The Fix by Michael Massing. New York: Simon & Schuster, 335 pp., $25.00.
The dust jacket of Michael Massing's The Fix summarizes his thesis in bold red letters: "Under the Nixon Administration, America Had an Effective Drug Policy. WE SHOULD RESTORE IT. (Nixon Was Right)." That is a pretty extraordinary claim to make regarding an administration that gained office in large part through the "Southern Strategy" that had at its heart Nixon's declaration of a "War on Drugs" and whose policies created the cocaine epidemic that caused so many new concerns a decade later. At most, I would agree that the Nixon administration's pursuit of a fundamentally bad policy included some worthwhile efforts that have been devalued by every subsequent administration. This was not because Nixon or his closest advisers were right about drug policy but because Nixon was more interested in foreign policy issues and his benign neglect of domestic policy allowed a number of positive developments to blossom in the midst of the mire of incompetence and corruption that characterized his presidency.
Perceptively concluding that "policies being formulated in Washington today bear little relation to what is taking place on the street," Massing attempts to depict the real effects of drug policy at the street level. Unfortunately, he doesn't rely on the epidemiologic evidence or read the careful analyses conducted by researchers like myself who have systematically examined what is truly taking place on the street. Instead he relies on the journalist's usual - and usually misleading -- tool of dramatic anecdotes.
Massing's anecdotal case is presented through the stories of Raphael Flores and Yvonne Hamilton. Flores runs Hot Line Cares, a drop-in center for addicts in Spanish Harlem. Hot Line Cares, which Flores founded in 1970, is essentially just a cramped office in of an otherwise abandoned tenement where Flores and his staff advise and assist addicts who want to get into treatment. Given the fragmented state of drug abuse treatment in New York City, and in most other American communities, it is no easy task to connect addicts with appropriate care and even harder to connect them with adequate aftercare. Massing writes, "If a Holiday Inn is full, it will at least call the Ramada down the street to see if it has a vacancy. Not so two treatment programs"
Yvonne Hamilton is a crack addict trying to get her life together. Massing describes her trials and tribulations as she copes with her illness and makes her way through New York City's treatment non-system. It is an affecting story and well told. The author presents it as an argument for treatment and perversely as an argument against decriminalization or legalization. But she is one of the many examples that show that prohibition does not prevent addiction. And improvements in her drug problem seem to have less to do with the treatment she did receive than with changes in her life situation.
These two lives provide a touchstone to which his narrative will later return. The middle third of the book shifts dramatically in tone as Massing chronicles the evolution of the war on drugs in Washington. During Nixon's tenure, the government spent more money on treatment (the "demand" side) than on stopping drug trafficking (the "supply" side), which he argues led to declines in both drug overdoses and crime rates. As successive presidents felt pressure to emphasize the "war" rather than treatment, he asserts that the number of chronic addicts skyrocketed. In the third and last section Massing returns to Spanish Harlem, where Hamilton continues a difficult struggle to remain drug-free and Flores struggles to keep his center afloat and to keep from falling into addiction himself.
It is the second part of the book that is the heart of Massing's thesis. It is a tale that is familiar to those of us who are active in the field of drug policy and, in addition to scholars, other journalists have told it before -- Dan Baum in and Mike Gray in -- but I will summarize (with some details Massing missed or left out) the history of drug policy under Nixon for the reader who is not familiar with the story.
In 1968, as Richard Nixon was making his comeback run for the presidency, he adopted the "Southern Strategy" that has been the key to Republican victories in presidential races ever since. Since the end of Reconstruction every Democratic presidential candidate had been able to rely on the votes of the "solid South" but the Northern Democrats' support for civil rights had been the cause of increasing disaffection in the South, as epitomized by Strom Thurmond's independent run for President against Truman in 1948. Then, in 1964, Alabama Governor George Wallace's bid for the Democratic nomination for President showed that racism won votes in the North as well as the South. Nixon wanted to win the South, as well as racists' votes in the North, without offending more traditional Republican voters by an openly racist campaign. The answer Nixon and his advisers found was to campaign against crime, which most Americans quite falsely equated with minorities. So what if the crime rate was actually declining, Americans seem to always believe that crime is increasing just as they seem to always blame it on cultural or racial outsiders.
