Update
Volume 13, Number 3 (September 1997)
Someone has said that the further we look into the past, the better we understand the future. This is certainly true of cocaine. Cocaine is derived from the coca plant grown in South America, particularly Columbia, Peru, and Bolivia. Coca leaves have been chewed by the Indians of South America for centuries. In the Inca empire, coca leaves were used for ceremonial and sacred purposes. It was believed that the god Inti sent the Indians the coca plant to reduce the burden of life. Another myth is that a woman, executed for adultery, sent the coca plant to seduce and punish her persecutors. Notice the association of the coca plant with spiritual and sexual connotations. This continues today when addicts talk about the spirit of cocaine and how it is associated with a galloping sexuality in some people.
In the 15th century King Philip of Spain forbade the chewing of coca leaves by the Indians. However, he changed his edict when he was informed that chewing coca leaves reduced the appetite and increased the motivation and stamina of Indians working in high altitudes. Notice the powerful precedence of economic interest over moral concerns in cocaine addiction.(1)
Cocaine hydrochloride was first synthesized in Europe in 1859 by Albert Niemann, professor at the University of Gottinghen. In 1859, Pablo Mantegazza wrote his prize-winning essay heralding cocaine hydrochloride's ability to remove fatigue, increase strength, raise spirits, and cure impotency. In 1865, the Corsican Andrew Mariani introduced the popular wine-cocaine mixture, "vin Mariani," as a cure for everything. Enjoying immense popularity in Europe and America, it made him wealthy and drew testimonials from such luminaries as Thomas Edison, the Czar of Russia, Jules Verne, Emile Zola, Henrik Ibsen, the Prince of Wales, and Sarah Bernhardt. Pope Leo XIII, a frequent imbiber, gave Mariani a gold medal for his service to mankind. In 1880, the Russian nobleman Professor Vassili Von Anrep discovered the local anesthetic properties of cocaine, and in 1884, Sigmund Freud, a student of Von Anrep, published his "uber coca," the first of his enthusiastic papers about the experience of using cocaine. According to Freud, cocaine hydrochloride lifts the spirit, decreases fatigue, relieves impotence, and cures depression. Freud turned away from the therapeutic use of cocaine when a friend, Von Fleisel, who was taking cocaine as treatment for morphine addiction, developed a toxic psychosis in which he became delirious and saw snakes crawling over his body. In 1885, Albrecht Erlenmeyer accused Freud of unleashing cocaine as the third scourge of mankind, after alcohol and opiates.(2')
In 1886, John Styth Pemberton of Atlanta, Georgia, combined cocaine and caffeine into a brown syrup which became the popular soft drink, Coca Cola. This spawned a dozen cola competitors, and cocaine became a favorite ingredient in both patent medicines and pharmaceutical products.
In 1891, 200 cases of cocaine intoxication were reported. In 1898, the medical community turned against the wonder drug. Southern politicians launched a racist campaign suggesting that cocaine not only gave black men superhuman strength but made them want to rape white women. As a result, in 1903 cocaine was taken out of Coca Cola. In 1907, cocaine use peaked with over 1.5 million pounds entering the country. The problem of addiction was particularly serious in New York City. Like today, there was a sense of hopelessness about the efficacy of treatment, and one New York Times editorial is purported to have stated, "Let the cocaine fiends die." The problem of escalating addiction led to the passage of the Harrison Act in 1914, the first federal anti-drug law providing severer penalties for cocaine than opium. But illicit drug use continued. In 1922, the narcotic drug import and export act misclassified cocaine as a "narcotic," so cocaine use went underground for about five decades, mainly being used by the wealthy and some jazz musicians. The new openness to drugs in the 1960s gave rise to a cocaine renaissance, and in 1972, led by the entertainment industry, cocaine re-emerged as the "in" drug of the so- called "beautiful people," and began its spread down scale.'2'
My clinical experience with cocaine began in psychiatric training when my first patient suffered from a cocaine psychosis in which she saw multicolored rabbits jumping around my office. Returning to my island nation in 1980, I was exposed to a new phenomenon involving young men and women destroying themselves by smoking a drug they called Bahamian rock. They said that, by heating cocaine hydrochloride with baking soda and water, they obtained a volatile rock-like substance. After snorting cocaine hydrochloride powder for five years or more, they claimed that when they smoked the rock cocaine the high was more intense. They described the high as giving a thousand orgasms, or as a never-ending Christmas party. In 1983, there were 32 cases and in 1984 the total number of cases jumped to 564 cases entering into treatment. The sudden increase in addiction occurring in a vulnerable population was defined as an epidemic.
