the United States. This leads to the supposition that 2 medical attack on addiction in this country would undercut the cat's way of life, as Finestone and others have described it, both by isolating addicts from each other and by changing the significance of drug use.Dissident, deviant, or antisocial subcultures or groups in foreign countries sometimes emphasize the use of drugs other than the opiates. Marihuana, for example, is used in London by West Indian groups and in certain clubs, as well as by some jazz musicians. However, no appreciable tendency has been noted in Britain to substitute heroin for marihuana. A similar situation exists in Jamaica and other parts of the Caribbean area where marihuana use is very widespread and heroin addiction rare. In Jamaica, in particular, marihuana cultivation and use, both of which are prohibited and heavily punished, have become an important part of a back-to-Africa protest movement promoted by an organization known as the Ras Tafari. It appears that only illegal drugs tend to acquire this kind of symbolic significance. Thus, while there is some morphine addiction in Jamaica, it seems to be completely unconnected with the Ras Tafari and marihuana and is regarded only as a minor medical problem."
The use of addicting drugs by young persons is a matter of especially serious concern. The evidence seems to indicate quite clearly that the situation most favorable for the spread of drug use among young persons is one in which addiction is dealt with as a criminal matter and one which includes a flourishing illicit traffic. It is in this situation that drugs become glamorous and attractive to youth, and these are also the conditions which seem to favor the creation of subcultures of drug users which, by recruitment of new members, tend to become self-perpetuating.
A common argument advanced against a program of the type under discussion is that, with the legal penalties removed, there would be fewer obstacles to becoming addicted and that those already addicted would have a free hand and an open invitation to spread the habit to others. What is overlooked in this argument is that everywhere in the world, availability of drugs for addicts through medical prescription is necessarily linked with nonavailability of drugs for other persons because of the relative absence of a black market. It is true, of course, that the habit tends to spread from users to nonusers but this probably occurs to a lesser extent in countries with medical programs because these programs keep addicts relatively separated from each other, thus giving them a chance to keep their habits secret. The profits of the illicit trade also probably play a part in promoting the spread of addiction.
LONGTERM ADVANTAGES OF A MEDICAL PROGRAM
From the discussions in other portions of this book and especially from the description of narcotics control programs in other parts of the world in chapters 6 and 7, most of the effects envisaged as long-run consequences of a medical program for addicts are fairly obvious. Some of the less obvious ones should perhaps be specifically stated.
One of the great difficulties in the United States today, as we have seen, relates to the lack of reliable information about our addicts. A medical program automatically generates more reliable statistical data than does a police program. In most European countries figures available from druggists and doctors tell most of the story of addiction, and police data contribute only a minor supplement.
Dealing with addicts by congregate methods in large and expensive public institutions has many obvious evil effects upon the inmates and tends to impede reform and rehabilitation. In addition such a program requires large outlays of public funds and creates a special bureaucracy of narcotics officials. The medical program envisaged here makes use of existing institutions and medical personel, avoids the evils of congregate treatment, does not necessitate the creation of a special narcotics bureaucracy, and costs little in the way of public funds. Under such a program some addicts, certainly many more than now, would be able to work and pay their own way; others might conceivably be covered by insurance for the costs of medical treatment of addiction; others could be subsidized by relatives and friends.
A medical program would reduce the crime problem in a variety of ways, the most obvious being that the user would not have to steal to pay fantastic illicit prices. This fact would in turn react upon the illicit traffic by reducing demand, prices, and profits. The argument that making drugs available to addicts stimulates the illicit traffic and that the clinics in this country around 1920 had this effect is patently false, as we have shown (chapter 5). As Lady Frankau's report from London suggests, a medical program can sometimes motivate the addicted criminal to abandon crime, and in general it makes it possible for an addict to abandon crime even though he may not abandon his habit. Another effect of a similar nature is that the non criminal who becomes addicted is not forced into crime. For example, if a nurse in a hospital is discovered to be an addict and is arrested and jailed for stealing narcotic supplies from the hospital. the most probable consequence is that she will become a prostitute and an associate of pimps, addicts, thieves, and drug peddlers if she does not commit suicide. Under a non punitive program she might be taken off drugs and put on duty in a situation where drugs were not accessible to her.
