FEATURES:
Killing Them Softly

By Joe Loconte

Do needle-exchange programs ward off disease—or consign addicts to death on the installment plan?

In a midrise office building on Manhattan’s West 37th Street, about two blocks south of the Port Authority bus terminal, sits the Positive Health Project, one of 11 needle-exchange outlets in New York City. This particular neighborhood, dotted by X-rated video stores, peep shows, and a grimy hot dog stand, could probably tolerate some positive health. But it’s not clear that’s what the program’s patrons are getting.

The clients are intravenous (IV) drug users. They swap their used needles for clean ones and, it is hoped, avoid the AIDS virus, at least until their next visit. There’s no charge, no hassles, no meddlesome questions. That’s just the way Walter, a veteran heroin user, likes it.

"Just put me on an island and don’t mess with me," he says, lighting up a cigarette.

A tall, thinnish man, Walter seems weary for his 40-some years. Like many of the estimated 250,000 IV drug users in this city, he has spent years shooting up and has bounced in and out of detoxification programs. "Don’t get the idea in your mind you’re going to control it," he says. "I thought I could control it. But dope’s a different thing. You just want it." Can he imagine his life without drugs? "I’m past that," he says, his face tightening. "The only good thing I do is getting high.

Heroin First, Then Breathing

Supporters of needle-exchange programs (NEPs), from AIDS activists to Secretary of Health and Human Services Donna Shalala, seem to have reached the same verdict on Walter’s life. They take his drug addiction as a given, but want to keep him free of HIV by making sure he isn’t borrowing dirty syringes. Says Shalala, "This is another life-saving intervention." That message is gaining currency, thanks in part to at least 112 programs in 29 states, distributing millions of syringes each year.

Critics say free needles just make it easier for addicts to go about their business: abusing drugs. Ronn Constable, a Brooklynite who used heroin and cocaine for nearly 20 years, says he would have welcomed the needle-exchange program—for saving him money. "An addict doesn’t want to spend a dollar on anything else but his drugs," he says.

Do needle exchanges, then, save lives or fuel addiction?

The issue flared up earlier this year when Shalala indicated the Clinton administration would lift the ban on federal funding. Barry McCaffrey, the national drug policy chief, denounced the move, saying it would sanction drug use. Fearing a political debacle, the White House upheld the federal ban but continues to trumpet the effectiveness of NEPs. Meanwhile, Representative Gerald Solomon and Senator Paul Coverdell are pushing legislation in Congress to extend the prohibition indefinitely.

There is more than politics at work here. The debate reveals a deepening philosophical rift between the medical and moral approaches to coping with social ills.

Joined by much of the scientific community, the Clinton administration has tacitly embraced a profoundly misguided notion: that we must not confront drug abusers on moral or religious grounds. Instead, we should use medical interventions to minimize the harm their behavior invites. Directors of needle-exchange outlets pride themselves on running "nonjudgmental" programs. While insisting they do not encourage illegal drug use, suppliers distribute "safe crack kits" explaining the best ways to inject crack cocaine. Willie Easterlins, an outreach worker at a needle-stocked van in Brooklyn, sums up the philosophy this way: "I have to give you a needle. I can’t judge," he says. "That’s the first thing they teach us."

This approach, however well intentioned, ignores the soul-controlling darkness of addiction and the moral freefall that sustains it. "When addicts talk about enslavement, they’re not exaggerating," says Terry Horton, the medical director of Phoenix House, one of the nation’s largest residential treatment centers. "It is their first and foremost priority. Heroin first, then breathing, then food."

It is true that needle-sharing among IV drug users is a major source of HIV transmission, and that the incidence of HIV is rising most rapidly among this group—a population of more than a million people. Last year, about 30 percent of all new HIV infections were linked to IV drug use. The Clinton administration is correct to call this a major public-health risk.

Nevertheless, NEP advocates seem steeped in denial about the behavioral roots of the crisis, conduct left unchallenged by easy access to clean syringes. Most IV drug users, in fact, die not from HIV-tainted needles but from other health problems, overdoses, or homicide. By evading issues of personal responsibility, the White House and its NEP allies are neglecting the most effective help for drug abusers: enrollment in tough-minded treatment programs enforced by drug courts. Moreover, in the name of "saving lives," they seem prepared to surrender countless addicts to life on the margins—an existence of scheming, scamming, disease, and premature death.