This form of cocaine, now called "crack," spread like wildfire. It appeared to be a no-barrier drug, affecting persons in all levels of society. I recall a letter from a 15-year-old girl. She said that her pusher asked for her mother's jewelry, and she gave it to him. He asked for her mother's money, and she gave it to him. And now he wanted her body. It was her letter that encouraged a nation-wide campaign against this debilitating drug experience which was corrupting our young men, destroying our young women, and wreaking havoc on families, neighborhoods, and communities. To compound matters, the National Broadcasting Company (NBC) made allegations accusing the Bahamian government of corruption, and harboring members of the Columbian cocaine cartel, as for example, when Carlos Lehder bought beautiful Norman's Cay in the Exumas. This eventually led to a Bahamian Commission of Enquiry(3) confirming complicity in the drug trade. As matters worsened, I was appointed head of the National Task Force on Drugs(4) which developed a report outlining the causes, scope, and other aspects of the crack cocaine epidemic. This resulted in an official study and publizing of the first country-wide crack cocaine epidemic.(5) In 1984, Carleton Turner from the Reagan White House visited the Bahamas to examine the extent and damage of the epidemic.
Subsequently, the crack cocaine epidemic entered the United States circa 1985-1986. It is extremely amazing to see the damage the drug has done in ten years, especially in the inner city, where men's and women's lives have been destroyed through drugs, crime, and violence. It is terrifying to think what could happen in the next ten years if the situation is not brought under control. Although the epidemic has subsided, cocaine addiction is now endemic, continuing to devastate individuals and the infrastructure of communities. According to The National Drug Control Strategy report (1966):
the insidious nature of addiction has been realized as many of these formerly occasional users have progressed to chronic, hard-core drug use. Families and neighborhoods are being torn apart by the crime and health consequences that so often accompany addiction. While one in four users is a hard-core drug abuser, this minority consumes the majority of the illegal drugs and commits a disproportionate number of drug-related crimes. About two thirds of these hard-core users come in contact with the criminal justice system each year.(6)
Recognizing the seriousness of the situation, what is our socioethical responsibility in dealing with this devastating phenomenon? According to Potter, socioethical analysis involves empirical definition of the situation (the facts), quasitheological assumptions, that is, concerns about the range of human freedom and the extent of human power to predict and control historical events and human destiny, modes of moral reasoning, and affirmations of loyalty. And, of course, no socioethical analysis is complete without implementation.(7)
I. The Facts
Good ethics demand good data. Perhaps the most pervasive impediment to dealing with the drug problem in general, and cocaine addiction in particular, is a strong sense of denial. Manifested in every hue and color, denial involves misinformation about the danger involved, misplaced idealism, simplistic solutions, and strong projective tendencies to blame. Projection may make us feel better with a sense of false pride, but healing is only possible when we take responsibility. Denial is also expressed in such statements as: "The war on drugs has failed;" "Treatment does not work;" "Addiction is an inner-city problem," and "Legalization is the only solution." Matching the public sense of denial is the addict's denial-- "I can handle it," or the pusher's rationalization, "I will do one more cocaine trip, make some money, and then stop." Most dangerous is the parent's denial, "It could never happen to my family," or "Only derelicts and losers go on drugs."
Denial has produced a state of confusion, lack of information, hopeless innuendo, and inaction. It mitigates against uniting community support to produce a symphonic togetherness in dealing with the problem. Facing the facts of cocaine addiction in general, and crack cocaine in particular, requires a deep sense of humility and unflinching commitment to the truth. Firth's "Ideal Observer" theory offers a good model to deal with facts. According to Firth, the ideal observer aims to be omniscient (informed), omnipercipient (perceptive), disinterested and dispassionate (objective), consistent, and otherwise normal (recognize limitations).(8)
When cocaine hydrochloride is snorted, 25 percent pure cocaine crosses the blood-brain barrier in 15 to 20 minutes, giving a high that lasts from 15 to 25 minutes. But when crack cocaine is smoked, 80 percent pure cocaine crosses the barrier in eight seconds, providing a high which lasts for about one minute. Using up the pleasure neurotransmitter, dopamine, the subsequent highs are less intense, of shorter duration, and the fall more precipitous. Acting as a positive reinforcement, the memory of the first high lures addicts into binge use with diminishing highs and more devastating lows. Post-cocaine crashes then act as negative reinforcement to seek more crack. The crack binge may go on for days, with the addict taking minimal food and water. In order to ease the crash, addicts use strong alcohol (rum, whiskey, etc.), or marijuana and heroin. As a result, crack cocaine addiction increases the use of other addictive substances. The chronic addict who suffers neurotransmitter depletion has decreasing highs and increasing lows. Thus, the drug promises euphoria but gives dysphoria.
