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May 9, 2000

The Domestic Consequences of Heroin Use

Mitchell S. Rosenthal, M.D.
President
Phoenix House Foundation

My name is Mitchell S. Rosenthal. I'm a psychiatrist and the president of Phoenix House, a national nonprofit substance abuse services agency. Phoenix House operates a network of more than 70 programs in eight states, with a treatment population in excess of 5,000, and both national and local programs of prevention and education.

For more than 35 years, I have been treating young substance abusers, working with families, schools, social service agencies, courts, and correction systems. And I am here today, with these young residents, in treatment at Phoenix House, to talk about some new and troubling developments on the drug scene.

Drug abuse in America, despite popular perceptions, is not primarily an inner city phenomenon. Today, it is found everywhere. It is everybody's problem, and every parent's fear.

Drugs have long been part of suburban youth culture. Just about every middle class kid, black, white, or Hispanic can get drugs. Most will try drugs. Only, today, the drug that many are trying is heroin. And some who try go on to die.

I want talk about these youngsters, and about their parents—home-owning, health-insured parents—who don't know where to find the help their children need. And that's no surprise. Because, for most parents that help—the appropriate kind of drug treatment—is simply not available from private sector health plans or government-funded programs.

Now, I will admit to being somewhat skeptical about the advent of a new "drug crisis." Over the years, I have seen the popularity of various illicit substances rise and fall. I have seen the dread of widespread heroin addiction give way to fears of pervasive cocaine use, which were in turn, replaced by a greater alarm about crack. Meanwhile the allure of PCP waxed and waned. Yesterday, there was a sharp rise in concern about methamphetamine. Today, Ecstasy is in the spotlight.

Moreover, I recognize that abuse of one drug is generally not all that different from abuse of another. Youngsters who go beyond sampling and occasional use to become steady, and heavy users, do so for many of the same reasons. And parents who fixate on the substance itself—whose overriding concern is the specific nature of the chemical involved—generally fail to confront the far more important matter of what lies at the heart of their child's drug abuse.

This being said, there are aspects of the recent increase in heroin use that I find deeply troubling. For decades, the number of heroin users in the country has remained fairly steady, ranging between 500,000 and 700,000. Just three years ago, the National Drug Control Strategy reported 600,000 users. But in this year's Strategy, the Office of National Drug Control Policy puts that number at 980,000 for 1998. Most troubling are the growing numbers of new users and young users and the rising incidence of heroin abuse in areas where this had once been a relatively rare occurrence.

In 1996 alone, nearly 150,000 new users turned to heroin. And, over the past decade, the average age of first-time use has fallen from above 26 to below 18. During this time, heroin use among high school seniors rose from one percent to two percent—about where it was in the mid-Seventies. And the latest findings from the University of Michigan's high school survey—Monitoring the Future—found levels of heroin use above two percent for tenth graders, and at least as high for eighth graders.

At Phoenix House, we've seen these changes in the user population reflected in recent admissions to treatment. We've also heard it in calls to our national helpline— 800-DRUGHELP—which handles more than 120,000 calls a year, and recorded a substantial rise in heroin inquiries this past year.

Increasingly, calls for help about heroin are coming from the suburbs, and from parents—for the suburbs are heroin's latest venue, and the targets there are teens.

In the New York metropolitan area, 3.5 percent of seventh-to-twelfth grade students on suburban Long Island have tried heroin, two percent have used the drug within the past month, and one percent admit to heavy heroin use. New York State's substance abuse agency reports similar findings for suburban Westchester County—and these are survey results for youngsters who have remained in school, not dropouts. Meanwhile in New York City itself, heroin use among seventh-to-twelfth graders is substantially lower. Barely 2.5 percent have ever used. Less than one percent have used within the month, and just six-tenths of one percent admit to heavy use.

One reason suburban teens are now more likely to try heroin than their inner city counterparts may be because of a knowledge gap—a difference in experience. Most inner city families know all too well—for they have seen up close—the devastation of heroin addiction. Few suburban families share such memories. Their children may have heard about the dangers of heroin addiction—and they most likely have. But it is school knowledge, not life knowledge—cerebral, not visceral.

