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Second Opinion:
War on Drugs
Hosted by Abigail Trafford
Washington Post columnist
Tuesday, April 10, 2001; 2 p.m. EDT

Welcome to Second Opinion, a weekly column and Live Online discussion with Post Health columnist Abigail Trafford.

Did you see the movie "Traffic?" It's about the different parts of the drug-trafficking world from cartels in Mexico to the living rooms of middle America? To go to the movie is to get an education on how complex the problem is--and how the nation's war on drugs has failed. The debate is heating up in Washington to find more effective approaches to reduce the toll of drugs and devastation of addiction. In the last decade, medical researchers have made gains in designing prevention and treatment programs.

To discuss the treatment side of the war on drugs is Alan Leshner of National Institute on Drug Abuse discuss the treatment side of the war on drugs.

Submit your questions in advance or during the hour.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

Abigail Trafford: Hello everybody! Ever wondered about how the country is doing on the war on drugs? Ever worried about a friend or family member who's addicted to drugs? to Alcohol? to cigarettes? Now's your chance to ask the expert. Send your questions and comments.

Abigail Trafford: Dr. Leshner, welcome. What did you think of the movie "Traffic?"

Alan Leshner: I particularly liked the movie Traffic because it did an excellent job conveying just how complex this issue is. A simple "supply side" approach won't work, but we do need to also increase emphasis on controlling demand -- the prevention and treatment side of the issue. Traffic really did show how difficult and complex this issue is and raise the level of the discussion.

Abigail Trafford: Tell us about the Prism awards. What are they?

Alan Leshner: My Institute, NIDA, gives out this award every year (this is the 5th year) in partnership with the Entertainment Industries Council and the Robert wood Johnson Foundation to recognize accurate depiction of substance abuse and addiction. we give awards in about 20 categorie. The idea is to reward good behavior and encourage those doing such good depictions to do more!

Abigail Trafford: How important are films and television shows and books in educating people about substances of abuse? Give us some examples--good and bad.

Alan Leshner: The entertainment industry is, after all, the most extensive and high impact educational system in this country. So it is particularly important to have them "educate" accurately. And not all shows and books do that. some of the excellent ones include "The Corner" which was both a very graphic book and a graphic TV special miniseries as well. Inaccurate might be an example like "Pulp Fiction" where someone was, in effect brought back to life when it couldn't have been done.

Alexandria, VA: Like alcohol users, users of other drugs run the gamut from occasional to addicted. While treatment seems appropriate for the compulsive and addicted user, what is the sense in either treating or incarcerating adults who are not addicted? Shouldn't they be allowed to use lawfully and serve as role models for responsible use?

Abigail Trafford: But can a person use drugs such as cocaine and heroin "responsibly?" Dr. Leshner?

Alan Leshner: The great danger in occasional use, beside the obvious short-term effects of intoxication and interfering with virtually every cognitive/thought function, is that no one knows when they are about to "go over the ledge" into addiciton. My own view is that there is no such thing as "recreational drug use". It isn't like playing tennis or ping pong. The short and long-term dangers are too great and 6the consequences virtually always go beyond just the individual user -- to his or her family, work place, etc.

Abigail Trafford: In a perfect world, what would you like to see happen on the treatment and prevention side? What kinds of programs are needed? How much money would it take to design and implement a really effective strategy?

Alan Leshner: There are no simple solutions on any side. The programs that work are almost always much more complex than simple solutions. But, we do have any extensive science base to inform the development of good programs....we have summarized the science based principles of both prevention and treatment, and those princple can be found easily on our website...www.drugabuse.gov

Abigail Trafford: Some basic questions: how many Americans are addicted to illegal drugs? How many are addicted to alcohol? Smoking? What are the features that are common to addiction of all these types of substances?

Alan Leshner: Two issues are interesting here. first, we believe there are about 5 million "hard core" heroir, cocaine, methampheatmine addicts, and many many more addicted to alcohol and nicotine. It's interesting that of those who ever used asubstacne, the highest percentage going on to addiciton is to nicotine (33% of those who ever tried) vs. 16% for heroin and cocaine, 12-13% for marjiuana, 14% for alcohol.

Abigail Trafford: What's the definition of "recovery" from addiction? Is once an addict, always an addict? What does it take to "overcome" an addiction. The daughter of the drug czar in "Traffic" got herself addicted and then got into treatment. Is her case typical?

Alan Leshner: addiction must be seen as a chronic relapsing illness...which, sadly, it is for most people. Therefore what we see is a) management of the illness over time, with b) longer intervals between relapses after successive treatment episodes.

