NOTES FROM THE DRUG WARS
By Ernest Drucker
Director of the Drug Treatment Program and Professor of Epidemiology and Social Medicine at Montefiore Medical Center/Albert Einstein College of Medicine in the Bronx
The Criminalization of Motherhood II
When philosophers are Drug Czars
"When genuine philosophers _ _ become rulers of _ _ the state they will take over the children, remove them from the manner and habits of their parents, and bring them up in their own customs and laws. " Plato, The Republic
On the edge of a new millenium, America tenaciously clings to its past. Beset by our most severe social problems in decades, we are turning back the clock: on a woman's right to a safe abortion; on capital punishment; on school prayers; corporal punishment by teachers; and on free speech. And now it is proposed that the state take custody of the children of drug users and restore the orphanage - an idea born over 2000 years ago and an institution we thought had died with Charles Dickens. This proposal is offered as a way to meet our responsibilities to save the youngest victims of drugs so called "cocaine babies". And certainly, in America, some help for the newborn infants of addicted mothers would seem long overdue.
On the face of it "crack", the highly potent and widely available smokeable form of cocaine, appears to be destroying inner-city families at a rate unparalleled in modern experience. In New York City alone, over 63,000 children are now in foster care - more than 90% of them African-American and Hispanic. Up from 12,000 in 1960. And New York City's infant mortality among minorities, which declined steadily since 1960, has now risen 10% in the last few years. The rate of congenital syphilis among newborns increased by 400-500% among non-white children in New York City between 1984 - 1989. All of these effects are linked to the rampant "crack epidemic" in which frequent and dangerous sexual behaviour is the norm.
In the public hospitals of this city 15% to 20% of all newborn infants test positive for cocaine, indicating that their mothers have used the drug within the last 48 to 72 hours. In the scientific and medical literature, heavy maternal crack use is associated with lower birth weight and increases in neurological complications and behavioural disorders believed to extend well beyond infancy into early childhood and beyond. Both scientific reports and popular accounts in the press describe pathetic infants
shrunken shadows of the healthy babies of drug-free mothers, irritable beyond consolation, unable to focus on the human face or to bond to even the most loving and attentive caretakers.
Surely this is a "devil drug" and all who care about the welfare of helpless children must work to put an end to its use. Or, failing that, to protect the newborn (and the unborn) from its ravages. What civilized society could do less? And who better to protect them than William Bennett - the no nonsense Director of National Drug Control Policy - the American Drug Czar. Working out of the executive office of the President of the United States, Bennett presides over the U.S. "war on drugs". With his PhD in philosophy (his dissertation was on Kant) and a law degree from Harvard, Bennett projects an image both of strong leadership and intellectual credibility. He served as Secretary of Education under Ronald Reagan for four years, where he became well known for strong statements and weak programs. Now, in a recent address to the National Urban League, one of the oldest mainstream African-American civil rights associations, Bennett has called for "radical steps" to deal with our drug problems' impact on children.
John Jacobs, the Urban League President, had said earlier that drugs are "killing more Blacks than the Klan ever did... destroying more children and more families than poverty..." He called for an Urban Marshall Plan to address the roots of the problem
urban decay, insufficient housing, underfunded education and inadequate health care. Jacobs spoke of the need to infuse massive financial and human resources into the reconstruction of our great cities, just as was done under the Marshall Plan with such dramatic results in Europe after World War II.
The Bush Administration recently rejected such aid as too costly and politically unnecessary, since the urban poor didn't vote that often - especially for Republicans. Indeed following a review of current poverty programs, the Bush administration announced that they would opt to dust off some old programs or, to use the terms of the study group, "to continue to play with the same toys - just give them a fresh coat of paint" - language revealing the sensibilities of Marie Antoinette. Still substituting rhetoric for resources, Bennett now calls for an Urban Children's Plan - a radical proposal to rescue the children of the slums. He advocate's a sharply increased role for the government in the care of children whose parents are drug users.. While admitting that governments "as great as they may be... have never raised a child", Bennett notes that many inner city children have, in effect, "been orphaned by drugs" and that "we must save them by removing them from their families." "We should not assume," he warns, "that biological connection assures a happy ending (or) that parents and family guardians are capable of providing for the physical, moral and cognitive needs of the child . . ."