One of the most interesting therapeutic implications is in the effects upon the general availability of drugs and the repercussion this might have upon the chances of helping users to remain free after breaking their habits. We have already seen that Lady Frankau urged Canadian addicts in London not to seek out other users. Dr. O'Donnell, in a study made in Kentucky of former patients at the Public Health Service Hospital at Lexington, observed that many of those who were abstaining from drugs had moved away from the sources of illicit drugs into communities where there was no illicit market or where they did not "know the ropes." O'Donnell concludes that "This factor of unavailability may go far in explaining the high rate of abstinence in this group [relatively rural], in contrast to previous follow-up studies which were conducted in, or included, large metropolitan areas where the illegal narcotics market has never been completely abolished."18
It was long ago that a prominent police administrator, August Vollmer, said:
Drug addiction, like prostitution and like liquor, is not a police problem; it never has been and never can be solved by policemen. It is first and last a medical problem, and if there is a solution it will be discovered not by policemen, but by scientific and competently trained medical experts whose sole objective will be the reduction and possible eradication of this devastating appetite. There should be intelligent treatment of incurables in outpatient clinics, hospitalization of those not too far gone to respond to therapeutic measures, and application of the prophylactic principles which medicine applies to all scourges of mankind.19
Giving medical men in general the right to handle addicts would contribute to the end envisaged by Vollmer, making this particular scourge a subject of -inquiry and experimentation for many other, than a small number of medical men in the Public Health Service. The United States might, in this way, convert into a positive advantage the fact that she now has more heroin addicts than all of the nations of Europe combined.
It may be contended that one of the most important long-range effects and advantages of the medical treatment of addicts is that it is the decent, just, and humanitarian thing to do. Apart from the abstract ethical arguments suggested by this thought, there is the fact that people tend to support programs which they regard as just and fair and to admire their courts and the machinery of justice when they operate to produce real justice and when they seem to promote the basic human values of our society. Official cruelty and disregard for human values tend to lead to the opposite result. It has been argued, in support of severe penalties and the use of compulsion, that such devices have worked well with doctors who are addicts. When faced with the alternatives of staying off drugs or being deprived of their licenses to practice medicine, about ninety per cent are said to have remained free of drugs for five or more years. The others almost invariably committed suicide. Does this represent the kind of ethical values and attitudes toward human life which we wish our citizens to have? Is this suicide rate a fair price to pay for the result claimed?
Another consequence of handling the narcotic addict within the orbit of the doctor-patient relationship is the gain in privacy. Like the details of many other problems that people take to their family physicians, the details of addiction to narcotics are not pleasant. Under existing arrangements the circumstances of addiction are exploited by the tabloids and the addict never knows when the details of his habit and his personal life may appear on the front 'Pages of his community newspaper. With addiction a private matter between the doctor and his patient, the yellow journals would be deprived of raw material and the user would have a chance to keep knowledge of his addiction from becoming public.
CIVIL COMMITMENT OF ADDICTS
The idea of civil commitment of drug addicts is actually quite an old one, for many of the states have long had statutes on their books authorizing such commitment.20 These laws have been largely unused. One of the difficulties has been that when civil commitment proceedings are undertaken and the user discovers this fact, he can flee the community unless he is forcibly detained. Forcible detention, however, requires that he be charged with an offense, and this means criminal rather than civil procedure.