Actually, few people enter treatment voluntarily. People say that people enter treatment only because they are "court-mandated" or "mommymandated". and, of course, we now know you don't have to want to treatment initially in order for it to work. In fact, pressure adds to treatment effectiveness.

Abigail Trafford: Let's go back to recreational drug use. If people can drink alcohol and not get addicted, why can't they smoke pot or do a little bit of cocaine and heroin and not get addicted? Is the daughter in Traffic typical of someone who experiments and then gets hooked? Or is she in the minority?

Alan Leshner: Of course there are great differences among people in how susceiptible they are to becoming addicted and that has a large genetic component. So it's impossible to predict how "addictable" one is...so, my view againg is that it's extremely dangerous to even "experiment". you may be a highly vulnerable person and you have no way to know that.

Reston, VA: Why do we try to lock up people like Darryl Strawberry--people who aren't criminals but are very sick? It's obvious that prisons don't rehabilitate these type of people and does it make sense to house them with criminals who have committed heionous crimes against others. Recent article in Newsweek (I think) discussed the impact of drugs on the brain chemistry and how difficult it is for an addict to handle that craving. If we have drugs to treat depression, why haven't we come up with drugs to treat addiction, which seems to be a far larger problem? Is it because of who really is making the money in the drug industry?

Alan Leshner: My expertise is on the health side, not the criminal justice side. But I can say I am encouraged that we are more and more seeing a blending of approaches where more and more people are advocating treatment addicted criminal offenders while they are under criminal justice control. And it works.

The issue of medications for addiction has been a difficult one. My Institute devotes almost $100 million a year searching for anti-addiction medicines of many different types. And we brought the patch and gum for nicotine, an anti-opiate called LAAM, and a new one called burprenorphine. But it has been very difficult to find medications with a really strong "signal" or effect. Moreover, many pharmaceutical companies think there isn't a big market, so they're not interested. But mroe and more, as the science gets better, we are developing good collaborations. we now have about 60 medications in trials for cocaine addiciton, and are very hopeful about three or four.

Pittsburgh, PA: Do you anticipate the opening of additional methadone clinics in the coming future?

Abigail Trafford: And tell us what methadone clinics offer and who would benefit from expanded services?

Alan Leshner: There have been literally dozens of studies demonstrating the effectiveness of methadone as a treatment for heroin addiction. And many matheadone clinicas are doing a superb job. But those that do the best are those that include other treatment components, like intensive counselling, and can refer to or provide other services (medical, dental, housing, legal support, family therapy, work training). These are the best..they do "whole person treatment".

Victorville, CA: Good morning.

Here in California, the movie industry has been giving away those cocaine mirrors with each movie ticket purchased for the film, "Blow."

They have met with heavy criticism; yet, they continue to do it. They say their movie does not promote or glorify drugs. Having never seen it, I am not sure if that is true.

But certainly, those mirrors promote drugs. Why would an industry do such a thing? Is there a legal way to stop this promotion?
(I'm astounded even with the heavy criticism, they haven't ceased their promotion.)

Thank you.

Alan Leshner: I haven't seen "Blow" yet but I udnerstand it's very graphic. We of course don't want anyone doing anything that will glorify drug use in any way or promote it.

washington, dc: Since the War on Drugs is a tremendous failure, shouldn't our nation consider other models such as regulation and education. Obviously the "War" approach is ineffective and prohibition actually increases the availability and thus use of drugs amongst our children. Do you not agree that it is time for a more humane and progressive approach to this dilemma?

Alan Leshner: My problem with the war metaphor is that it never really was waged in all its complexity. It became distorted. Think about the War on Cancer, The notion is to apply pressure from all sides in all ways...sadly we haven't done that well with addiction. It became the war on drugs or drug users, not on addiciton. I suggest we get rid of all simplistic metaphors. After all, we don't have a war on education....

As to stratgeis, I fovar a compreheansive approach that focuses on both supply and demand. If we don't limit supply, availability will go up and so will use.

Columbus, Ohio: What is managed health care?

Abigail Trafford: Managed care is the label used to describe health plans that closely monitor and in some plans determine the kind of care you can receive as a beneficiary. One type of managed care is the health maintenance organization that has its own staff of physicians and other health professionals. Other plans review treatment options are state in the policy what they will and will not cover. Most people with private insurance are in some sort of managed care plan. Now, Dr. Leshner, how has the trend towards managed care affected treatment for addiction? Is substance abuse covered in most health plans?

