Based on the rhetoric, America's war on drugs seems poised to shift into a more enlightened phase where treatment of addicts gains favor over imprisonment of low-level offenders. Questions abound, however, about the nation's readiness to turn the talk into reality.
The economic case for expanding treatment, especially amid a recession, seems clear. Study after study concludes that treating addicts, even in lengthy residential programs, costs markedly less than incarcerating them, so budget-strapped states could save millions.
The unmet need for more treatment also is vast. According to federal data, 7.6 million Americans needed treatment for illicit drug use in 2008, and only 1.2 million — or 16 percent — received it.
But the prospect of savings on prison and court costs hasn't produced a surge of new fiscal support for treatment. California's latest crisis budget, for example, strips all but a small fraction of state funding away from a successful diversion and treatment program that voters approved in 2000.
"It's easy to talk a good game about more treatment and helping people," said Scott Burns, executive director of the National District Attorneys Association. "But it smashes head on into reality when they don't put their money where their mouth is."
Money aside, the treatment field faces multiple challenges. At many programs, counselors — often former addicts themselves — are low-paid and turnover is high. Many states have yet to impose effective systems for evaluating programs, a crucial issue in a field where success is relative and relapses inevitable.
"Fifty percent of clients who enter treatment complete it successfully — that means we're losing half," said Raquel Jeffers, director of New Jersey's Division of Addiction Services. "We can do better."
The appointment of treatment expert Tom McLellan as deputy director of the White House Office of National Drug Control Policy in April was seen as part of a shift of priorities for the drug czar's office.
McLellan said he sees greater openness to expanding treatment but also deep misunderstanding or ignorance about scientific advances in the field and the need to integrate it into the health care system.
Most Americans, he suggested, have an image of drug treatment formed from the movies — "cartoon treatment" involving emotional group encounters — and are unaware of a new wave of medications and other therapies that haven't gained wide use despite proven effectiveness
"For the first time, it can truly be said that we know what to do — we know the things that work," he said. "But do we have the economic and political willingness to put them into place? If we do, we'll see results."
McLellan, insisting he's not "a wild-eyed liberal," said expanding treatment wouldn't negate the war on drugs.
"Law enforcement is necessary, but it's not sufficient," he said. "You need effective preventive services, addiction and mental health services integrated with the rest of medicine. You shouldn't have to go to some squalid little place across the railroad tracks."
By federal count, there are more than 13,640 treatment programs nationwide, ranging from world-class to dubious and mostly operating apart from the mainstream health-care industry.
Dr. H. Westley Clark, director of the federal Center for Substance Abuse Treatment, said his agency wants states to develop better measurements of programs' performance.
"The data shows treatment saves money — $1 spent to $4 or $7 saved," Clark said. "If you're an altruist, making treatment available is a good thing. If you're a narcissist, it's a good thing — you'd pay less in taxes."
Treatment advocates are closely watching Congress, hoping the pending health care overhaul will expand insurance coverage for substance abuse programs. Recent federal data indicates that 37 percent of those seeking treatment don't get it because they can't pay for it — and many land in prison.
The work force in drug treatment is, for the most part, modestly paid, with counselors often earning less than the $40,000 per year that it costs to keep an inmate in prison in many states.
"Some of the stigma that goes with addiction adheres to the staff as well," Jeffers said. "Most agencies are trying to do right — but the field is getting increasingly complicated. The business skills that are needed aren't always the same skills that make a good clinician."
Yet generally, front-line counselors win high praise — especially the ex-addicts who bring savvy and credibility to the job.
"People in the field weren't driven to it by the money or glamour, but often by personal experience or that of a loved one," said Keith Humphreys, a treatment expert from Stanford University now working for the drug czar's office. "They may not have the fanciest degrees, but they are incredibly caring."
Garnett Wilson served prison time for armed robbery in the 1980s and now — at 61 — has two decades of drug counseling under his belt as a valued employee of the Fortune Society, which provides support services to ex-offenders in New York City.
As he cajoles the men in his groups, he strives to remember his own battle to change.
"Some of the people who've been through it become too rigid," he said. "Preaching doesn't work. They forget how hard it is to rise above your environment, and they alienate the people they're trying to help."
Wilson says he focuses his efforts on "those guys that are ready."
Perhaps Joe Smith is one of them.
A 29-year-old from Brooklyn, Smith recently served eight months in prison for a weapons offense and was a heavy marijuana user, but now — studying and job-hunting — says he's determined to go straight.
"It's been kind of tough," he said. "The hardest part is just to come to it every day, but when you come to think about it, it's not so hard — because if you don't, it's back to jail."
Another client, Ronnie Johnson, has been back in New York City barely a month after more than a decade in prison upstate.
"It's like family here — everybody's supportive," said Johnson, 39, contrasting the Fortune Society staff with drug treatment workers in prison who were "just doing it for a paycheck."