Even better than campaigning against crime, the Nixon team soon realized, was campaigning against drugs. Most Americans, again falsely, equated drug users with violent criminals. Better still, for that great "silent majority" whose votes they sought a campaign against drugs symbolized a campaign against both Blacks and much hated hippies and anti-war protestors. When Nixon declared "war on drugs" he was appealing to the basest elements of the American electorate and it worked, just as it has worked for other candidates since.
The success of his anti-crime/anti-drug campaign presented Nixon with a serious dilemma when he took office - people were expecting results. At first his administration considered admitting that constitutionally crime control was a state responsibility and proposing to act through support of training programs and grant-in-aid to state and local police forces, but his approach had little political pizzazz and was largely abandoned after it failed to impress the public. Nixon had some ideas of his own, such as a nationwide mandatory death penalty for selling drugs - a strategy that has been tried in Red China and in Singapore and has clearly failed in both nations - but fortunately he was more interested in foreign policy and left the search for a solution to the drug problem in the hands of John Ehrlichman and the White House Domestic Policy Council.
Within the Domestic Policy Council Egil "Bud" Krogh Jr., a young lawyer who is better remembered as the man who headed the White House "plumbers" of Watergate fame, was charged with responsibility for finding a way to visibly impact drugs and crime before the 1972 election. Massing portrays Krogh as something approaching the tragic hero of the tale, but I'm not sure that many other than Massing and Krogh himself hold such a positive view of his public service. In any case, it is true that Krogh played a key role in shaping both the good and the bad in the Nixon administration's drug policies.
In one of his other roles as liaison to the government of the District of Columbia, Krogh had become acquainted with psychiatrist Robert Dupont who was running one of the early methadone maintenance programs in DC. Krogh was reluctant to accept a maintenance approach to addiction but he did see that it was the one approach that actually had some evidence of effectiveness. In June of 1970, Krogh sent the Council's youngest lawyer Jeffrey Donfeld to visit methadone programs in New York and Chicago, including the first such program, which was directed by Vincent Dole and Marie Nyswander of Rockefeller University, and a "mixed modality" model developed by University of Chicago psychiatrists Jerome Jaffe and Edward Senay.
Donfeld was dubious about the claimed effectiveness of methadone treatment and even more dubious about its political acceptability - in terms that have since become familiar, he wondered if it would send the wrong message. Donfeld found Jaffe in particular to be "politically sensitive" to the emotional issues involved in methadone maintenance. Donfeld believed that the "mixed modality approach," which he called "different strokes for different folks", by offering a range of treatments that included detoxification, drug-free, and maintenance approaches, effectively masked the methadone program from political criticism.
Much as Raphael Flores is the hero of the first part of the book, Jerome Jaffe is Massing's hero for the second part. Jaffe has described his meeting with an essentially clueless Nixon. He sidestepped Nixon's idea of the death penalty for dealers and suggested that the one value of law enforcement might be in pushing up the street price of drugs and thus encouraging more addicts to seek treatment - this idea was later taken up by Peter Reuter of the Rand Corporation but his research showed that the effect of aggressive law enforcement on supply was essentially nil and on price was tiny.
Jaffe attempted to make four points in his meeting with the President an d each was to bear fruit in shaping the future of drug policy under Nixon. The first was the need for more research and evaluation of treatment. The expansion of a small division within the National Institute of Mental Health into a National Institute on Drug Abuse and a National Institute on Alcoholism and Alcohol Abuse grew in part out of this recommendation. Second, he noted that currently there were a dozen different federal agencies funding treatment that didn't even talk to each other. He felt that coordination of all these efforts was needed in pursuit of a coherent national strategy. This led to the creation of the Special Action Office for Drug Abuse Prevention, which he was startled to find himself appointed director of, as the nation's first "drug czar". Third, given the extent of heroin addiction, he urged that methadone maintenance should not be restricted to a few small research projects but should be made widely available. Fourth, he urged that funding for treatment be dramatically increased. These last two points were at the heart of what Massing refers to as "The Fix".
Jaffe's first big White House assignment was to develop a plan for controlling the skyrocketing prevalence of heroin use among U.S. servicemen in Vietnam, which involved 10 to 15 percent of all GIs in Vietnam if not more. Pentagon policy was that heroin use was a crime and that any serviceman who used heroin should be arrested and prosecuted. The result of this was an over-burdened military justice system but no reduction in heroin use. Jaffe urged that the Pentagon should adopt a treatment approach instead of a punitive one.
