O'Brien - First of all, there absolutely is not enough treatment. That is one of the reasons why I agreed to come over here, because I say it every time I can. I recently had a meeting with George Bush, and I told him that it's ridiculous for us to talk about a war on drugs because there's actually less treatment available today than there was 15 years ago.
Q. - How many people need to be treated here compared to the number of spaces you have?
O'Brien - Well, the large program that I run is for veterans, and it's well staffed. Any veteran in the Delaware Valley that has a drug problem comes to us, and we get 15 to 17 new patients a day. They come in with desperate stories, and we want to help them, but we're already filled.
Schandler - Our program, which deals with the lower end of the socio- economic scale - the poor, the near-poor - is fairly large. Even our non- hospital detox, which can accommodate 21 women and about 45 men, will have a waiting list of two to three weeks. That's absurd.
This business of treatment on demand is sheer nonsense if there is no ability to absorb those people who knock on the door. In dealing with the cocaine addict, when they look for treatment there's a point of readiness, and if you lose them then, they don't have too many options - other than go back on the street. We can't refer to any other agency in town, because they're all going through the same situation.
Q. - There seems to be a perception that, even if you had treatment on demand, a lot of these people will be back on drugs within a few weeks or months, and we'd essentially be wasting a lot of money. How do you respond?
Schandler - I don't think you have any real choice. To ignore it doesn't make the situation any better. It doesn't make me too much happier to find out that Bell Telephone, with their very sophisticated employees' assistance program, talks about a 50 percent success rate with people who are diagnosed primarily as alcoholic, and less than 20 percent with the cocaine addict. And that's people who are employed, with families - all the pluses that are supposed to help.
Part of it is that cocaine is relatively new to the treatment community. Everybody's learning to deal with this new kind of cat who's coming through the door. They're different. They're a pain in the ass to work with. When they come off of detox, they tend to be younger, brighter, aggressive, arrogant as hell, a lot of bravado.
Where we have had success - and we've had beaucoup failures - is where we've had control on a 24-hour-a-day basis, seven days a week, for four to six months. Where there's been enough time to take a look at a whole lifestyle.
But a four- to six-month program isn't cheap. It takes time to set 'em up, they're expensive to run, and funding agencies want quick and magic cures. There isn't a quick and magic cure.
Q. - Where do the people in residential treatment go?
Schandler - We have three residential facilities where people live under 24-hour-a-day supervision - one for single men, one for women without children, one for women with young children, which is relatively new.
That appears to be working in terms of "a success rate." It means they leave with a job, drug-free, and a place to live, and to the extent that we can do any kind of followup, we're running about a 40 to 50 percent success rate after six months.
Our outpatient facility has become kind of a revolving door, because we can therapize the living hell out of them, but they're still going back to a setting where the social contagion is so great, it's awfully tough to not succumb.
O'Brien - There are really two kinds of treatment needed. The first is the acute emergency treatment where the patient becomes psychotic, violent, suicidal. These patients are overrunning our emergency rooms. Some emergency rooms have just closed their doors and won't let any more in.
After the person has had treatment for this acute emergency, and they come down from that, they often are interested in getting the second kind needed for the basic underlying problem, and that's where we have zero slots available right now throughout the city, for treating the underlying addiction.
How good are we at treating them? Addiction is a chronic disease, and you can induce remissions. You can get people back to work, leading a normal life. Some of our cocaine patients have a better long-term prognosis than the heroin addict or alcoholic. The prognosis depends on what they accomplished before they became addicts. A person starts using drugs at age 12 or 14, they never finish school and never hold a job, they are socially ill as well as being addicted, then don't come for treatment until they are about 25 years old - you can return them to their previous level of functioning, but they weren't functioning then anyway, so the prognosis is very bad.
But we're seeing a lot of people with cocaine simply because it is so addicting, in their 30s and 40s. (They've) already finished school, held jobs. As a matter of fact, in our program 75 to 80 percent of our people were employed during the month in which they came in.
People stop and start drugs all the time. It's the restarting, the relapse that you want to deal with.
Right now, we randomly assign people to inpatient or outpatient treatment for cocaine. The patients assigned to the inpatient program had about an 89 percent chance of completing the treatment. Those who get to the outpatient program have only about 35 to 40 percent chance.
Three months later when you follow them up, they're both doing equally well. The cocaine use is about 10 to 20 percent of what it was before they came into the hospital. Does that mean they're clean? No. Most of them have gone back to some use of cocaine; it's very rare that they just become abstinent. Still, they're much better off than they were before treatment
because most of them are back at work.
A patient who's in treatment will be better off if instead of using cocaine five times a week he's using it once a week or once every two weeks. We're not shooting for that as a goal, but I'm being honest with you, this is what's happening and the goal is to eventually get them down to zero. I can't tell what the percentage of cases that we get that.
Q. - Is there anything unique about treating cocaine addicts?
O'Brien - We know pretty much how heroin works and we know how to block its effects, so we know how to treat the withdrawal. You have to combine the psychological and the pharmacological, and we don't have a pharmacological assistance yet for cocaine. So we're treating cocaine now largely as any other addiction, once they get over the acute phase of it, and we think that we can improve our results if we can find the right drug.
Q. - Is there enough research?
O'Brien - Nationally, this has been a neglected area. There aren't enough people in the field doing this kind of research, and they're trying to start it up real fast. People are criticizing Bush's program for not giving enough money to research, but there's only so much money that the research community can use at the moment. There needs to be more people trained.
Schandler - We have a lot of catching up to do. Not too many years ago, government publications dealing with drugs indicated that cocaine was not addictive.
Q. - I'm learning a number of things from this conversation. One is that there's a difference between middle-class and underclass cocaine addicts. I think most of our readers are concerned about the underclass addict, the person who is out there robbing, or the addicted mother having crack-addicted children in the hospital and then abandoning them. Is there an agreement on the best way to deal with this population?
Schandler - Without sounding like the young Great Society all over again? Coming into our program are people who for the most part are poor, functionally illiterate, don't have job experience, single parents - if there is a parent on the scene. Their heroes are the guys on the corner with the gold and the girls and the cars, who take an attitude of "What the hell?"
All right, so how do you turn that around? I'm not sure. Except that if you don't turn it around, you're going to continue to see this thing spread
because there aren't many options open. You've got a cultural setting that is absolutely ripe for some kind of escape.
The poor man's drug used to be alcohol, now it's cocaine. You don't even have to go to the State Store.
Q. - So basically you're saying that you can't isolate drug treatment from treating inner-city poverty?
Schandler - Yeah, we're a little Band-Aid, working on selected individuals, even though we're a large program. But we have minimal impact on the larger scene in the city.
O'Brien - I would second that entirely. I can be even more specific. We can save a lot of money in this country if we would just have better prenatal programs for the poor, especially the poor women who are abusing drugs. I heard the statistic the other day that 400,000 babies a year are exposed to cocaine. They're going to cost a lot in the future to society.
If you say that you treat middle-class addicts differently from poor addicts, that's true no matter what drug it is. You always have a much harder time treating people who have little support, because drugs are just one of many problems. You solve the drug problem temporarily, but they have all these other problems, so ultimately they're going to go back to the drug.
Schandler - We have a program for addicted women with small children, or who are pregnant. We've just had our seventh child delivered drug free. Which means we've paid for the project almost two-fold in terms of what the community has been saved.
The fear of these women in treatment, with their children, is: Where are they going to live afterward? You have a lot of good effort going down the tube if this woman and her kids are suddenly back in the setting where that social contagion is so great, that they're doomed. None of us is that strong.