A more important reason may be the factors that make heroin a more attractive product these days, for it is cheaper than ever before—and stronger. The purity of street heroin has risen from seven percent in the Eighties to better than 40 percent today. In the Northeast, it's above 60 percent in New York and Boston, and at 75 percent in Philadelphia. These days, kids can get high on a bag costing less than 10 dollars.

Purity makes the heroin high easier to achieve without having to inject. Youngsters who sniff or snort the drug often believe they can avoid addiction, as long as they don't use needles. But snorting or smoking heroin provides no barrier to dependence—or to overdose. Moreover, as tolerance develops and desire grows for a higher high—a stronger rush—most youngsters who start by snorting will turn to injection. And this adds blood-borne infections to the dangers of their addiction—including HIV and hepatitis C.

Why do youngsters try heroin?

For much the same reason that they try any drug. To belong, to be "with it," to be "cool." They try it because they have low self-esteem, because they are troubled or depressed. They try it because they are insecure and crave acceptance, which are pretty much defining characteristics of adolescence.

But not every teen who yields to peer pressure and smokes a joint is going to snort heroin. Despite false notions of a safer nasal route, most suburban youngsters aren't likely to run the risk. Those who do—and persist after what is often an unpleasant introductory experience—are generally troubled youngsters—angry, guilty, or afraid—whose drug use offers relief from pain. Then, when adolescents become deeply involved in illicit drug taking—when the getting and using of drugs is the central reality of their lives—they become part of a different culture.

What we know of addiction and the behavior of addicts teaches us that, though they may come to drugs by different routes—from different circumstances and backgrounds, and with different resources, deficits, and psychological profiles—once they are on the pathway, they become remarkably alike.

This is particularly true when the drug, like heroin, is not only illegal but deemed particularly destructive. Its use then represents a dramatic departure from norms of the dominant culture. A new acculturation takes place, with rites of passage, reinforcing rituals, and special language.

And while the rate of acculturation may vary, it involves, for all, the same erosion of values and pro-social skills, the same adoption of drug-taking, lifestyle characteristics. And so, we should not be surprised when today's young heroin users become engaged in crime.

How, then, do we deal with these troubled, self-destructive, alienated, and often anti-social young people? The answer does not lie in increased efforts at interdiction, nor harsher drug laws. And for these adolescents, it's a little late for a better or more potent brand of drug abuse prevention.

What they need is treatment—the right kind of treatment, for the right length of time.

Now, when it comes to drug abuse treatment, there is—and has always been—great public ambivalence. You can win public approval with a hard line—demanding stiff penalties for drug offenses. And support for prevention is no less popular.

Most communities will happily invest in prevention. Doing so says they are aware of drug abuse, eager to do something about it, and hoping to avoid local drug problems. But they are far more reluctant to invest in treatment. For this says their community already has a local drug problem.

Nevertheless, there is considerable government support for treatment, and Phoenix House depends heavily upon federal funds and our partners in state and local government to treat the more than 5,000 former drug abusers in our programs.

Large-scale public investment in treatment dates from the late Sixties and was prompted not so much by compassion for addicts, as by the threat they posed to the rest of society. Even today, the most politically compelling argument we can make for treatment is the way it reduces recidivism. So, it is easier to find funds for prison programs—where addicts can be punished while cured—than it is for community-based programs, like our Phoenix Academies. These are residential high schools where teens in treatment, like those with me today, can catch up on learning lost to drugs in an environment that integrates treatment with education, work, and discipline.

As General McCaffrey, director of ONDCP, admits, there is "a significant treatment gap" in America today. Among the approximately five million drug users who needed immediate treatment in 1998, only 2.1 million received it. There are now roughly 750,000 treatment slots in the United States, which includes all kinds of programs—detoxification, methadone maintenance, drug-free outpatient, day treatment, and short and long-term drug-free residential. Certain parts of the country have little treatment capacity of any sort. Some states, for example, have no methadone programs. And—outside of prisons—there are only 12,000 to 14,000 beds in tough, demanding drug-free residential programs like those of Phoenix House.