The new program which has become popular during the last few years avoids the difficulty noted with respect to the older and now defunct program by using the leverage of a criminal charge to keep the addict in custody before commitment. In the New York program under the Metcalf-Volker Act of 1962 the criminal charge is held over the addict's head to encourage him to cooperate in the civil commitment proceedings and the attempted rehabilitation under the direction of the Department of Mental Hygiene. If the addict proves unworthy and the rehabilitation program fails, he can then be brought back to criminal court and tried on the criminal charge. Under the California program adopted in 1961 and amended in 1963, the addict is first tried and convicted, and the civil commitment proceedings are then substituted. When the program fails, the user may then be returned to the criminal court for sentencing. The President's Advisory Commission recommended California procedure over that of New York in this respect, because of the difficulty under the New York plan of trying 2 case after the lapse of so much time.21
Civil commitment as currently conceived and recommended by the President's Ad Hoc Committee, as described at the White House Conference, and as recommended by the President's Advisory Commission on Narcotic and Drug Abuse in 1963, originates from police sources. The logic is - follows: addiction is a dangerous communicable disease; the addict should be "quarantined" to check the spread of the disease; if the addict relapses repeatedly after being taken off drugs he should be quarantined for long periods or for life. The Federal Bureau of Narcotics has long promoted this view and it is this fact which is the main basis for its claim that it favors a medical approach to addiction. In the Bureau's pamphlet on narcotic clinics, it has included in later editions a statement by a retired Canadian policeman who recommends that addicts who are certified as such by three doctors be committed to federally operated narcotics hospitals for a period of not less than ten years. If a user were twice committed it was suggested that he be sent to an institution for life, and that he be provided with a useful avocation "but permanently within the confines of the institution."22
The civil commitment program now being urged upon the states and recommended at the federal level does not in fact involve medical control or a real medical program, although it does use some of the vocabulary of the healing professions. The President's Advisory Commission, describing its federal scheme, specifies that "The crucial decisions would be made by the Judiciary and the Attorney General."23 In California, addicts who are civilly committed are sent to establishments which are operated by the Department of Corrections and which differ from prisons mainly in name. There is no real qualitative difference between the "rehabilitative" program imposed upon addicts and that imposed upon those who are being punished for the commission of crimes. From the addict's viewpoint, he is being punished because he is forcibly deprived of his liberty and suffers the social stigma of the criminal. On the assumption that addiction is a proper subject of medical care the civil commitment program would have to be characterized 'as a sham, or as a travesty of a real medical plan.
The worst features of the current civil commitment fad may well be connected with its pretense of being something other thanpunitive. Its current popularity is probably largely due to the fact that it seems to offer advantages to both the police and the medical philosophy of addiction. To the former it offers the continuation of the old practices of locking addicts up and of dodging the constitutional guarantees of the Bill of Rights which are built into the procedures of the criminal law. To the liberals and medically oriented it offers a gesture toward a new and more humanitarian approach and a hew vocabulary for old practices. For the addict the situation remains substantially unchanged even if he can qualify as one of the select few eligible for civil commitment, except that he may expect to spend more time in institutions. The price of illicit drugs and the illicit traffic are untouched by this program, and the addict must still commit crimes to maintain himself. He still lives in fear of the police and is still exploited by peddlers. If he seeks to quit his habit voluntarily the only establishments to which he has easy access are jails and their equivalents.
The threat of tyranny and injustice inherent in the rationale of compulsory civil commitment for drug addicts may be illustrated in a variety of ways. Suppose, for example, that we apply the same logic to alcoholics or to those with venereal disease, making them all subject to being locked up. California law applies compulsory civil commitment not only to actual heroin addicts. but also to those who "by reason of repeated use of narcotics or other restricted dangerous drugs are in imminent danger of becoming addicts." Compulsory commitment processes are appropriately applied only, when the person to be committed is shown to be dangerous or helpless and satisfactory evidence on this is presented in a court of law. Justice requires that each case be handled on an individual basis. The civil commitment program bypasses the whole concept of due process of law while pretending not to, by prejudging addicts as a group. This is accomplished by leaving unchanged present laws which automatically make virtually 211 addicts law violators It is not necessary to demonstrate, for example, that an individual user is a social threat of any kind, nor would it be a defense if an addict could prove in court to the satisfaction of a jury that he was neither helpless nor a menace. Suppose that a druggist who is an addict is discovered because he falsifies his book; to conceal the fact that he is diverting drugs to his own use. Civil commitment proceedings against this man would destroy his reputation and his usefulness to society just as effectively as criminal commitment. The civil commitment of addicts is another instance in which "treatment" may well turn out to be more punitive than "punishment."