Curious Science

Over the last decade, NEPs have secured funding from local departments of public health to establish outlets in 71 cities. But that may be as far as their political argument will take them: Federal law prohibits federal money from flowing to the programs until it can be proved they prevent AIDS without encouraging drug use.

It’s no surprise, then, that advocates are trying to enlist science as an ally. They claim that numerous studies of NEPs prove they are effective. Says Sandra Thurman, the director of the Office of National AIDS Policy, "There is very little doubt that these programs reduce HIV transmission." In arguing for federal funding, a White House panel on AIDS recently cited "clear scientific evidence of the efficacy of such programs."

The studies, though suggestive, prove no such thing. Activists tout the results of a New Haven study, published in the American Journal of Medicine, saying the program reduces HIV among participants by a third. Not exactly. Researchers tested needles from anonymous users—not the addicts themselves—to see if they contained HIV. They never measured "seroconversion rates," the portion of participants who became HIV positive during the study. Even Peter Lurie, a University of Michigan researcher and avid NEP advocate, admits that "the validity of testing of syringes is limited." A likely explanation for the decreased presence of HIV in syringes, according to scientists, is sampling error.

Another significant report was published in 1993 by the University of California and funded by the U.S. Centers for Disease Control. A panel reviewed 21 studies on the impact of NEPs on HIV infection rates. But the best the authors could say for the programs was that none showed a higher prevalence of HIV among program clients.

Even those results don’t mean much. Panel members rated the scientific quality of the studies on a five-point scale: one meant "not valid," three "acceptable," and five "excellent." Only two of the studies earned ratings of three or higher. Of those, neither showed a reduction in HIV levels. No wonder the authors concluded that the data simply do not, and for methodological reasons probably cannot, provide clear evidence that needle exchanges decrease HIV infection rates.

The Missing Link

The most extensive review of needle-exchange studies was commissioned in 1993 by the U.S. Department of Health and Human Services (HHS), which directed the National Academy of Sciences (NAS) to oversee the project. Their report, "Preventing HIV Transmission: The Role of Sterile Needles and Bleach," was issued in 1995 and set off a political firestorm.

"Well-implemented needle-exchange programs can be effective in preventing the spread of HIV and do not increase the use of illegal drugs," a 15-member panel concluded. It recommended lifting the ban on federal funding for NEPs, along with laws against possession of injection paraphernalia. The NAS report has emerged as the bible for true believers of needle exchange.

It is not likely to stand the test of time. A truly scientific trial testing the ability of NEPs to reduce needle-sharing and HIV transmission would set up two similar, randomly selected populations of drug users. One group would be given access to free needles, the other would not. Researchers would follow them for at least a year, taking periodic blood tests.

None of the studies reviewed by NAS researchers, however, were designed in this way. Their methodological problems are legion: Sample sizes are often too small to be statistically meaningful. Participants are self-selected, so that the more health-conscious could be skewing the results. As many as 60 percent of study participants drop out. And researchers rely on self-reporting, a notoriously untrustworthy tool.

"Nobody has done the basic science yet," says David Murray, the research director of the Statistical Assessment Service, a watchdog group in Washington, D.C. "If this were the FDA applying the standard for a new drug, they would [block] it right there."

The NAS panel admitted its conclusions were not based on reviews of well-designed trials. Such studies, the authors agreed, simply do not exist. Not to worry, they said: "The limitations of individual studies do not necessarily preclude us from being able to reach scientifically valid conclusions." When all of the studies are considered together, they argued, the results are compelling.

"That’s like tossing a bunch of broken Christmas ornaments in a box and claiming you have something nice and new and usable," Murray says. "What you have is a lot of broken ornaments." Two of the three physicians on the NAS panel, Lawrence Brown and Herbert Kleber, agree. They deny their report established anything like a scientific link between lower HIV rates and needle exchanges. "The existing data is flawed," says Kleber, executive vice president for medical research at Columbia University. "NEPs may, in theory, be effective, but the data doesn’t prove that they are."

Some needle-exchange advocates acknowledge the dearth of hard science. Don Des Jarlais, a researcher at New York’s Beth Israel Medical Center, writes in a 1996 report that "there has been no direct evidence that participation is associated with a lower risk" of HIV infection. Lurie, writing in the American Journal of Epidemiology, says that "no one study, on its own, should be used to declare the programs effective." Nevertheless, supporters insist, the "pattern of evidence" is sufficient to march ahead with the programs.