In addition to building more orphanages, Bennett recommends increases in foster care, adoption and construction of long-term residential settings. And, "not just for babies, but for children and teenagers up to the age of majority", who Bennett calls "de facto orphans roaming the streets of our American cities.. without supervision or guidance". Courts and other special judicial bodies would decide when the step of seizure of these children was necessary, but should act "aggressively" in the face of this "emergency". "We don't help weak nor non-existent families", Bennett explains, "by either romanticizing them (sic) or denying their impotence".
He goes on to cite several examples: all-too-familiar war stories of the modern slum, chronicles of abuse and neglect of young children at the hands of desperate and degraded parents addicted to illegal rugs - these days mostly crack/cocaine. Homeless or sick with AIDS, unable to enter or stick with limited drug treatment services now available, lost souls of the modern metropolis. But souls who, despite their afflictions, still get pregnant and give birth to babies. Bennett, the realist, reminds us that he has looked closely at the situation and understands the "real world" and the "real facts".
What's wrong with this picture?
For those who have dedicated themselves to helping families in trouble - to preserving and, wherever possible, healing the family structures which we all need to grow up human
Mr. Bennett's proposals are troubling. They contradict decades of theory and practice on aiding disrupted families whether due to drugs or to any other social or psychological cause. With all the difficulties associated with reconstructing or helping shattered families, one still seeks in vain for a successful alternative And it certainly isn't the orphanage. But Bennett's approach flows naturally from the "war on drugs."
The model is fundamentally destructive - it replaces reason with force and turns other humans into enemies in order to justify harsh measures. And it is premised on several key points - all of which can be refuted. First, blaming drug per se
especially crack - for the damage to family life of the poor in the inner-cities; second, the belief that we cannot successfully treat cocaine addiction; third, the absence of alternative arrangements for the care of children of drug users - especially those that might be found within the family and social networks of the poor; and. finally, the preferability of the government's caring for these children - both in the short-term and, since familial roles and responsibilities extend well into later life, assuming that responsibility over the long haul.
Crack cocaine: myth and reality
The first, generally unquestioned, premise of the whole business is the role of the drug itself - crack/cocaine. The widespread publicity that this particular drug has gotten and its characterization as a uniquely potent and addictive substance, are essential to its mystique. Indeed both drug users and drug warriors may be attracted to it for this reason. But this reputation is built on an extremely shaky foundation of research and reportage which tend to foster myth and misinformation.
Those in the field should know better. There is an old axiom in drug research that warns us about concentrating too closely on the drug itself - on the pharmacology of the actual chemical. The particular drug is only a part, often a small part, of the meaning of addiction. Norman Zinberg's now classic work Drugs, Set and Setting, emphasized the fact that drugs per se never account for all the phenomena we attribute to them. Rather, the circumstances of their use (the setting) and the particular history of the individual user (the set) are powerful determinants of the outcome of any single episode of drug use and ultimately, of the characteristic patterns associated with compulsive use or addiction which we may see later on.
In the case of crack/cocaine, it is important to know several facts about the drug itself. First, this is still cocaine, a drug that has been widely used for more than a century and about which a great deal has been known - and forgotten. I am amazed at the number of people (even some in the drug field) who believe that because of its preparation in this smokeable form, crack is somehow fundamentally different from cocaine. What is different (in this and every other smokeable form of any drug) is the ease of use compared with injection and the speed at which the drug and its active metabolites reach those parts of the central nervous system which react to them, i.e., the rapidity of onset, duration of action, and the effective potency of the dose.