The civil commitment program is customarily linked with a program of close parole supervision after release, sometimes associated with a nalline testing program. Nalline is a drug which indicates from the effects it produces whether the individual has recently had doses of opiates. Parolees who are required to take these tests are said to relapse less often and quickly than otherwise. With a cooperative addict there seems to be little doubt that nalline could be advantageously used for therapeutic ends. It is presently being used primarily for punitive ends, and sometimes it is part of local programs designed to chase addicts into other communities. Capt. T. T. Brown of the Oakland, California, Police Department, who is one of the staunchest champions of the nalline program, frankly says that "the rest is a boon to the community utilizing it and a bane to neighboring metropolitan centers for many addicts flee the area using nalline .... "24
The following remarks by C. S. Lewis seem peculiarly appropriate to the civil commitment scheme:
But do not let us be deceived by a name. To be taken without consent from my home and friends; to lose in liberty; to undergo all those assaults upon my personality which modem psychotherapy knows how to deliver; to be remade after some pattern of normality" hatched in a Viennese laboratory to which I never professed allegiance; to know that this process will never end until either my captors have succeeded or I have grown wise enough to cheat them with apparent success
Who cares whether this is called Punishment or not? That it includes most of the elements for which punishment is feared--shame, exile, bondage, and years eaten by the locust-is obvious.25
Those who hope for basic reform are sometimes inclined to regard the civil commitment bandwagon as the opening wedge of a movement toward more important changes. This view may be right. It may, on the other hand, have the opposite effect because it is often viewed as 2 non punitive, quasi-medical program. If it fails or accomplishes little, ideas like that of locking addicts up in concentration camps may gain ground.
A compulsory civil commitment program of the type now in force in New York and California, if it is linked with a long period of close parole supervision and possibly with a nalline testing program, is an expensive one. During periods of public excitement generated by the mass media there is likely to be greater willingness to spend public funds than during periods of quiescence. That is why it is very likely that some of the more elaborate programs now in use will be abandoned in the future and that others will degenerate, changing from high-minded, rehabilitative, well-staffed programs to routine, poorly staffed, custodial ones.26 Penologists are thoroughly accustomed to this degenerative process. No matter what arguments are presented from the humanitarian viewpoint concerning the ultimate social advantages of curing addicts of their habits, the fiscal facts are that addicts are relatively difficult and unresponsive and that money spent on them could be spent with greater justification, in terms of results, on others. As long as public funds are limited, this view will be an important one. A proliferation of programs for drug addicts also occurred after the First World War and almost all of them have vanished without a trace.
LIMITED TREATMENT PROGRAMS
In recent years there has been a considerable proliferation of various types of experimental treatment programs for addicts. Someof these are aimed at testing the feasibility of new ideas, as, for example, the selection of addicts to be placed on maintenance dosesto determine whether they would be able to work. Others ate aimed to reach addicts in prison to motivate them to stay off drugs or to help them when they are released by providing psychiatric and counseling services or helping to secure employment. There has been a considerable expansion of halfway houses which seek to ease the path of the addict as he tries to get used to living outside of prison. Others, handled by medical men or psychiatrists, have included management of the physical withdrawal of drugs followed by aftercare and the attempt to get at the emotional problems which are thought to underlie addiction.27
Despite the apparent abundance of these programs, they collectively reach only a small number of addicts and many of them are of a temporary nature, destined to vanish when the funds run out, when the initial enthusiasm disappears, or when the individual who is the center of inspiration for the program dies, moves away, or changes his interests. Most of these programs find themselves faced with heavy odds created by the present policy which inspires strong sentiments of fear, resentment, suspicion, and hopelessness in the users. Sometimes police interest in the users embarrasses these programs, and sometimes, if the program is managed by physicians who think they have the right to prescribe narcotics to addicts, the police may watch the establishment very closely with the idea of putting it out of business. The main objective of the bulk of these private, semiofficial, or experimental programs may fairly be described as seeking ways of counteracting evil effects created by the official program.