Cocaine addiction in general, and crack cocaine smoking in particular, affects all body systems, producing diminished respiratory function, irregular heart rate, headache, stroke, etc. Psychologically, cocaine leads to depression, and variants of cocaine psychoses with paranoia. Socially, cocaine produces ethical fragmentation and decreased social inhibition, leading to stealing, prostitution, murder, etc. Producing community fragmentation at all levels, the drug destroys families, corrupts governing authority, and leads to "bombed-out" neighborhoods.
Of particular importance are the chronic heavy users who make up one quarter of the addicts, use two-thirds of the total cocaine, and account for two-thirds of those involved in the criminal justice system annually.(9) They also act as vectors and reservoirs for infectious diseases, such as AIDS and tuberculosis. As cocaine use becomes endemic in an area, the resulting fragmentation leads to increased crime rates and the proliferation of youth gangs which provide protection, a sense of community, and control of drug supplies.
In crack cocaine addiction, cue reinforcement occurs in which persons, money, or gold associated with the use of cocaine produces a pseudo-high in non-using addicts, propelling them to seek the drug. This has particular relevance to understanding the connection between hard-core chronic cocaine addiction and crime. For example, a chronic addict is stimulated by seeing someone wearing a Rolex watch. They attack the person to steal the watch, but find that when they pawn the watch and buy cocaine, the high from the cocaine is less than the high they experienced from the cue stimulation.
In my experience, whether by causation or association, cocaine is a viologenic drug. Crack associated violence has increased in urban areas; for instance, in Atlanta, the DEA reports increased hand gun violence and in Lubock, Texas, young hispanic gang members distributing crack have led to turf wars and increased drive-by shootings. Manchrek, et al, showed that 55 percent of cocaine psychosis is associated with violence.(10)
Cocaine arrests show a mixed picture. Declines have occurred in Boston, Miami, and New Orleans, with increases in New York City and Honolulu.(11) A number of drug indicators in the past year indicated increased cocaine use among youth. For example, past-month use of cocaine increased for 10th graders primarily due to crack cocaine use.(12)
Although vast sums of money have been spent on the interdiction process, there has been only marginal success in curbing the supply of cocaine. The late Dr. Sidney Cohen, a well-known expert in the field of drug abuse treatment, put it this way:
There have been massive seizures of cocaine and coca [in the] past, laboratories were destroyed in Columbia, and thousands of coca bushes uprooted and burned in Peru and other countries. But in spite of this, the coca plantations have spread over the immense land areas of northwestern South America.(13)
This depressing reality does not imply that enforcement activities should be curtailed, but that enforcement alone is not enough. Demand-reduction strategies such as education and rehabilitation should match our commitment to law enforcement.
Cocaine addiction has invaded the work place, and along with existing high rates of alcoholism, leads to poor attitudes, decreased productivity, stealing, and violence. Although the subject of much debate concerning the civil liberties of employees versus the protection of society, urine screening has been widely implemented in the work place. Mandatory random urine testing has been recommended for employees whose alertness on the job may affect public safety, such as pilots, train captains, nuclear industry workers, etc.
The invasion of cocaine into professional sports has had a dethroning effect on this powerful alternative to drug abuse which is held in such high esteem by young people. Seeing the drug scourge take hold of sports heroes--the ones who have made it against so many odds--is especially tragic not only for the ones whose lives are destroyed, but for young people desperately looking for role models.
These and other issues provide a bird's eye view of the urgency and complexity of the cocaine problem. Good ethics demand good data. There can be no proper resolution without a commitment to examine all the issues involved.
Being Perceptive
The solution to the drug problem depends not only on our being informed, but also on our ability to empathize or identify with the pain of those who suffer. This requires the ability to place ourselves in the position of others, to feel what they feel, and then move to treat them as we would like to be treated. Such empathic projection requires patience, tolerance, and understanding. It means moving beyond the narcissistic calculus to be touched by another. According to Alfred North Whitehead, this sensitivity transforms a fact from being a mere fact to being invested with all its possibilities, thus becoming "the architect of our purposes, and the poet of our dreams."(14)
The fearsome spectacle of widespread drug abuse is more than a red line on a statistical chart--it is destroying our families, prostittuting our daughters, and robbing the manhood of our sons. Hear the mother detail the death of her child. They told her to do the best for her kid, and she tried. They told her to send her child to school, and she did. They told her she lived in a green and pleasant land-- an idyllic paradise--and she believed them. But the high went higher than high, the crash even deeper, and the bullet rang; the rope tightened, and her son--her child-- was dead. As a psychiatrist, I have mourned with many such grieving mothers. What a terrifying experience!