Mixed Results

That argument might make sense if all the best studies created a happy, coherent picture. They don’t. In fact, more-recent and better-controlled studies cast serious doubt on the ability of NEPs to reduce HIV infection.

In 1996, Vancouver researchers followed 1,006 intravenous cocaine and heroin users who visited needle exchanges, conducting periodic blood tests and interviews. The results, published in the British research journal AIDS, were not encouraging: About 40 percent of the test group reported borrowing a used needle in the preceding six months. Worse, after only eight months, 18.6 percent of those initially HIV negative became infected with the virus.

Dr. Steffanie Strathdee, of the British Columbia Centre for Excellence in HIV/AIDS, was the report’s lead researcher. She found it "particularly disturbing" that needle-sharing among program participants, despite access to clean syringes, is common. Though an NEP advocate, Strathdee concedes that the high HIV rates are "alarming." Shepherd Smith, founder of Americans for a Sound AIDS/HIV Policy, says that compared to similar drug-using populations in the United States, the Vancouver results are "disastrous."

Though it boasts the largest needle-exchange program in North America, Vancouver is straining under an AIDS epidemic. When its NEP began in 1988, HIV prevalence among IV drug users was less than 2 percent. Today it’s about 23 percent, despite a citywide program that dispenses 2.5 million needles a year.

A 1997 Montreal study is even more troubling. It showed that addicts who used needle exchanges were more than twice as likely to become infected with HIV as those who didn’t. Published in the American Journal of Epidemiology, the report found that 33 percent of NEP users and 13 percent of nonusers became infected during the study period. Moreover, about three out of four program clients continued to share needles, roughly the same rate as nonparticipants.

The results are hard to dismiss. The report, though it did not rely on truly random selection, is the most sophisticated attempt so far to overcome the weaknesses of previous NEP studies. Researchers worked with a statistically significant sample (about 1,500), established test groups with better controls and lower dropout rates, and took greater care to account for "confounding variables." They followed each participant for an average of 21 months, taking blood samples every six months.

Blood samples don’t lie. Attending an NEP was "a strong predictor" of the risk of contracting HIV, according to Julie Bruneau of the University of Montreal, the lead researcher. Bruneau’s team then issued a warning: "We believe caution is warranted before accepting NEPs as uniformly beneficial in any setting."

The findings have sent supporters into a frenzy, with many fretting about their impact on public funding. "While it was important that the study be published," Peter Lurie complained to one magazine, "whether that information outweighs the political costs is another matter." In a bizarre New York Times op-ed, Bruneau recently disavowed some of her own conclusions. She said the results could be explained by higher-risk behavior engaged in by program users, a claim anticipated and rejected by her own report.

And that objection lands NEP supporters on the horns of a dilemma: Any control weaknesses in the Canadian reports are also present in the pro-exchange studies. "You can’t have it both ways," Kleber says. "You can’t explain away Montreal and Vancouver without applying the same scientific measures to the studies you feel are on your side."

Defending an expansion of the programs, AIDS policy czar Thurman says, "We need to let science drive the issue of needle exchange." The best that can be said for the evidence so far is that it doesn’t tell us much. Without better-controlled studies, science cannot be hauled out as a witness for either side of the debate.

Death-Defying Logic

Critics of needle exchanges are forced to admit there’s a certain logic to the concept, at least in theory: Give enough clean needles to an IV drug user and he won’t bum contaminated "spikes" when he wants a fix.

But ex-addicts themselves, and the medical specialists who treat them, say it isn’t that simple. "People think that everybody in shooting galleries worries about AIDS or syphilis or crack-addicted babies. That’s the least of people’s worries," says Jean Scott, the director of adult programs at Phoenix House in Manhattan. "While they’re using, all they can think about is continuing to use and where they’re going to get their next high."

Indeed, the NEP crowd mistakenly assumes that most addicts worry about getting AIDS. Most probably don’t: The psychology and physiology of addiction usually do not allow them the luxury. "Once they start pumping their system with drugs, judgment disappears. Memory disappears. Nutrition disappears. The ability to evaluate their life needs disappears," says Eric Voth, the chairman of the International Drug Strategy Institute and one of the nation’s leading addiction specialists. "What makes anybody think they’ll make clean needles a priority?"