Two of the more permanent organizations of this nature are Narcotics Anonymous and Synanon. Both are self-help organizations in which addicts encourage each other to quit and stay off drugs. The former is modeled after Alcoholics Anonymous. The latter has also been influenced by A.A. but has developed a unique and highly interesting program of its own.28 Synanon's headquarters are in a large old building on the Santa Monica beach.
From there it has spread to a number of other localities and the number of members has increased appreciably but does not exceed more than a few hundred. Statistics of a reliable nature concerning the effectiveness of Synanon and Narcotics Anonymous are not available and very extravagant claims are made, especially for the former. Narcotics Anonymous groups exist in a number of prisons as well as outside.The Synanon program has attracted a great deal of attention from the mass media and a great deal of support, At the same time, it, like other similar groups of addicts, aroused determined opposition from Santa Monica citizens who tried to force it out of that community. It appears to he rather studiously ignored by the narcotics officialdom.
Synanon accepts addicts who volunteer and meet certain standards. The newcomer is attended by older members in relays during the first few days while he is breaking his habit. When this is done he finds himself drawn into an intense, organized program of activities which are planned both for his own good and for the good of the organization. Synanon houses both men and women and, in some instances, children, and its members represent all social classes and a wide variety of social types. Any visitor will find it a fascinating place and a beehive of purposeful activity. It is something in the nature of a cult and a way of life for its members. From the publicity that has been accorded it, Synanon is known to drug users throughout the United States and it is certainly a symbol of hope for many.
The existence and expansion of the Synanon movement represents a challenge to the prevailing conception of the drug addict as a psychological cripple, or as one who is masochistically happy in his vice and has no desire for anything but his drugs and a life of crime. It is also a challenge to the officially sponsored view that drug users respond only to authoritarian handling and will not of their own volition seek to break their habits. The latter belief is also belied by much other evidence including the fact that many thousands of drug users submit themselves for commitment to jail in order to get help to carry them through withdrawal.
A curious aspect of the reaction to Synanon has been the indifference and even hostility of narcotic officials both within the state and at the federal level." It is reported that the parole and probation of addicts was revoked when they entered Synanon and that a commission of six officials making a study in 1960 stopped briefly at Synanon but did not mention it in their report to Governor Brown. Although Synanon representatives went to the White House Conference, they were largely ignored there and also by the President's Advisory Commission. Perhaps the officials are resentful of the fact that the Synanon movement seems to be doing very well without them and that this program, operated by the addicts themselves, has caught on to a far greater extent than any that has been imposed upon the users by outsiders.
SOME OBJECTIONS ANSWERED
Many objections are made in this country to the type of program advocated here, which may be brushed aside with little discussion, because they are of a purely hypothetical sort or are made by persons who do not understand our narcotics problem and who are unacquainted with foreign programs. It is sometimes said, for example, that the proposed program might cause the underworld to make a systematic effort to create new addicts to replace those who would be removed from the illicit market. Sometimes it is argued that if there were no punishment more persons would want to become addicts. It is said that the program is in violation of our international agreements respecting narcotics. It is suggested that addicts might refuse to go to doctors and insist, instead, on buying high-priced, heavily diluted drugs from pushers. It is also arguedthat addicts who now commit crimes to raise money to buy drugs prefer this to a system which provides them with legal drugs and makes crime unnecessary for them. It is sometimes assumed that what is being advocated is free availability of drugs to all.