Is cocaine addiction the new slavery? Hear a pusher call an addict "my slave." Running out of money, addicts sell themselves to pushers to obtain more cocaine. Is this not the classic character defense of the repetition compulsion? Upon being freed, the slave chooses to return to the bondage of a new slavery.
Consider the effects on the addict's children. Listen to the poetry of an 8-year-old girl whose mother is a cocaine addict and leaves home for a week at a time:
Life is nothing to me,
Life don't mean a thing to me.
With my life, it is terrible;
People pulling me apart.
The things I go through are horrible,
And some are breaking my heart.
Can we feel the violence destroying her life? Is her personalized pain universalized in our hearts?
Being Objective
Recognizing the complexity and emotional nature of the cocaine problem, a sense of objectivity is necessary in working towards meaningful solutions. Using the model of the legal jury system, this might best be achieved by multidisciplinary formats to prevent particular interests or biases from dominating the process. A microcosm of society itself, the cocaine crisis requires input from all segments of the community. Noting the difficulties in achieving this type of cooperation, Archibald says,
Researchers can't communicate with treatment workers, physicians can't communicate with educators, and so on. At the same time, people in research, treatment, and prevention tend to look down on the police. And vice versa.(15)
Although there were growing pains, the multidisciplinary composition of the National Drug Council of the Bahamas provided a mutual educational experience, broadly based analysis of the local cocaine situation, and a cooperative approach in working toward its solution. This led to a symphonic response with the community, calling for action against drug abuse.
Being Consistent
Consistency dictates that, even as we press to eliminate illegal drug use, whether it be cocaine, designer drugs, or marijuana, we simultaneously seek to affect healing related to the abuse of prescription drugs, alcohol, and cigarettes. Abuse of any substance is often related to abuse in other areas. Cocaine addicts admit increased alcohol and marijuana use to control the "crash" after the cocaine high. Early marijuana use in school-age children is now seen as a precursor to subsequent cocaine use in the mid-teen years--for example, many high school students undergoing treatment for cocaine addiction began smoking marijuana in pre- or early adolescence. If the cocaine epidemic provides the stimulus for the development of a consistent and effective approach to all drug abuse, the community would benefit enormously.
Recognizing Limitations
It is magical thinking to believe that a short, simple solution exists. Healing must start with the development of an effective infrastructure which slowly brings about the desired changes. This process, fraught with ambivalence and frustration, confronts our limitations, taxes our patience, and often produces burnout. Confrontation with our limitations and helplessness is painful. As professionals, we are so enmeshed in our "perceived" role--as the great doctor or psychologist--that it is hard to relate to our actual role, that of a frail human being who is limited and vulnerable. To be effective in the field of cocaine addiction treatment requires a meaningful balance between the perceived and the actual role, manifested by a sense of competency with a realistic awareness of limitations. We must have the personal integrity to say, "I don't know;" the ability to tolerate frustration and failure, and still find the strength to persist, to give hope in spite of despair.
II. Value Beliefs
Impacting the cocaine problem requires not only accurate knowledge and technical expertise, but also an unflinching commitment to a humane value system and moral center. According to Arieti:
Values always accompany and give special psychological significance to facts.... When we deprive facts of their value, we fabricate artifacts which have no reality in human psychology. An individual may suspend his value judgment when he wants to examine a fact from a specific point of view, but then the ethical content has to be re-established if the fact is to have human significance. If we remove the ethical dimension, we reduce man to subhuman animal.(16)
Emphasizing the importance of a moral center, Eisenberg argues that what one believes about the nature of human beings exerts a subtle but controlling influence on the attitudes, behaviors, and treatment of individuals.(17)
Western ethics are based on the Judeo-Christian tradition which, at its core, views all human beings as having been made in the image of God (Gen. 1:27). Providing the basis for personhood, dignity, and human rights, this age-old concept is the operative force enhancing personal meaning, interpersonal relationships, and human community. Elaborating on this concept, Niebuhr says this "reverence" for all human beings is the quintessential element for meaningful social reform.(18) Thus all individuals, regardless of race, class, handicap, illness, sex, or age, are persons with meaning and dignity, deserving the utmost respect and concern.
The principle of autonomy inherent in this respect for the uniqueness of human personhood carries with it responsibilities and duties as well. The person with a cocaine problem should not be seen as a "junkie," but as a person who has the right to be respected, a right which may involve receiving proper treatment. Similarly, he/she has a responsibility as a person in society to other persons in that society to work on the drug problem by taking advantage of treatment opportunities offered. The basis of our relationship in caring for or working with addicted persons is our mutual personhood, with mutual respective rights and responsibilities. By recognizing in each other the shared human qualities which transcend individual differences or problems, we actualize the principle of reciprocity in a practical way so that we treat others as we would want to be treated.