Ronn Constable, now a program director at Teen Challenge International in New York, says his addiction consumed him 24 hours a day, seven days a week. Addicts call it "chasing the bag": shooting up, feeling the high, and planning the next hit before withdrawal. "For severe addicts, that’s all they do," Constable says. "Their whole life is just scheming to get their next dollar to get their next bundle of dope."

Ernesto Margaro fed his heroin habit for seven years, at times going through 40 bags—or $400—a day. He recalls walking up to a notorious drug den in the Bedford-Stuyvestant section of Brooklyn with a few of his friends. A man stumbled out onto the sidewalk and collapsed. They figured he was dying.

Margaro opened a fire hydrant on him. "When he finally came to, the first thing we asked him was where he got that dope from," he says. "We needed to know, because if it made him feel like that, we were going to take just a little bit less than he did."

This is typical of the hard-core user: The newest, most potent batch of heroin on the streets, the one causing the most deaths, is in greatest demand. "They run around trying to find out who the dead person copped from," says Scott, a drug-treatment specialist with 30 years’ experience. "The more deaths you have, the more popular the heroin is. That’s the mentality of the addict."

Needle Entrepreneurs

Some younger addicts may at first be fearful of the AIDS virus, though that concern probably melts away as they continue to shoot up. But the hard-core abusers live in a state of deep denial. "I had them dying next to me," Constable says. "One of my closest buddies withered away. I never thought about it."

Needle-exchange programs are doing brisk business all over the country: San Diego, Seattle, Denver, Baltimore, Boston, and beyond. San Francisco alone hands out 2.2 million needles a year. If most addicts really aren’t worried about HIV, then why do they come?

In most states, it is difficult to buy drug paraphernalia without a prescription. That makes it hard, some claim, to find syringes. But drug users can get them easily enough on the streets. The main reason they go to NEPs, it seems, is that the outlets are a free source of needles, cookers, cotton, and bleach. They’re also convenient. They are run from storefronts or out of vans, and they operate several days a week at regular hours.

And they are hassle-free. Users are issued ID cards that entitle them to carry drug paraphernalia wherever they go. Police are asked to keep their distance lest they scare off clients.

Most programs require that users swap their old needles for new equipment, but people aren’t denied if they "forget" to bring in the goods. And most are not rigid one-for-one exchanges. Jose Castellar works an NEP van at the corner of South Fifth Street and Marcy Avenue in Brooklyn. On a recent Thursday afternoon, a man walked up and mechanically dropped off 18 syringes in a lunch sack. Castellar recognized him as a regular, and gave him back 28—standard procedure. "It’s sort of like an incentive," he explains.

It’s the "incentive" part of the program that many critics find so objectionable. An apparently common strategy of NEP clients is to keep a handful of needles for themselves and sell the rest. Says Margaro, "They give you five needles. That’s $2 a needle, that’s $10. That’s your next fix. That’s all you’re worried about."

It may also explain why many addicts who know they are HIV positive—older users such as Walter—still visit NEPs. Nobody knows how many there are, because no exchanges require blood tests. In New York, health officials say that perhaps half of the older IV addicts on the streets are infected.

Defenders admit the system is probably being abused. "An addict is an addict. He’s going to do what he needs to maintain his habit," says Easterlins, who works a van for ADAPT, one of New York City’s largest needle-exchange programs. Naomi Fatt, ADAPT’s executive director, is a little more coy. "We don’t knowingly participate" in the black market for drug paraphernalia, she says. And if NEP clients are simply selling their syringes to other drug users? "We don’t personally care how they get their sterile needles. If that’s the only way they can save their lives is to get these needles on the streets, is that really so awful?"

Name Your Poison

In the debate over federal funding for NEPs, herein lies their siren song: Clean needles save lives. But there just isn’t much evidence, scientific or otherwise, that free drug paraphernalia is protecting users.

The reason is drug addiction. Addicts attending NEPs continue to swap needles and engage in risky sexual behavior. All the studies that claim otherwise are based on self-reporting, an unreliable gauge.