Alan Leshner: Managed health care is providing a whole package of services through or organized by a single set of providers. And the provider often gets paid on a per patient basis, not on the basis of servies delivered per se. In addiction, for a long time, reimbursement was extremely weak and therefore the managed care companies were not providing full treatment services. But the trend now, as more people understand that there is a science base to good treatment, is toward nmore comprehensive treatment, ev en through managed care companies. and the Federal coverage plans now reuiqre full treatment coverage.

Abigail Trafford: What constitutes effective treatment for addiction?

Alan Leshner: We define effective or successful treatment as "restoring the person to full functioning in the family, workplace, community", not just reducing drug use. We know that focusing only on drug use won't do it. and of course we know addiciton often includes relapses so we want to increase the intervals between relapses as they occur.

Baltimore, Maryland: Dear Alan,

What is the effect of co-dependency in relationships on addiction? Several years ago, my mother fled a marriage to an alcoholic.

He would go through months of drinking, which would generally end with violence upon my mother--dragging her out of bed by her hair, raping her, beating her, you name it.

She would leave for a while--he would get sober, "get help." She'd got back, and the whole thing would start again. (Yes, the poor woman has issues).

I wonder if recovery programs can help people revamp/relearn proper social skill? I used to work in Native American Indian affairs, and ran into many recovered addicts that talked about sometimes reverting to "dry drunk" behavior.

There definitely seems to be something to it. My mother's boyfriend of the past three years is a recovered alcoholic/cocaine addict--but still behaves like one. Instead of running off to bars--its cofee houses.
Incoherent drunken harranges are replaced with nasty AA-inspired speak. (He feels she makes him victim because her three jobs--at age 59--keep her spending enough time with him).

Any thoughts?

Alan Leshner: My view is that people can be restored to full, productive funcitoning in all spheres. But they need help in all those spheres. and the truth is that mean people are still mean, addicted or not, and not all addicts get mean...so perhaps it's about the choice of people, not just their addictions.

And family and couples thereapy as a part of treatment can be extremely useful in dealing with some of the issues you mention.

Golden Valley, MN: Isn't marijuana considerably different than methamphetamine or heroin? I've heard you can get addicted to heroin the first time you use it, but I find it hard to believe that occasional use of marijuana constitutes addiction.

Alan Leshner: It's actually not true that you get addicted to heroin the first time you use it...or very very few people do. Addiction occurs over time. and marijuana is quite addicting for some poeple, although of course not everyone who tries it becomes addicted. In fact, about 12% of those who ever try marijuana go on to addiciton, whereas with heroin, it's more like 16%.

DC: It is always politics. Liberals prefer treatment and conservative prefer law enforcement. How would you solve? Let people who use drugs [die]or prevent it?

Abigail Trafford: What's the common ground here for treatment and prevention? What can people of all political stripes agree on. My sense is that there is more bipartisan agreement in Congress on treatment and prevention issues that people would think. Your thoughts, Dr. Leshner?

Alan Leshner: I see more and more poeple adopting a comprehesnvie view of what we need to do. Simple trying to force a choice between supply control and prevention and treatment is the wrong approach....the answer is "all of the above". And more and more people in policymaking roles seem to recognize the importance of multi-element stratgies. There is great support now for prevention and treatment on both sides of the political aisle.

Fairfax, VA: With all due respect, supply side control has failed and will never be successful. Legalization of all drugs is the only way to drag ourselves out of the morass that we are currently in. Through legalization there will be accurate information and control on use through accurate information. See the ending crack epidemic and injected speed. Both of those drug epidemics wound down as a result of real information, not inaccurate propoganda, spreading through the drug using community.
Furthermore, legalization would end the tragic effects of our addictions on foreign countries such as Columbia (see NYTimes article today on upper class flight) and Afghanistan. Especially after having seen Traffic, how can you defend supply side efforts?

Abigail Trafford: I agree that the supply side of the war on drugs has not been the success its advocates would like. Traffic makes that point pretty well. There's a lot of debate about legalization and decriminalization and regulation. And it's important to get a public dialog on these issues. But our guest today is the guy on the demand side of the war, which needs a lot of attention, too. As a director at NIH, he can't really talk about the supply side. Certainly the supply of drugs is important. One question for your Dr. Leshner: what do studies show about how the availability of drugs affects usage?

Alan Leshner: The simplest answer here is that availability drives use rates...so I'm against anything that implies we should make drugs more easily available. And from a public health point of view, why would we do anything that could be contrued as encouraging use of dangerous substances?...and all these abusalbe drugs are dangerous,

Washington, DC: Why is this war on drugs often such a war on states of mind? It's OK to drink alcohol or smoke cigarettes as long as you don't hurt others with DUI, but the government says that absolutely any marijuana use, for example, is totally criminal. Treatment is better than prisons, yes. But is it right for the government to rule on how we think about drug use in general? Is all use abuse?