The moral responsibility inherent in this reciprocal, empathic, interpersonal relationship requires allegiance to other vital principles such as trust, forgiveness, truth-telling, love, promise-keeping, justice, liberty, and non-injury. Being absolutely germane to the human community, these principles may be called constitutive imperatives--the underlying principles upon which all laws governing society are made.
Johnson and Butler emphasize the importance of this concept:
Respect for individuals requires that every individual be treated in consideration of his uniqueness, equal to every other, and that special justification is required for interference with their purposes, their privacy, or their behavior. It implies sets of liberties, rights, duties, and obligations especially of promise-keeping and truth-telling.(19)
The cocaine problem may be described as a crisis in values, as they relate to the community in general and the individual in particular. How could the cocaine epidemic spread so rapidly? The sad truth is that persons in the producer countries of South America, the transshipment areas of the Caribbean, and massive consumer centers like the United States, are willing to sacrifice basic human values for sordid gain through blood money. The words of a crack-addicted person ring true: "Money is more important than people and principle does not count."(20)
III. Moral Reasoning
The moral reasoning inherent in any process profoundly influences the way persons are treated. Forms of moral reasoning range from the ethical egoism of Kohlberg's Stage I to the more sophisticated formalism of Stage VI.(21) Western ethics are mainly influenced by two ethical systems: formalism and utilitarianism.
Formalism is deontological and requires commitment to basic principles such as justice, promise-keeping, honesty, and non-injury. The major thrust is being faithful to principles in spite of consequences or outcome. Utilitarianism, on the other hand, is teleological and has as its basic tenet the facilitation of the best balance of pleasure over pain and the greatest good for the greatest number.
Connected to utilitarianism is the prevailing value of instant gratification or success, as opposed to the formalistic approach which emphasizes the need to struggle for long- term, more enduring results. In the areas of education, enforcement, or rehabilitation, the utilitarian perspective would emphasize immediate results. When and if such results are not forthcoming, frustration, anger, and burnout follow. There are no magical solutions to the cocaine problem, and even if the short-term results are not what we wish, it is our duty to persist in working toward a society where persons may choose a drug-free lifestyle and, if addicted, may receive treatment with dignity and respect.
Another major ethical issue is the utilitarian argument that drug addicts are the losers of society who choose to destroy themselves by their personal choice of addiction. As a result, they should not receive attention and resources at the expense of the majority. Firstly, this is a misunderstanding of the addictive process. The bane of addiction is that the user continues to use compulsively despite devastating adverse consequences. With cocaine addiction, a biological hunger drive is created, which puts the brain on automatic pilot for cocaine, though this may be contrary to the desire of the addict. Secondly, this form of social utilitarianism ignores the pathos of the vicious world of the addicted person. Though appealing to the majority of the most powerful, this philosophy offers little for those who are in the minority and/or without power. When unchecked, this motivation has led to atrocities inflicted on such disadvantaged groups as the mentally ill, the mentally retarded, and racially despised groups considered expendable for the greater good.
Underlying the social utility concept is the assumption that only life of a certain quality has worth. There is a tendency to define personhood on the basis of relative social utility. Whenever one's utility/disutility ratio is affected, worth as a person is diminished. Being a cocaine addict reduces utility and basic worth in society. Thus the utilitarian view of justice denies positive presumption and equality under the euphemism "for the public good." This strains the moral fiber of society itself and undermines the meaning of such principles as promise-keeping, justice, and liberty for all its members.
IV. Loyalties
Loyalties dictate the ultimate ends we serve. The war against drugs requires a clear understanding of loyalties in terms of ends and means. The ultimate goal is to create an environment in which individuals would freely choose a drug-free lifestyle, or, if addicted, would receive treatment in programs which respect the meaning and dignity of human personhood. Yet so often, whether in areas of enforcement, education, research, or rehabilitation, we become frozen in our own ideas and fused to our personal projects. Refusing to be flexible and open to the overall perspective, we are subject to petty jealousies, destructive competition, and defensive communication. As a result, efficiency and creativity are compromised, and the program becomes an end in itself rather than the means to serve the best interests of those being treated.