By not talking much about drug abuse, NEP activists effectively sidestep the desperation created by addiction. When drug users run out of money for their habit, for example, they often turn to prostitution—no matter how many clean needles are in the cupboard. And the most common way of contracting HIV is, of course, sexual intercourse. "Sex is a currency in the drug world," says Horton of Phoenix House. "It is a major mode of HIV infection. And you don’t address that with needle exchange."

At least a third of the women in treatment at the Brooklyn Teen Challenge had been lured into prostitution. About 15 percent of the female clients in Manhattan’s Phoenix House contracted HIV by exchanging sex for drugs. In trying to explain the high HIV rates in Vancouver, researchers admitted "it may be that sexual transmission plays an important role."

Kleber, a psychiatrist and a leading addiction specialist, has been treating drug abusers for 30 years. He says NEPs, even those that offer education and health services, aren’t likely to become beacons of behavior modification. "Addiction erodes your ability to change your behavior," he says. "And NEPs have no track record of changing risky sexual behavior."

Or discouraging other reckless choices, for that matter. James Curtis, the director of addiction services at the Harlem Hospital Center, says addicts are not careful about cleanliness and personal hygiene, so they often develop serious infections, such as septicemia, around injection areas. "It is false, misleading, and unethical," he says, "to give addicts the idea that they can be intravenous drug abusers without suffering serious self-injury."

A recent University of Pennsylvania study followed 415 IV drug users in Philadelphia over four years. Twenty-eight died during the study. Only five died from causes associated with HIV. Most died for other reasons: overdoses, homicide, heart disease, kidney failure, liver disease, and suicide. Writing in the New England Journal of Medicine, medical professors George Woody and David Metzger said that compared to the risk of HIV infection, the threat of death to drug abusers from other causes is "more imminent."

That proved tragically correct for John Watters and Brian Weil, two prominent founders of needle exchanges who died of apparent heroin overdoses. Indeed, deaths from drug dependence in cities with active needle programs have been on an upward trajectory for years. In New York City hospitals, the number has jumped from 413 in 1990 to 909 in 1996.

Good and Ready?

Keeping drug users free of AIDS is a noble—but narrow—goal. Surely the best hope of keeping them alive is to get them off drugs and into treatment. Research from the National Institute for Drug Abuse (NIDA) shows that untreated opiate addicts die at a rate seven to eight times higher than similar patients in methadone-based treatment programs.

Needle suppliers claim they introduce addicts to rehab services, and Shalala wants local officials to include treatment referral in any new needle-exchange programs. But program staffers are not instructed to confront addicts about their drug habit. The assumption: Unless drug abusers are ready to quit on their own, it won’t work.

This explains why NEP advocates smoothly assert they support drug treatment, yet gladly supply users with all the drug-injection equipment they need. "The idea that they will choose on their own when they’re ready is nonsense," says Voth, who says he’s treated perhaps 5,000 abusers of cocaine, heroin, and crack. "Judgment is one of the things that disappears with addiction. The worst addicts are the ones least likely to stumble into sobriety and treatment."

According to health officials, most addicts do not seek treatment voluntarily, but enter through the criminal-justice system. Even those who volunteer do so because of intense pressure from spouses or employers or raw physical pain from deteriorating health. In other words, they begin to confront some of the unpleasant consequences of their drug habit.

"The only way a drug addict is going to consider stopping is by experiencing pain," says Robert Dupont, a clinical professor of psychiatry at Georgetown University Medical School. "Pain is what helps to break their delusion," says David Batty, the director of Teen Challenge in Brooklyn. "The faster they realize they’re on a dead-end street, the faster they see the need to change."

Justice for Junkies

Better law enforcement, linked to drug courts and alternative sentencing for offenders, could be the best way to help them see the road signs up ahead. "It is common for an addict to say that jail saved his life," says Dr. Janet Lapey, the president of Drug Watch International. "Not until the drugs are out of his system does he usually think clearly enough to see the harm drugs are causing."

The key is to use the threat of jail time to prod offenders into long-term treatment. More judges seem ready to do so, and it’s not hard to see why: In 1971, about 15 percent of all crime in New York was connected to drug use, according to law enforcement officials. Today it’s about 85 percent.

"There has been an enormous increase in drug-related crime because the only response of society has been a jail cell," says Brooklyn district attorney Charles Hynes. "But it is morally and fiscally irresponsible to warehouse nonviolent drug addicts." Since 1990, Hynes has helped reshape the city’s drug-court system to offer nonviolent addicts a choice: two to four years in prison or a shot at rehabilitation and job training.