Alan Leshner: we touched on this before, but, again, the war metaphor is too simplistic...and this is not the kind of issue we win or lose a war about. Again, I'm against anything that encourages use.

Washington, DC: As a scientist, don't you feel it is wrong when the anti-drug organizations make blatently incorrect, borderline-lie, statements such as "Most people who use heroin started out using Marijuana". Isn't it true that most people who use heroin have taken tylenol in the past? So should we outlaw Tylenol?

Abigail Trafford: You've pushed a hot button! I've heard those statements too. Most people who use heroin started out smoking as teenagers. Scientists and health officials are looking for those "gateway" drugs and experiences that lead to trouble later on. But it's also true that most people who experiment with cigarettes as teenagers do NOT go on to heroin. Dr. Leshner, how can we sort through all this? Certainly we're not going to ban Tylenol.

Alan Leshner: This is one of those issues where the situation is of course more complicated that simple words like "gateway" can explain. It's true that relatively few poeple who smoked marijuana or tobacco or drank alcohol go on to cocaine and heroin. But on the other side, the very great majority of people who do use cocaine and heroin started out with marijuana, tobacco, acohol. And if you don't use these by time you are 20, the odds are almost zero will will devlope and addiciton, so it's not a linear effect but something is happening there.

DC: I in no way consider the use of illegal drugs harmless. However, I believe that unless law makers are willing to consider banning alcohol, there will always be a glaring hypocrisy the size of the grand canyon staring right back in the face of America. Alcohol is a drug; it alters your mood, impairs your motor skills, and is highly addictive. Alcohol has killed more people (via addiction and DUI's) and broken up more families than all other illegal drugs combined. We arrest drug dealers, yet glorify alcohol use. Athletic stadiums around the country are named after alcohol manufacturers, yet we throw the book at pot users. I have a friend who worked for several prominent politicians. He told me that on the very same day politicians passed stricter and harsher laws on illegal drug use, politicians and staff members would get loaded on alcohol at cocktail parties that night. Could you give me your thoughts?

Alan Leshner: There's a great difference between taking something away and doing something to ecnourage its use. a) alcohol clearly is a drug. b) when we tried prohibition, although there were many other societal consequences, use rates did go down. so controlling legality or supply does affect use.

I take a long view that says if we knew 5000 years ago that aochol would cause 130,000 premature deaths a year or 500 years ago that tobacco would cause 400,000 premature deaths a year, we never would have made them legal. as with all other drug issues this one needs to be seen in the contexts of the current time.

Fairfax, VA: Dr. Leshner,

Having worked with a federal interagency task force related to drugs, I must tell you that I snorted with laughter while watching "Traffic": In the scene on the plane in which the drug czar asks "Who here is from treatment?" and the response is "We don't have anyone from treatment." In the group I worked with, there was a lot of negative feelings and sniping between the public health and criminal justice sides of the equation, with HHS folk upset at the focus on supply side by DOJ and ONDCP.

To what extent does politics, rather than science, come into play in how this country deals with addiction? How are we to contain this problem if everyone is too busy watching out for their own backs to think about the people in actual need.

Alan Leshner: from my own experience we are making progress in blending public health and public safety approaches. I give as many talks about the health aspects of addiciton and treatment to criminal justice types as I do to health types. I see the national discourse as beginning to change. I just hope that continues and that we can develop appropirate blkended stratgies fast enough to make this opporutnity a successful natural experiment.

Reston, Va: Do you think we can use the alcohol prohibiton of the 1930s as an example of the failure of today's war on drugs and how to get out of it?

Alan Leshner: I answered something like this before...so just to repeat, prohibition did decrease alcohol use...the problem was all the collateral damage. I'm the demand guy, so I'm most concerned about what keeps use rates down.

Reston, 20190: As a long time member of AA (I did some drugs, too...) I have an opinion on the "recreational/social user" stuff.

I have seen many social drinkers. They have one drink, feel little or no psychological effect, and are fine for the night. I've never seen someone take one hit off of a joint and, when it comes around again, say "No thanks, I'm fine". That's the difference between alcohol and drugs.

Abigail Trafford: Dr. Leshner--is this a good distinction between drugs on alcohol? What about the physciological/genetic makeup of the drinker/user--isn't that also a factor in the rectreational user verses addict question?

Alan Leshner: In virtually all ways alcohol qualifies as a drug. The same proportion of people who ever try alcohol go on to addiciton as to other drugs, with little variation. and there are great differences (caused by both genetic and environmental factors) in susceiptibility to addiciton, so for many people any experimentation is very risky.