All of these arguments, and quite a few others, are refuted by the experience of dozens of foreign countries which practice the type of program in question. In none of them have the nefarious effects suggested above made their appearance. The nations that presently handle addiction as a medical problem are parties to the same international agreements. that we are. The assumption that the underworld might engage in a systematic campaign of proselytising new addicts indicates a complete lack of understanding of illicit operations and of how the drug habit is acquired. A similar lack of understanding is indicated by the idea that if addicts were not punished many people would at once set out deliberately to become addicted. The assumption that the program being considered here involves free availability of drugs to all is contradicted by all foreign experience and by logic and is an essentially frivolous objection. Availability by prescription makes narcotics relatively inaccessible; it is the illicit traffic that makes for indiscriminate availability.
There are many persons in the United States, some of them favorably disposed toward reform, who feel that the drug problem and cultural conditions in the United States are so unique that there is little or nothing to be gained from the study of foreign experience. From this point of view, it is contended that what is needed is an extensive research program to explore, first, the nature and extent of the present problem, and then the probable effects of any proposed changes.
The cry that "more research is needed" before anything can be done is a familiar, time-honored device used by those who are opposed to reform or who do not care to face issues. It is true that research is desirable; but it will not necessarily provide answers to policy questions. Research results are always subject to variable interpretations and to misrepresentation. If reform is to wait until research has made it certain what all the consequences of given changes will be, it will wait forever. Moreover, on many relevant issues no research is needed. We do not need it, for example, to demonstrate that our present narcotics laws are unjust and ineffective, that successful medical programs for handling addicts exist abroad, or that jails are not ideally suited for the treatment of disease.
On the matter of the absolute uniqueness of the American narcotics situation, the burden of proof would seem to rest on those who assume this view. It too is a last ditch defense of the status quo. The medical system of handling addicts is used in virtually all of the countries that resemble us most closely and from which our people, our language, our customs, our legal and social institutions are derived. The behavior of addicts, moreover, is remarkably the same everywhere in the world and very highly predictable in the sense that one can assert with confidence that addicts everywhere will do whatever they must to obtain their supplies.
An argument that is as baffling as any is that providing addicts with drugs is immoral and wrong and should be prohibited by the criminal law. From this point of view a medical program for addicts is "legalization" and this in turn means social approval of addiction. It is argued by some adherents of this view that since addiction is an admitted evil it must be forbidden by the criminal law even if this should in turn lead to even greater evils, as it does. There should be, in short, no compromise with the Devil. An argument of this sort is essentially absolutistic and unanswerable. The only remedy that suggests itself is that persons holding these views should become personally acquainted with some drug users.
Legalization, it should be unnecessary to say, does not mean approval. Alcoholism and venereal disease are both legal, for example. The threat in this kind of moralistic thinking is that it opens the door to comstockery and prohibitionism of the kind that gave us the Volstead Act. If heroin users are criminals, why not declare that the use of alcohol and tobacco are 21SO sinful practices to be forbidden by the law and stamped out by the police'The program of reform suggested here is a gradual one which would aim at increasing progressively the number of addicts receiving legitimate medical care from practitioners. Since some users are already being taken care of in this way the proposals amount merely to an extension of what is already being successfully done on a limited scale. This program could be put into effect by a gradual and progressive liberalization of present restrictions upon medical men. It is anticipated and assumed that close supervision and control would be exercised over the entire program by the Public Health Service in collaboration with the medical profession. It is suggested that doctors would be authorized to handle addicts only when they were qualified and willing to do so. It would be essential that hospital facilities be made available throughout the nation to handle addicts during the withdrawal period.
A program such as this, in its initial stages, would involve little public expense, since it would first be applied mainly to drug users with sufficient means to pay their own way. Hospitalization for withdrawal should be included in the scope of medical insurance programs and handled like any other hospitalization. Ultimately, some special provision at public expense might be deemed desirable for the most hopelessly demoralized users who could not be reached by the above means. The narcotics dispensary-clinic offers one possibility, compulsory institutionalization another.