Massing suggests that Jaffe's solution relied for its effectiveness on the GIs' overpowering desire to return to the United States. He advised the Pentagon to subject all GIs to urinalysis before shipping them home. GIs who tested positive for heroin would have to stay in Vietnam for detox. The military's reaction to his plan was to object that it would play havoc with the complex logistics of troop movement, to which Massing reports that Jaffe replied, "I cannot believe that the mightiest army on Earth can't get its troops to piss in a bottle" When his plan was implemented, Massing reports that the percentage of GIs using heroin quickly dropped by more than half.
Jaffe himself tells it quite differently. It appears that as an academic and researcher he was aware of the growing evidence that most heroin users do not become addicted and the early follow-ups showing that most of the troops who were addicted to heroin in Vietnam abstained successfully, and usually without any treatment, after returning home (Jaffe and Harris, 1974). He didn't fool himself into believing that the urine screening program actually deterred heroin use among the troops while serving in Nam. What he expected was that once word of the urinalysis got around heroin using GIs who weren't addicted would stop using for the last weeks before rotation home and only the truly addicted would be unable to do so and thus fail the urine test. This is apparently what happened but it gave the politically useful appearance of a far greater success. The classic follow-up study by Robins, et al. (1980) confirmed that most of the GIs who became addicted to heroin while serving in Vietnam recovered fully and permanently after returning to the US and also found that recovery rates were not improved by receiving treatment - a finding the implications of which I discussed in several publications of that period (Duncan, 1974, 1975, 1976 & 1977).
I believe that the rapid recovery of Vietnam addicts demonstrates that for most of the GIs who became addicted, heroin use served as a coping mechanism for dealing with the stress of serving in a war zone. The relief they obtained by using heroin served as a negative reinforcer and negative reinforcement produces powerful habituation. Once they returned home their heroin using behavior extinguished in an environment where for most of them it was no longer being reinforced. Those who persisted in their addiction, according to Robins, et al. (1980), were the ones who returned to conditions of poverty, an alcoholic parent, etc. - exactly the ones who would continue to need a stress reliever. Treatment was far less relevant than environmental change, which is what Moos et al. have found to be true for alcoholism treatment (Moos, Finney, & Cronkite, 1990; Finney & Moos, 1992).
As Massing reports, Jaffe was able to convince the Nixon administration to increase funding for drug abuse treatment eightfold over what it had been when Nixon took office. For the only time so far since America began its failed experiment with drug prohibition, the treatment budget was larger (twofold) than that for drug law enforcement. Massing attributes a decline in narcotics-related deaths and in crime rates to this budget increase and a more than 300 percent increase in the number of persons in treatment. It would be nice for treatment advocates like me if that was true but no knowledgeable analyst is likely to agree that it is.
While more addicts in treatment probably played some role in reducing the numbers of narcotics-related deaths, there were two other factors that probably played a far greater role. First, was the introduction in 1971 of naloxone (Narcan®), a full narcotic antagonist, which replaced nalorphone (Nalline®), a partial narcotic antagonist, as the drug of choice for treating narcotic overdoses. Second, was the growing popularity of amphetamines and other stimulants resulting in them replacing heroin as the primary drug of addiction in America. This may also have contributed to the decreasing death rate in a tertiary fashion by reducing demand for heroin and therefore reducing the price and increasing the purity of heroin on the street which would reduce deaths that often result from allergic reactions to the impurities in illicit heroin.
There is strong evidence that the availability of methadone maintenance in a community with large numbers of heroin addicts will bring about a reduction in rates of property crimes, especially the burglaries and petty thefts that addicts most often engage in to raise money to support their habit. It is very likely that the expansion of this modality under Nixon and Jaffe did lower crime rates. Crime rates, however, were already trending downward and the continuation of that trend was probably more important than any government policy.
The gravest defect of The Fix lies in its tacit assumption that the general direction and goal of our nation's current drug policy is fine and just needs some tinkering with its budget priorities in order to "fix" it. Well, Nixon didn't fix it, nor will or can any future president. The goal of eliminating recreational drug use has never been achieved anywhere nor is there any good reason why society should be better for achieving such a goal.