Reston, VA: I am a sophmore in high school and I am currently doing a comparative government project. Can you tell me any websites, phone numbers, or places where I can get information on drugs in the United States and even more importantly from other parts of the world such as Europe. Additionally, I have to interview someone on the topic of drugs. Who is a person that you might know that can do this interview or where can I find someone to interview?

Thanks

Alan Leshner: I recommend our web site, which is www.drugabuse.gov

I'm not sure the best way to find someone to inerview, but you might start wiht your local police departemnt or a local treatment program.

Washington DC: My husband is an addict, as are/were his parents and others in his extended (maternal side) family. I have children and am terrified of the implications of this family history. Has research been done on this aspect of addiction?

Alan Leshner: There is no quesiton that geenetics plays a large role and that both alcohol and drug problems tend to run in families. Some is pure genetics, some is the effect of growing up in a drug using household. I recommend being alert, but not panicked.....

Reston, Va: Do you believe in adopting a more lenient drug policy which is similar to policies in Eurpope such as the Netherlands, in America?

Abigail Trafford: And how well is addiction treated in Europe? Do those countries have different treatment and prevention philosophies compared to the U.S.?

Alan Leshner: no country has legalized drugs although there is great variation in policy approaches. Since I'm a health expert, not a supply side expert, I need to stick to issues I am more expert on, and don't really know enough about the policies you refer to.

Baltimore, Maryland: I realize that jerks remain that way, whether addicted or not. However, my mother's husband may or may not have been such a human aberration if he hadn't gotten addicted to alcohol.

Perhaps recovery should be viewed as a process for the entire family? For the addict to get better, he/she certaintly cannot have someone around condoning his/her behavior--or allowing him/her to backslide.

I assume there is no such thing as "just a few drinks" or "just a few lines" when it comes to addicts.

Abigail Trafford: You raise so many good points. Recovery is a process for the whole family. Dr. Leshner what is the abuser/enabler dynamic that we hear so much about? How does the enabler have to change as well as the abuser? Are there treatment facilities for the whole family? And finally the question: Can an alcoholic or an addict ever drink/use again?

Alan Leshner: One lesson we have learned from research on treatment is that to resotre someone to full funcitoning we very frequently need to include the whole family in the treatment activities. family therapy is often a very necessary part, both to prebent enabling and to restore confidence the patient can be restored to membership in the family.

Abigail Trafford: A followup to that: how do you know if you are getting addicted? How do you know you are slipping over the edge from using to abusing?

Alan Leshner: Sadly we dont know much about the literal transition point between volutnary use and compulsive use or addiction....we only seem to know once when threshold has been passed or the person has "gove over the edge". But we d see early signs of problems coming and if we can get people when they're first having trouble controlling use we have a much better chanmce of success in treatment.

Washington, DC: What does 'treatment' really mean? How do we avoid a treatment bureaucrasy filled with hypocrisy and waste, especially when the leading treatment method is based on a 12-step AA approacho whose tenets include the famous 'decision to turn our will and our lives over to the care of God as we understood him.' (step 3). Where are the other treatment methods that are more scientific and not quasi-religious? I, personally, don't want god in my 'forced' medical treatment.

Abigail Trafford: How does someone get help outside the 12-step model that involves a "higher power" or God? And at the same time, it seems that there is a spiritual dimension to recovery. Your thoughts, Dr. Leshner?

Alan Leshner: First of all, self-help groups are adjuncts to treatment -- and extremely useful ones -- not a substitute. And spirituality has been an important part of treatment for many many people, so it clearly has a role. But there are many different treatment approaches...some focus more or less on different pieces of the issue...what we need to do is do a much better job of matching people to treatment approaches that will work for them. for example, some people dov ery well with high levels of confrontation, others hate confrontation...the same is true for spiritual components...

Abigail Trafford: We now think of addiction as a brain disease. What has research shown about what happens in the brain when someone gets addicted? And what is the most addicting substance of all?

Alan Leshner: Two decades of scientific resrach has shown that repeated drug use changes the brain in long-lasting ways that last long after the individual has stopped using drugs. And we believe that is what makes addiction a brain disease. It's also why it's so hard to stop.

we don't have ways to know which substance is most addicting...it varies by person and route of administration. So for some people one particular drug is most dangerous, for others a different one. Some has to do with genetics, some with circumstances surrounding initial drug use...

Abigail Trafford: Our time is up. Sorry we couldn't get to all your questions. We'll talk about these issues again.

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