V. Implementation
The cocaine crisis, with its horror stories of threat to individuals, families, and countries, evokes panic and a tendency to impulsive action. On the other hand, as we learn more about the severity and complexity of the situation, there is a parallel tendency to feel overwhelmed, to despair, and to withdraw. Recognizing that both of these options are counterproductive, clarification of goals and effective implementation are best served by thoroughly analyzing the data base (facts), value beliefs, moral reasoning, and loyalties inherent in one's plan of action. In light of the complexity of the situation, the war against cocaine requires a multiplicity of well-coordinated approaches as represented in the following initiatives:
*The Need for a Symphonic Approach. In light of the complexity of the situation, the war against drugs in general, and cocaine in particular, requires a symphonic approach. Archibald stresses that, without coordination, success will be at best isolated and temporary:
Drug traffickers are multinational corporations with highly developed systems including marketing specialists, promotion specialists, and training for couriers. They have it in their power to change the political map of the world. In contrast, the addictions field is rife with territorialism and mutual disdain, specialty for specialty, group for group.(22)
In the Bahamas, it was not until each sector of society realized it was under attack by the drug problem that a community groundswell resulted in an effective symphonic response. This meant the coming together of the police, educators, politicians, business persons, media, the religious community, and ordinary consumers in fighting against drugs.
*The Development of Innovative Treatment Approaches. Traditionally, the drug war has had an overemphasis on interdiction and reduction of supply. In my view, this is important, but must be balanced by an aggressive, continuous, and creative approach to demand reduction. Life is wounded, and we all experience a hole in our souls. As a result, we look for means of comfort, solace, and pain-relief by wrapping ourselves in numerous addictions, such as, drugs, money, sexual issues, workaholism, etc. My argument is that regardless of supply, unless we seek to find positive ways to heal the hurting hearts, especially of our children, the search will continue for substances to fix the holes in our souls. Beyond this, we need innovative approaches to treatment. Treatment should be simple, cost-effective, accessible, and built around a critical but limited number of professionals, supplemented by trained volunteers or retired persons. According to the Rand Corporation Study, $34 million invested in treatment resources for cocaine use equals as much as an expenditure of $783 million for source-country programs, or $366 million for interdiction.(23)
Treatment services should follow a cone shaped model with few inpatient or residential centers at the apex and the majority of outpatient services at the base. In the Bahamas, the government took the lead in establishing an array of inpatient and outpatient services. This was supplemented by treatment outreach programs developed by each major religious denomination. Coordinated by the rehabilitation committee of the National Drug Council, the comprehensive array of services afforded each addict the opportunity for free, accessible, and effective treatment.
*The Development of Treatment Programs in Prison. As stated earlier, even though the number of new users of cocaine is down, by far the most troubling problem is the increasing number of hard-core chronic users. Going in and out of prison, these addicts are hardened and powerfully disruptive to society. The development of creative programs in prison can be extremely effective in their rehabilitation. However, from my experience, the treatment is more effective if the program in prison is interphased with a community treatment program upon discharge.
*The Development of Treatment Programs in Homeless Shelters. The crack crisis has lowered the average age of homelessness to about 22 to 27 years old. Sadly, giving a person a bed to sleep on and a meal to eat may enable his or her addiction. As a result, some homeless shelters have become crack dens. In the past three years we have developed a pilot program at a homeless center at the Gospel Mission in Washington, D.C. The program consists of spiritual direction, prayer, scripture reading, 12-step approaches, development of values and community, remedial education (basic education including GED, computer literacy, and grooming), psychological support (anger management and impulse control), and vocational training, (training at fast food chains, etc.). The results are promising, because when addicts become homeless they hit rock bottom. As a result, they are humbled because their denial and projective defenses are broken, and they are more willing to seek help.
*Relate Education, Training, and Work to the Treatment Program. Thousands of addicts in treatment spend time in individual and group therapy with little exposure to educational training and work. This is counterproductive because an addict, even off drugs, is vulnerable to the vicious cycle of re-addiction if he or she has no future as far as education, training, or work is concerned. Why can't addicts in treatment clean parks, paint the homes of elderly persons, or volunteer to work with mentally retarded or physically handicapped persons? The hallmark of Haven programs in the Bahamas and Washington is that the addict is put to work immediately upon entering treatment.
*Development of Drug Courts. Drugs and crime are intimately related. Drug courts could delay sentencing to prison by placing the addict in a treatment program. The court then monitors the program of the individual by specific markers, such as behavior, urine screening, or drug use. Thus, if addicts do not follow through in treatment, they are sentenced to prison. Recognizing that this is a form of mandatory treatment, I have seen it work in the Bahamas.