There is a notion, now becoming prevalent in some circles, that if we are patient and invest enough in research, science will soon come up with a pharmaceutical "cure" for addiction. This idea plays off the perception of drug abuse as a "brain disease."

To be sure, drug abuse does affect the brain. But all that we have learned from brain imaging and PET scans, everything we've discovered about serotonin and dopamine, tells us nothing about treatment that we did not know before. Indeed, the discoveries we've made of late tend to reinforce the concepts on which present drug-free treatment rests.

Today's dopamine studies seem to discount differences among psychoactive substances. PET scans appear to show how addicted brains lose control over impulsive and irrational behavior. And other current research is making it clear that learning can reverse the biochemical abnormalities of addiction.

Increasingly, research is demonstrating that we already have treatment models that work.

Nevertheless, enthusiasm for a "magic bullet," a chemical remedy for addiction, persists and encourages belief in a solution to addiction that is quick, easy, painless, and cheap. But, Senators, there is no such solution.

Certainly, there is no solution that is quick. Sustained recovery requires prolonged involvement in the treatment process. Research—including the long-term outcome studies of Phoenix House residents—has conclusively demonstrated the relationship between successful outcome and time in treatment.

Yet private managed care companies today are cutting the once standard, 28-day chemical dependency program to seven days—even to four. Many government agencies now refuse to pay for "long-term" treatment that lasts any longer than six months. And, in at least one jurisdiction, the maximum stay is now three months.

Let's understand that recovery, which is the goal of treatment, consists of considerably more than quitting drugs. It involves changes in attitudes, behavior, and lifestyle. It means undoing the acculturation that serious drug involvement entails. So, effective treatment must address the underlying causes of drug abuse. For many hard-core drug abusers, treatment must also address the social, medical, educational, and vocational deficits that are barriers to productive new lives.

Among treatment models we know to effect lasting changes in attitudes, values, and behavior is the therapeutic community or TC. It isn't the only such model. But it represents an approach to the treatment of substance abuse that NIDA-supported research has consistently shown to be effective. In recent years, it has demonstrated increasing flexibility, and become available in a variety of different formats. Among these formats is the Phoenix Academy model, the basis of treatment for adolescents at Phoenix House.

Treatment models other than the TC may be equally effective for heroin users new to drug taking, who are able to hold down jobs and meet their social and personal responsibilities. For them, prolonged involvement in a program of structured and intensive outpatient care may do.

For many heroin addicts, the use of chemical interventions, such as methadone, is a useful—sometimes necessary—part of treatment. But we have got to recognize the limitations of what methadone can do, and the need for human clinical interventions—for counseling and other support services—if pharmacotherapies are to work. And we should be wary of employing any pharmacotherapy in the treatment of adolescents.

For them, there are reasons that make therapeutic community treatment particularly appropriate. These include the TC's focus on behavior, on cognition, on values and morality, and on problem solving and vocation. Within the highly structured environment of the treatment community, young people come to understand themselves and others, take responsibility for themselves—and others. They learn to trust and buy into the TC's "view of right living."

This kind of treatment, however, is rare. Parents who look to HMOs to provide it for their children are not likely to find it, and there are all too few publicly funded programs. The overwhelming majority of the nation's 12,000 to 14,000 TC beds are for adults—not for adolescents.

So, if the members of this caucus were to ask me, "What is to be done?" I would say first expand adolescent treatment. And allocate a major share of new treatment resources for therapeutic communities.

I would say next that government should help promote treatment in much the same way that it now helps promote prevention. The goals should be:

to confront public ambivalence,

to increase acceptance of and demand for treatment,

and overcome the widely held, but readily disprovable,

assumption that drug abuse treatment is largely ineffective.

I would suggest a federally subsidized campaign, targeting drug users and their families. Messages should both encourage acceptance of treatment and make clear the responsibility of caring parents not only to seek treatment appropriate for their addicted children but also to demand that their children accept such treatment.

Senators, the heroin may come from abroad, but the addiction problem is homegrown. And for youngsters like these, there can be no low-cost, high-speed interventions—no chemical shortcut. There is no quick fix that will give them back the happy, normal, teenage life held hostage by heroin.

Thank you.