I directed one of the early treatment centers to utilize the "mixed modality" approach that Jaffe advocated and I continue to believe in its value. The fragmented state of most treatment services today, so well illustrated by Massing's two examples, certainly is a serious barrier to the effectiveness of treatment. So I would certainly agree with Massing that America would benefit greatly from both a return to greater funding for treatment and the use of multimodality treatment. But no public health problem can be adequately controlled through treatment, or secondary and tertiary prevention as we in public health prefer to call it. It is only through primary prevention that a problem as big as drug addiction can be meaningfully reduced. It certainly cannot be reduced by operating a system in which between a third and two-thirds of the current patients don't need any treatment at all because their drug use is recreational and not addictive.
Effective primary prevention of drug abuse, however, has to be something far different from telling people to "just say no" and telling prophylactic lies to kids in D.A.R.E. classes. First of all, effective prevention (primary, secondary or tertiary) must focus on the actual problem of addiction rather than on all use of certain selected drugs. Most users of any of the widely used drugs, with the exception of nicotine users, are not addicted, are not at great risk of becoming addicted, are not doing any substantial harm to themselves, and aren't harming anyone else by their use of the drug. Even a small proportion of tobacco smokers are not addicted and are not harming themselves by smoking. Society has no valid interest in preventing drug use but a very clear interest in preventing addiction.
Second, primary prevention cannot be achieved by scaring people - least of all by scaring them with lies. Programs like D.A.R.E. make a strong impression on many preadolescents and early adolescents who swear they are never going to use drugs but by their mid-teens most of them have learned through observation that much the D.A.R.E. officer told them was lies and they are not only ready to experiment with drugs but cynical in viewing any valid warnings they might receive from adults about real risks. Effective prevention must be based on facts not scare stories. Instead of insisting that kids should stay drug-free forever, which virtually no one in our society is or should be, we should be teaching them how to responsibly assess drugs and situations of use so that they can choose wisely what and when and how regarding drug use.
Criminalizing drugs and drug use makes all levels of prevention more difficult. No drug user or abuser is going to be better off for being arrested. Treatment in the criminal justice system is a good idea for those who are arrested for real crimes such as theft or assault but treatment in the criminal justice system is always fighting an uphill battle against the harm done by the system. Numerous studies have shown that any form of punishment for drug use increases the likelihood that the drug user will become or persist in being addicted.
Massing is a very fine journalist but he doesn't have the background necessary to conduct a meaningful analysis of drug policy and its effects. You can't learn to be a physicist by watching Nova specials and you aren't going to gain much of an understanding of drug policy by reading books like The Fix. As an introduction to the problems in the field it has merit but I would recommend the equally well written journalistic accounts by Baum (1996) or Gray (1998).
Baum, D.(1996). Smoke and Mirrors: The War on Drugs and the Politics of Failure. New York: Little Brown.
Duncan, D. F. (1974). Reinforcement of drug abuse: Implications for prevention. Clinical Toxicology Bulletin, 4(2), 69-75.
Duncan, D. F. (1975). The acquisition, maintenance and treatment of polydrug dependence: A public health model. Journal of Psychedelic Drugs, 7(2), 207-213.
Duncan, D. F. (1976). Stress and adolescent drug dependence. Medical Science, 4, 381
Duncan, D. F. (1977). Life stress as a precursor to adolescent drug dependence. International Journal of the Addictions, 12 (8), 1047-1056.
Finney, J. W., and Moos, R. H. (1992). The long-term course of treated alcoholism: II. Predictors and correlates of 10-year functioning and mortality. Journal of Studies on Alcohol, 53 (2), 142-153.
Gray, M. (1998). Drug Crazy: How We Got Into this Mess and How We Can Get Out of It. New York: Random House.
Jaffe, J. H., and Harris, G. T. (1973). As far as heroin is concerned, the worst is over. Psychology Today, 85, 68-79, 85.
Moos, R. H., Finney, J. W., and Cronkite, R. C. (1990). Alcoholism Treatment: Context, Process, and Outcome. New York: Oxford University Press.
Robins, LN, Helzer, JE, Hesselbrock, M, and Wish, E. (1980). Vietnam veterans three years after Vietnam: how our study changed our view of heroin. In: L. Brill and C. Winick (Eds), The Yearbook of Substance Use and Abuse, vol. II. New York: Human Sciences Press, pp. 213-230.