In the years ahead, New York may serve as a test case for the potential to expand treatment programs.
Earlier this year, its legislature approved sweeping reforms of harsh drug laws enacted in 1973 under Gov. Nelson Rockefeller.
The changes mean that thousands of nonviolent offenders who would have faced long, mandatory prison terms will be diverted to treatment. Even in a difficult financial climate, the state is allocating $50 million to boost treatment programs.
"New York will now treat addiction as a health concern and focus on treating the disease, rather than locking up the patient," said Karen Carpenter-Palumbo, commissioner of the state's Office of Alcoholism and Substance Abuse.
Her office oversees one of nation's largest addiction service systems, with some 1,550 programs serving more than 110,000 people a day. Yet that caseload represents only 15 percent of those needing treatment. An estimated 80 percent of the 60,000 offenders in New York's prisons have substance abuse problems.
As the system expands, Carpenter-Palumbo is working with treatment providers on new standards. If the field wants to be a full partner in the medical community, she said, it must be ready for rigorous evaluation.
Problems can range from inadequate staff levels to fraud to the simple lack of a warm welcome when clients first visit.
"Any person with an addiction, if you give them an excuse, they'll run," she said.
Paul Samuels of the Legal Action Center, a public interest law firm, hopes New York and other states will reduce the criminal justice system's role in determining details of treatment, such as whether an addict should be given methadone or other medication.
"That would be like a judge determining the kind of treatment you get for heart disease," he said. "It really should be decided by treatment experts."
The Rockefeller law reforms foretell a potential boom for organizations like Odyssey House, a New York City nonprofit.
It serves 300 people — young mothers, senior citizens, ex-convicts and others — at a residential treatment center in East Harlem. At another site, run by the state corrections department, Odyssey House has just taken over a treatment program for offenders who abused drugs in violation of parole.
Darrin Brown, who runs that program, says one challenge is convincing prison staff that treatment has merits.
"It's up to us to win them over," Brown said. "Their attitude is changing for the better — they can see the results."
Peter Provet, CEO of Odyssey House, says most of the East Harlem clients stay nine months or more, in a comprehensive program that costs $20,000 per year per client.
"You're talking about some of the most deprived, abused individuals there are," he said. "Part of our struggle, for years, is to get others interested in these people."
Among them is Clinton Goodwin, 59, who started dealing drugs at 19. Since then, he's served four stints in prison and been arrested five times, mostly recently in May. As an alternative to prison, he was given the option of participating in the Odyssey House program for at least 18 months.
Twenty years ago, serving time in Virginia, he entered a treatment program that failed to produce lasting change. "Nothing in it put me to the test," he said. "I kind of manipulated it.
"I might be more receptive now — I have daughters and grandchildren, and I don't want to betray them again," he said. "I know it can work for me — if I'm ready for it."
Some addicts prefer prison to a rigorous treatment program, said Provet. Others adjust only gradually.
Mary Celestino, 66, was arrested a year ago when officers found cocaine in her apartment, and entered Odyssey House in January in lieu of two years in prison.
"They're telling you what to do, when to get up, when to eat, when to sleep," she said. "I'm still trying to get used to it."
New York stands in contrast to many other states, where the push for more treatment has been undercut by the recession.
In fiscally troubled California, state funding for a landmark drug treatment program has fallen from $145 million three years ago to $18 million in the latest budget.
The result is limbo for many nonviolent offenders who, under terms of a 2000 ballot measure, are supposed to get treatment as an alternative to prison. There's now little space available as programs retrench, and experts worry that some offenders on waiting lists will lapse into crime.
"They end up being basically out on the street," said Thomas Renfree, executive director of the County Alcohol and Drug Program Administrators Association of California. "If they can't get into treatment right way, you're going to lose some of them."
Renfree says the diversion program had been highly successful — saving up to $4 for every dollar spent and diverting 36,000 people to treatment each year.
"There's a lot of lip service paid to it," he said. "But even some of those who think it's a good idea aren't willing to kick in the resources."
Meanwhile, California's corrections department has had to slash $250 million worth of rehabilitation services, forcing cutbacks in a drug treatment program that had sharply reduced recidivism rates.
Treatment advocates say their efforts to lobby for scarce funds often lag behind those of law enforcement.
"The treatment community has never been as effective — they're not as aggressive, not as well organized," said Margaret Dooley-Sammuli, the Drug Policy Alliance's deputy state director in Southern California. "If those two go at it, fighting for resources, who's going to win?"
Scott Burns, of the National District Attorneys Association, said many law enforcement officials are increasingly open to treatment, but not at the expense of their anti-crime budgets.
"There's always been competition between law enforcement and the treatment community for funds," Burns said. "Legislatures, and to some degree the federal government, talk a lot about how important treatment is, but somehow never seem to fund it at the levels people in the field feel they must have to make a difference."