Many treatment specialists believe drug therapies will fail unless they’re backed up with punishment and other pressures. Addicts need "socially imposed consequences" at the earliest possible stage—and the simplest way is through the criminal-justice system, says Dupont, a former director of NIDA. Sally Satel, a psychiatrist specializing in addiction, says "coercion can be the clinician’s best friend."

That may not be true of all addicts, but it took stiff medicine to finally get the attention of Canzada Edmonds, a heroin user for 27 years. "I was in love with heroin. I took it into the bathroom, I took it into church," she says. "I was living in a fantasy. I was living in a world all to myself."

And she was living in Washington, D.C., which in the early 1990s had passed tougher sentencing laws for felony drug offenders. After her third felony arrest, a district judge said she faced a possible 30-year term in prison—or a trip to a residential rehab program. Edmonds went to Teen Challenge in New York in January 1995 and has been free of drugs ever since.

Reducing Harm

Needle-exchange advocates chafe at the thought of coercing drug users into treatment. This signals perhaps their most grievous omission: They refuse to challenge the self-absorption that nourishes drug addiction.

In medical terms, it’s called "harm reduction"—accept the irresponsible behavior and try to minimize its effects with health services and education. Some needle exchanges, for example, distribute guides to safer drug use. A pamphlet from an NEP in Bridgeport, Connecticut, explains how to prepare crack cocaine for injection (see box). It then urges users to "take care of your veins. Rotate injection sites . . . ."

"Harm reduction is the policy manifestation of the addict’s personal wish," says Satel, "which is to use drugs without consequences." The concept is backed by numerous medical and scientific groups, including the American Medical Association, the American Public Health Association, and the National Academy of Sciences.

In legal terms, harm reduction means the decriminalization of drug use. Legalization advocates, from financier George Soros to the Drug Policy Foundation, are staunch needle-exchange supporters. San Francisco mayor Willie Brown, who presides over perhaps the nation’s busiest needle programs, is a leading voice in the harm-reduction chorus. "It is time," he has written, "to stop allowing moral or religious tradition to define our approach to a medical emergency."

It is time, rather, to stop medicalizing what is fundamentally a moral problem. Treatment communities that stress abstinence, responsibility, and moral renewal, backed up by tough law enforcement, are the best hope for addicts to escape drugs and adopt safer, healthier lifestyles.

Despite different approaches, therapeutic communities share at least one goal: drug-free living. Though they commonly regard addiction as a disease, they all insist that addicts take full responsibility for their cure. Program directors aren’t afraid of confrontation, they push personal responsibility, and they tackle the underlying causes of drug abuse.

The Clinton administration already knows these approaches are working. NIDA recently completed a study of 10,010 drug abusers who entered nearly 100 different treatment programs in 11 cities. Researchers looked at daily drug use a year before and a year after treatment. Long-term residential settings—those with stringent anti-drug policies—did best: Heroin use dropped by 71 percent, cocaine use by 68 percent, and illegal activity in general by 62 percent.

NEP supporters are right to point out that these approaches are often expensive and cannot reach most of the nation’s estimated 1.2 million IV drug users. Syringe exchanges, they say, are a cost-effective alternative.

NEPs may be cheaper to run, but they are no alternative; they offer no remedy for the ravages of drug addiction. The expense of long-term residential care surely cannot be greater than the social and economic costs of failing to liberate large populations from drug abuse.

Phoenix House, with residential sites in New York, New Jersey, California, and Texas, works with about 3,000 abusers a day. It is becoming a crucial player in New York City’s drug courts, targeting roughly 500 adolescents and 1,400 adults. "Coerced treatment works better than noncoerced," says Anne Swern, a deputy district attorney in Brooklyn. "Judicially coerced residential treatment works best of all."

Nonviolent drug felons are diverted into the program as part of a parole agreement or as an alternative to prison. They sign up for a tightly scripted routine of counseling, education, and work, with rewards and sanctions to reinforce good behavior. Though clients are not locked in at night, police send out "warrant teams" to make regular visits.

Prosecutors and judges like the approach because of its relatively high retention rates. Sixty percent graduate from the program, Swern says, compared to the 13 percent national average for all drug programs. Graduates usually undergo 24 months of treatment and must find housing and employment. Says Horton, "The ability of a judge to tell an addict it’s Rikers Island or Phoenix House is a very effective tool."