*Save the Children. We must put a ring around our children. The seeds of addiction are planted early in childhood through the breakdown of family, church, and school connections. Children need love in a structured environment. Being a transgenerational bonding community with its mandate to love and care, the church can be creative in reestablishing the connection between family and community. Volunteers, big brother programs, and foster grandparent programs are extremely helpful in creating a sense of caring in a community. In the Haven programs, the church has been a powerful bond between the community and the treatment program. In the Bahamas, crack addicts who have been sober for ten years or more have been integrated into caring religious fellowships.
Chronic crack addiction tends to be transgenerational, particularly affecting young males of crack-addicted fathers. One of the most beautiful experiences of my life was to be on a retreat for male crack addicts and their sons whom they had not seen for months or years. These retreats, held four times a year, allow father and children to be together in a caring environment.
Conclusion
Last, but not least, the spiritual perspective is extremely helpful in providing motivation, encouragement, and accountability in dealing with the many facets of drug addiction. Spirituality is that dimension of life which involves ultimate concerns or beliefs (God, higher power, Jesus Christ, etc.), as it relates to the evolution of personal meaning, the development of community, and an informed caring for the environment. Writing from the perspective of my own faith tradition, which is Judeo-Christian, I'd like to discuss some universal principles of spirituality as presented in the last supper.(24)
Love. Telling His disciples He loved them to the uttermost, Christ emphasized love as the building block and healing force of life. In a study of ten severe crack addicts with histories of violence and criminality, the one concern shared by all of them was that "they all wished they had a father who said he loved them!"(25) Regardless of the sophistication of the program, if love, expressed by such factors as acceptance, community, caring, honesty, and forgiveness is lacking, the program is less effective. I'll never forget the evening when one of the men in my program shared that he was a murderer who had served time in prison. He then asked me, "Dr. Allen, do you still love me?"
The psychiatrist may listen, the surgeon operate, and the physician prescribe, but only God's love heals!
Communion. Enjoying a meal together, the disciples experienced a deep sense of communion and togetherness. The major goal of initiatives in the war against drugs is to encourage the development of a healing, drug-free community. This, however, requires a spiritual base for communion--for example, the desire to do the good in spite of the outcome. In other words, fighting drugs is the good, and even if we fail, it is the right thing to do. In the early days of the crack epidemic in the Bahamas when I headed the Task Force on Drugs, my office was in the Sisters of Charity Convent. Love, prayers, and support from the nuns gave me courage to face the multiple problems, painful experiences, and possible choices in fighting against crack.
Resistance. The last supper was punctuated by the discordant notes of Judas' resistant and destructive attitude. But the supper continued in spite of the resistance. The war against drugs is fraught with so much negativism, learned helplessness, and frustration. With our faith in God, our higher power, we are challenged to move on in spite of resistance. The spiritual allows us to move beyond our frustration, to light a candle in the darkness to radiate hope and courage.
Humility. Divesting Himself of His outer garments, Christ humbled Himself and became a servant. Healing is only possible by moving from a willful attitude of pride to a willing spirit of openness and humility. Humility is the antidote to despair in the war against drugs, because it allows us to see reality as it is, and therefore establish meaningful goals and appropriate agendas. Facing our responsibility, humility means breaking through the projective defense of blaming others to serve in our respective roles in the war against drugs.
Simplicity. Using the simple articles of a basin and water, our Lord prepares to show love to His disciples. Life at its heart is very simple. I am always humbled by the success of the simple approach in dealing with addiction problems. As head of the Bahamas Task Force on Drugs, I was appalled to walk into an area called Black Village, where twenty young men were hitting crack cocaine in broad daylight. They rejected any hint of psychiatric help or rehabilitation approaches. The situation was dismal and appeared hopeless. After much deliberation, we hired a young pastor, Brother Zeke, from the same area, to be a street worker. Each morning he would sing and pray with the men and feed them McDonald's Egg McMuffins. To my surprise, within nine months many of the men sought help and the area was totally cleaned up.(26)
Service. As our Lord washed His disciples' feet, so we too are called upon to serve each other. Drug addiction has touched almost every family, leaving many of us hurt, discouraged, and frustrated. We need to listen, help, and do our best through education, prevention, and treatment to heal those in our midst. It is difficult enough to wash the feet of those who agree with us, but maybe the test of caring is seen in Jesus washing the feet of Judas, the one planning to betray Him. Fighting against drugs is a dangerous enterprise, with small victories and terrible frustrations. Often the test of our commitment to care is serving even when it hurts.
Transcendence. The spiritual has its essence in God's transcendent love. This means seeing the spark of God in each person, whether an addict, pusher, or abused person. Calling us to look beyond our faults, limitations, and hopelessness, the reminder of God's transcendent love makes possible a thousand new beginnings and allows us to be surprised by joy in seeing victory snatched from the jaws of defeat.