With crack smokers, this action occurs more rapidly than with injection of cocaine, i.e., within 10 to 20 seconds, and its effect is quite powerful. Hence its attraction to users seeking a powerful experience. However, it lasts for a much briefer time than even injection - one to five minutes. With frequent, heavy use of any form of cocaine, the withdrawal phenomena are pronounced including severe depression and agitation which, in turn, leads, to intense craving for another dose to modulate this effect. At some point, that next dose is taken largely to counter-act this reaction rather than to "enjoy" another brief high - an enjoyment that becomes increasingly elusive as regular use continues. Indeed it is this particular feature of heavy cocaine use (the rapid disappearance of pleasure) that drives most users to attempt to discontinue use and to seek help within months of the onset on heavy use. For heroin the figure is years. For alcohol, decades. But, as that help is generally unavailable for the inner-city cocaine user in America, compulsive users end up self-medicating for anxiety and depression by using Valium, Elavil, sedatives, alcohol and heroin: anything they can get. Depending on the user's status, these buffers permit continued cocaine use and help to soften or defer withdrawal phenomena.
But set and setting still play important roles in the use of cocaine and not all users manifest this uncontrolled pattern. There is now clear evidence that the regular use of even smokeable cocaine is not necessarily synonymous with the patterns we see among the underclass of American cities. Several well conducted studies in Canada (Patricia Erickson), The Netherlands (Peter Cohen), and Australia (Stephen Mugford) have now demonstrated that control of cocaine use, including smokeable cocaine, is quite possible. Indeed it is the norm. In the Amsterdam study fewer than 20% of 175 users of smokeable cocaine, all of whom had used the drug regularly for over six years, could be described as "problem users" as defined by social, psychological or medical disfunction. They could and did stop use for extended periods over the years, and frequently used the drug on weekends only - a pattern that is also evident among crack users in American cities. In the Australian and Canadian studies, findings suggest that cocaine use is no more difficult to control i.e., to stop or reduce use when it gets to be a problem, than are some other drugs. Even in the U.S. it is important to keep in mind that, according to NIDA, over 20 million people have tried cocaine in their lifetimes frequently more than once. But only about 2 million (10%) have done so in the last year, i.e., 90% of those who tried cocaine did not fall into regular use. Even among those who have used cocaine and crack in the last year (about two million), fewer than 25% are users on a weekly basis, i.e., regular users. And even among the inner city group most involved in "compulsive use", we still find that weekend use alone is common - a kind of binge known as "a mission" and we even find a syndrome of once-a-month use at the time of receiving welfare funds.
This is not to say that some very destructive aspects of cocaine use are not evident, especially in women trading sex for crack and in the violence of the drug trade associated with its sales. But in our experience in the Bronx, these patterns are quite similar to those seen in earlier decades, especially in the late 1960's and early 1 970's when there was a new burst of heavy heroin use - a wave that created the hundreds of thousands of intravenous users we see today. What we may be seeing now is a similar phenomenon - old users unaccustomed to handling this quantity and form of the drug and new users, in their teens and early 20s, introduced to drug use through crack and almost immediately moving to heavy, uncontrolled use: just as we frequently see in teenage alcohol use. These patterns of drug use must be understood not as a function of the chemical but as a product of normal, adolescent psychology or, more critical to our argument, heavy drug use associated with the intolerable conditions of life in the urban underclass.
And we do not need a new demonology for this specific drug. The old clinical models will do well enough. Recall that recreational amphetamine use came and left quite rapidly in the U.S. in the 1960's as the drug acquired a street reputation as dangerous ("speed kills"); LSD, at first romanticized by Timothy Leary and other drug gurus of the 60's ("turn on, tune in, drop out") seemed to lose much of its allure, and while some use continues, one does not see the frequent "bad trips" or psychological disfunction associated with those early years. The list goes on, a graveyard of "the drug of the month" - PCP (angel dust); smokeable methamphetamine (Ice); Quaaludes. Most recently MDMA (Ecstasy) is touted as a safe drug, well-suited to the middle-class lifestyles and the need to let loose and relax after a week in the yuppie fast track. But we'll probably discover ways to abuse this drug also, e.g., by taking 10 tablets instead of 1, and we soon will see the pathological phenomenon. Cannabis alone seems to endure as a relatively safe and popular drug. But in the current climate of "Zero tolerance" it is still the object of the largest number of drug seizures, confiscations and arrests over 50% of those in American prisons on drug charges are incarcerated because of marijuana.