Narcotics Anonymous (NA), like Alcoholics Anonymous (AA), is a community-based association of recovering addicts. Since its formation in the 1950s, NA has stressed the therapeutic value of addicts helping other addicts; its trademark is the weekly group meeting, run out of homes, churches, and community centers.

"You get the benefit of hearing how others stayed clean today, with the things life gave them," says Tim, a 20-year heroin user and NA member since 1995. NA offers no professional therapists, no residential facilities, no clinics. Yet its 12-step philosophy, adapted from AA, is perhaps the most common treatment strategy in therapeutic communities.

The 12-step model includes admitting there is a problem, agreeing to be open about one’s life, and making amends where harm has been done. The only requirement for NA membership is a desire to stop using. "Complete and continuous abstinence provides the best foundation for recovery and personal growth," according to NA literature.

As in AA, members must admit they cannot end their addiction on their own. The philosophy’s second step is the belief that "a power greater than ourselves can restore us to sanity." NA considers itself nonreligious, but urges members to seek "spiritual awakening"—however they choose to define it—to help them stay clean.

Teen Challenge, founded in 1958 by Pentecostal minister David Wilkerson, is a pioneer in therapeutic communities and has achieved some remarkable results in getting addicts off drugs permanently. One federal study found that 86 percent of the program’s graduates were drug free seven years after completing the regimen. On any given day, about 2,500 men and women are in its 125 residential centers nationwide.

The program uses an unapologetically Christian model of education and counseling. Moral and spiritual problems are assumed to lie at the root of drug addiction. Explains a former addict, who was gang-raped when she was 13, "I didn’t want to feel what I was feeling about the rape—the anger, the hate—so I began to medicate. It was my way of coping." Though acknowledging that the reasons for drug use are complex, counselors make Christian conversion the linchpin of recovery. Ronn Constable says he tried several rehab programs, but failed to change his basic motivation until he turned to faith in Christ. He has been steadily employed and free of drugs for 11 years.

"Sin is the fuel behind addiction," Constable says, "but the Lord says he will not let me be tempted beyond what I can bear." He is typical of former addicts at Teen Challenge, who say their continued recovery hinges on their trust in God and obedience to the Bible. Warns Edmonds, "If you do not make a decision to turn your will and your life completely over to the power of God, then you’re going to go right back." Or as C.S. Lewis wrote in another context, "The hardness of God is kinder than the softness of man, and His compulsion is our liberation."

Brave New World?

Whether secular or religious, therapeutic communities all emphasize the "community" part of their strategy. One reason is that addicts must make a clean break not only from their drug use, but from the circle of friends who help them sustain it. That means a 24-hour-a-day regimen of counseling, education, and employment, usually for 12 to 24 months, safely removed from the culture of addiction.

This is the antithesis of needle-exchange outlets, which easily become magnets for drug users and dealers. Nancy Sosman, a community activist in Manhattan, calls the Lower East Side Harm Reduction Center and Needle Exchange Program "a social club for junkies." Even supporters such as Bruneau warn that NEPs could instigate "new socialization" and "new sharing networks" among otherwise isolated drug users. Some, under the banner of AIDS education, hail this function of the programs. Allan Clear, the executive director of New York’s Harm Reduction Coalition, told one magazine, "There needs to be a self-awareness of what an NEP supplies: a meeting place where networks can form."

Meanwhile, activists decry a lack of drug paraphernalia for eager clients. They call the decision to withhold federal funding "immoral." They want NEPs massively expanded, some demanding no limits on distribution. Says one spokesman, "The one-to-one rule in needle exchange isn’t at all connected to reality." New York’s ADAPT program gives out at least 350,000 needles a year. "But to meet the demand," says Fatt, "we’d need to give out a million a day."

A million a day? Now that would be a Brave New World: Intravenous drug users with lots of drugs, all the needles they want, and police-free zones in which to network. Are we really to believe this strategy will contain the AIDS virus?

This is not compassion, it is ill-conceived public policy. This is not "saving lives," but abandoning them—consigning countless thousands to drug-induced death on the installment plan. For when a culture winks at drug use, it gets a population of Walters: "Don’t get the idea in your mind you’re going to control it."