After hiring Brother Zeke to do street work in Black Village, I went to check on the program about two months later. As I entered the area, I was accosted by six tough addicts. One of them whose name was Neal, had a bullet in his arm and lived in an old abandoned car. They accused me of injecting the Egg McMuffins with a drug. They complained that after singing, praying, and eating the Egg McMuffins, they were unable to get high on crack cocaine, so they had to hit as much cocaine as possible before visiting Brother Zeke. I don't understand this. But could it be that when they saw Brother Zeke, one of their own doing good, it awakened repressed memories of the spiritual teachings of their mothers, which neutralized the high from the cocaine?
Eight years later, I finally received permission for my drug programs to be accepted in Her Majesty's prison in Nassau. Going to the first session, I felt alone and nervous because other members of my team were not able to attend. As the guards closed the huge iron doors behind me, seeing about fifteen tough guys walking toward me, I felt scared and apprehensive. But then a guard, dressed in a khaki uniform with a prisoner carrying his coat, approached me. Putting his arm around me he said, "Don't worry, Doc, my name is Neal. I'm in charge here. Eight years ago, when I was a hopeless crack addict in Black Village, you sent Brother Zeke to feed me. I went to Teen Challenge in Florida to get off crack and then went on to finish school and return to work at the prison."
Shocked, I found it difficult to make the connection between the Neal I'd known living in the old abandoned car and this person standing beside me. It was an epiphany--the experience of the miraculous.
REFERENCES
(1 ) D.F. Allen, F. Jekel, Crack: The Broken Promise (London, UK: McMillian Academic and Professional Ltd., 1991).
(2 ) D.F. Allen, "The History of Cocaine" in The Cocaine Crisis, ed by D.F. Allen, (Plenum Press, New York) 7-13.
(3 )Report of the Commission of Enquiry 1987, Bahamas Government Publication.
(4 ) Report of the Task Force on Drugs 1985, Bahamas Government Publication.
(5) Jekel, D.F. Allen, et al "Epidemic Cocaine Abuse: A Case Study From the Bahamas" (The Lancet I,1986), 459-62.
(6 ) National Drug Control Strategy, 1996, p. 11.
(7) R. Pottter, War and Moral Discourse (John Knox Press, 1969), 23.
(8 ) R. Firth, "Ethical Absolutism and The Ideal Observer" (Philosophy and Phenomenological Research, 12 March, 1952).
(9 ) National Drug Control Strategy, 1996, p. 11.
(10 ) T. Manschrek, D.F. Allen, M. Neville, "Freebase Psychosis Cases From A Bahamian Epidemic of Cocaine Abuse," (Comprehensive Psychiatry Vol. 28, No. 6, Nov-Dec 1987), 555-644.
(11) Crack, Facts and Figures, (Office of National Drug Control Policy, Feb. 1996), p. 19, P.O. Box 6000, Rockville, MD 20849-6000.
(12 ) National Drug Control Strategy
(13 ) S. Cohen, Drug Abuse and Alcoholism Newsletter, Vol. XIV, No. 2, April 1985.
(14 ) A. N. Whitehead, The Aim of Education and Other Essays, (London: Earnest Henn, London, 1962).
(15) D. Archibald, "Coordinated Anti-Drug Action Is Imperative" (The Journal 15(2)-1, Feb. 1, 1986).
(16) S. Arietti, "Psychiatric Controversy: Man's Ethical Dimension" (Am. J. Psychiatry, Jan. 1975), 132-1.
(17) L. Eisenberg, "The Human Nature of Human Nature" (Science Vol. 176, April 14, 1972).
(18) R. Niebuhr, Moral Man and Immoral Society, (New York: Scribners, 1932, 1960).
(19) A.R. Johnson, L.H. Butler, "Public Ethics and Policy Making" (Hastings Center Report, Vol. 5, August 1975).
(20) Remark made by cocaine addicted patient in a community psychiatry clinic, Nassau, Bahamas.
(21) L. Kohlberg, "The Claim of Moral Adequacy of a Highest Stage of Moral Judgement" (Journal of Philosophy, Vol. 70, October 25, 1973), 603-46.
(22) D. Archibald, 1980, op.cit.
(23) P.C. Rydell, S. Everingham, Controlling Cocaine: Supply Versus Demand Program by Rand 1994.
(24) John 13:1-21.
(25) D.F. Allen, D. Matthews, Unpublished Study of a Review of the Characteristics of a Sample of Bahamian Crack Addicts.
(26) This occurred in 1984. The Reverend Zeke Munnings now works full time at the Bahamas' National Drug Council. *
David F. Allen, MD, The Renascence Clinic, Arlington, Virginia
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