The harmful effects of cocaine on the fetus and newborn are also the subject of serious dispute. Not that this drug, like others, is not deleterious to the developing fetus. But the exaggeration of this damage and the failure to discriminate between the effects of chemicals and the effects of the social and environmental conditions in which these infants and mothers exist - things like poor nutrition, homelessness and the absence of prenatal care that accompany uncontrolled drug use - all detract from our understanding of the drug's specific action. The exaggeration can be seen in a recent American Journal of Public Health article on maternal cocaine use which did document the increased risk of low birth weight when mothers used cocaine daily throughout pregnancy. But in the study this risk was, in fact, comparable in magnitude to the risk associated with regular tobacco use throughout pregnancy and diminished to relatively low levels if the use of cocaine was intermittent, as was the norm for the vast majority of users.
Further, many of the studies showing adverse birth outcomes for cocaine using mothers are deeply flawed. In these studies it is extremely difficult to control the many co-factors well known to affect the developing fetus especially for women who do not receive routine! prenatal care, a common situation in these marginalized populations. Cocaine and other drugs probably do increase these risks, but their principle basis of action is to be found in the disorganized lives of the users - not simply in the drugs that they take.
Nonetheless, a glut of recent articles in the press continue to focus on cocaine - it makes good copy and meets the need for a simple answer to complex problems. Less comprehensible however is the bias toward this same simplistic view to be found in the professional literature. A recent Lancet review of 60 articles submitted to the Society for Pediatric Research over the last ten years, evaluating cocaine's effects on newborns, found that 25 of 49 (50%) which found deleterious effects were published, but that only 1 of 11 (10%) of those failing to find such an effect was published - despite this last group having been judged methodologically superior to those with positive findings.
Treatment of crack/cocaine users
One of the keystones of the demonization of crack is the supposed rapidity of addiction and the difficulty (or impossibility) of successfully treating cocaine addiction. This pessimism is unfounded and based more on ideology than reality. As noted above, uncontrolled crack users (a minority of even regular cocaine users) do seek treatment rather quickly. They are motivated by the rapid loss of control and the unpleasantness of the withdrawal effects. Unfortunately there is no room at the inn.
Most American drug programs, especially the public ones, are constructed to treat heroin users. Methadone, the largest program as measured by number of clients (over 100,000 in the U.S.) only helps with opiate addiction. And residential therapeutic communities (the other large modality with over 35,000 slots nationally) require a level of commitment not commonly reached or sustained by most inner-city drug users. Based on twelve step and confrontational approaches, these programs often exploit the degradation and damaged self-esteem of drug addicts - frequently more for the profit or aggrandizement of the moral entrepreneurs who operate them, than for any demonstrated long-term benefit to the clients.
Despite these limitations in the forms of treatment available and the scandalous inadequacies in their availability (there is less than 1 treatment slot for every 15 heavy drug users in the U.S.), the treatment of cocaine dependency is quite possible. Detoxification can be done with either a week or ten days in a supportive residential setting with minimal technical and professional support. If such beds were widely available, much could be done to decompress the crises that occur regularly in the lives of users. Out-patient detoxification using acupuncture appears to show great promise. This inexpensive "user friendly" approach has been in use in the Bronx for several years where Dr. Micheal Smith at Lincoln Hospital treats over 3,000 crack and cocaine users each year. More than half of these are court remand cases, i.e., not self motivated. Yet they show striking results. Of those who stay the 2-3 weeks course, during which they come for daily sessions of acupuncture, peer support groups and some minimal counselling, over 50% show cessation of use and sustain this for a three month follow-up period. This is confirmed by negative urine tests. If other services are available to deal with this population's other problems (jobs, housing, psychiatric illness), the result would probably be even better.
The point here is that the pattern, of which compulsive use of cocaine is a part, may well have destructive consequences for both mother and infant but these are reasonably well understood clinically. Most treatment programs for cocaine users can cope with the consequences of sustained and heavy use at least as well as they can with those of other major drugs heroin, pills and alcohol. Not great, but much better than nothing at all and no cause to abandon care for cocaine users and seek "radical" alternatives.