The essential, basic idea of the entire program would be to use the leverage which the drug habit provides to prevent addicts from violating the law. Drug users would be given a fighting chance to be law-abiding persons even though they were addicts. Through the physicians caring for them pressure would be exerted upon them to reduce and control their dosage and to attempt to quit. This pressure ought to be nicely balanced so that it encourages the addict to quit without causing him to resort to desperate or illegal means of acquiring drugs, The addict purchasing illicit drugs would be subject to prosecution and punishment just as he would if he violated any other criminal law. The work of the police would have to do, as it does now, with the apprehension of illicit drug smugglers, dealers, and distributors and with addicts who persisted in patronizing this market. The effects of such police activity upon addicts would be to exert pressure upon them to resort to the physician f or supplies and treatment. The drug user, in short, would have strong positive motives for going along with this program and he would suffer inconvenience, discomfort, and punishment if he did not.It is sometimes contended that heroin addiction is the product of disorganization, tension, and alienation, particularly as manifested in the city slum, and that it is visionary to suppose that these conditions can be corrected by anything but fundamental social change. The error in this argument is the failure to recognize that availability of drugs is a sine qua non for the existence of drug addiction. European cities, like those of the United States, also have their slums. The drab, urban wastelands of Chicago and New York can be matched by those of London, Liverpool, Glasgow, and other British cities. The critical difference between British and American slums is that the latter contain an extensive illicit drug traffic while the former do not.
While it would be desirable that the Harrison Act be repealed and a fresh legal start made, this is not absolutely necessary. The proposal to permit physicians to handle addiction is not in conflict with present federal statutes or with present doctrines of the federal courts. It is in conflict only with the administrative regulations of the Treasury Department, which could be changed without any new congressional legislation, particularly since they now appear to be in conflict with Supreme Court interpretations of the Harrison Act.
While the public may not at present be prepared to demand reform, it is also unlikely that there would be any important popular outcry against the reforms suggested. While there is 2 general public concern over addiction and strong popular support for heavy penalties, it is also true that the public has become accustomed to regarding narcotics abuse, along with alcohol and barbiturate addiction, as something akin to disease. The heavy penalties provided by present laws are viewed as appropriate for the peddler rather than the addict. A program which quietly began to place larger and larger numbers of addicts under the care of doctors would therefore probably meet with little public disapproval, for there is much greater public confidence in the medical profession than there is in the police, lawyers, and prosecutors who are now in charge.
The program that is being advocated here is not British. It is rather a proposed expansion of an unofficial medical program thatis presently being applied in the United States to privileged addicts of the upper social strata. What is advocated is that the same consideration that is extended to an addicted society lady from Washington, to an addicted member of Congress, or to addicted members of the medical profession also be extended to drug users of humble social status who have no important connections. It is a plan for giving all addicts genuine equality before the law. It is consistent with our basic ideals of justice, of individual rights, of the proper treatment of the sick, and of the right to be judged as an individual rather than as a member of a category. It is a program toward which the United States is moving and for which there is no substitute.
introduction 1 2 3 4 5 6 7 8 9 10
Notesi. This apparently cannot now be done legally except through the use of the criminal sanction; it is a serious obstacle to an effective voluntary program because the addict characteristically changes his mind before withdrawal is complete.z. A powerful statement on this point is found in Isidor Chein, Donald L. Gerard, Robert S. Lee, and Eva Rosenfeld, The Road to H: Narcotics, Delinquency, and Social Policy (New York: Basic Books, 1964), PP. 323-343- Committee on Public Health, New York Academy of Medicine, "Report on Drug Addiction Il." The Academy's first r~port appeared in Bulletin of the New York Academy of Medicine, 31, 2nd series, No. 8 (Aug., 1955), 592-607. In the 1963 report (P- 70) the Academy suggested that the Federal Bureau of Narcotics "gracefully bow out of the practice of medicine" by removing the "unwarranted restriction" on medical practitioners contained in section 151-392 of Regulations No. 5