But there is an additional problem with treating maternal drug users almost no American treatment programs are prepared to deal with pregnant women or those with newborn children. In New York City, the American Civil Liberties Union has brought suit to require several programs to accommodate such women. In the absence of development of treatment programs attuned to their needs, little can be accomplished. A few model programs, such as the Early Family Outreach Program at North Central Bronx Hospital or the Center for the Vulnerable Child at Oakland's Children's Hospital, report very positive results based on early identification of drug using women (during pregnancy) and an orientation that does not make revelation of a drug problem the signal for punitive actions aimed at removing custody of the child. Yet, in the climate of the drug wars we are now prosecuting such women for "giving drugs" to their unborn children - not a strategy likely to get them to come forth for early identification and treatment.
Alternative systems of support - family networks and community
It is apparent that Bennett and the drug warriors are profoundly ignorant of the overwhelming evidence and the findings of decades of urban anthropological research. This and the experience of family therapists have demonstrated the massive extent and reliable characteristics of the family support and social support systems to be found in the communities of the urban poor. Indeed it is these systems that sustain life in the face of the endless assaults on families' integrity that goes with the terrority of the urban ghetto. What has changed recently is the overall prevalence of drug use, the increased violence associated with the drug trade, and the increased use of hard drugs by women. These trends do threaten to undermine these networks of care, but it would be far more preferable to pump resources into identifying and reinforcing such "natural support systems" than trying to supplant them with the tender mercies of William Bennett's state.
Additionally, the expense of the states doing this job, however poorly, is horrendous. In New York City foster care costs $15,000 per child per year; juvenile residences $25,000; and juvenile jails $40,000. The U.S. now spends over 6 billion dollars per year for foster care - about four times what we spend on drug treatment. Could not some of these resources be directed to sustaining, rather than further undermining, family supports? While Bennett does not believe a biological connection assures a "happy ending", it is virtual certainty that the orphanage, as in Dickens' time, will only extend the misery even further. If even a small proportion of these funds were directed to help families in need
maybe the outcome would be more tolerable - if not "happy".
But if the explanation for Bennett's radical policies and their popularity in some quarters, is not to be found in the chemistry of cocaine, perhaps we should look more closely at the alchemy of our own culture. Today fifty million Americans believe that these are the last days. These are fundamentalist Christians, people who see many of the problems of contemporary America - including drugs and AIDS - as clear confirmations of their literal belief that the end of the world is near. Dr. Robert J Lifton, the psychiatrist who has written on the holocaust and nuclear war, and his associate, Charles Strozier, Co-Director of the Center on Violence and Human Survival at John Jay College of City University of New York, recently examined the beliefs of this large and politically important group through the lens of their own extensive literature which includes many books on the family. One author, Jay Dobson, (a psychologist and author of "Dare to Discipline") believes that "pain is a marvellous purifier" and advocates swift and frequent physical punishment as a response to children's defiance. Mr. Dobson, who has served on several Presidential task forces on family policy, is closely allied with Phyllis and David York and their Toughlove approach to adolescents ("turn them in to the cops"). They carry, according to Lifton and Strozier, "a fierce ideological message" and a world view in which "the entire political process, with all its frustrations and compromise, is a deviation from the true path of gospel". Charles Colsen, the convicted Watergate conspirator who is now a born-again spiritual leader, tells us in Against the Night (his most recent book) "that the new barbarians are among us and we stand on the edge of a new dark age" brought on by, among other things, drugs.
So, when a politically ambitious William Bennett prepares us for an American state which, while unable to assure prenatal care and pre-school education for the poor (both of which have been proven effective), is now ready to assume vast new responsibilities for rearing hundreds of thousands of children, one must be sceptical. Bennett is open to a possible turn-about or "redemption" of drug-using parents. If they provide "credible evidence of their ability to provide for the child", they could regain custody. But in the absence of effective drug programs in sufficient quantity to care for their malady and to meet their other basic human needs, i.e., food, clothing and shelter, it is hard to imagine how they would fare. It is a bit like declaring an epileptic mother unfit to take responsible care of her child because she is likely to have a seizure now and then, but still denying her access to anti-convulsant medication. No doubt Mr. Bennett's inclination "to assume no happy ending" is a realistic prognosis given America's disinclination to do anything other than make war on its citizens who use drugs.