Maryland's ERs Feel Strain Of Mentally Ill
Matthew Mosk, Washington Post- 2/6/2002

Benjamin Hawkes had already rotated through the clinics and hospitals of Maryland's mental health system when, one day last February, he returned to the system's front gate -- a hospital emergency room -- on the brink of a catastrophic breakdown. But the doctors at Howard County General Hospital elected not to admit him. His mother lamented in a prescient e-mail to another of her children that the ER was "overworked, understaffed and psychiatrically deficient." "He really reached out for help this time," she wrote that night. "The mental health system is sick." The following day, Hawkes entered his mother's home wearing only a bathrobe and an American flag draped around his neck and began attacking her and a houseguest. He sliced their necks with kitchen knives, then bashed their faces with a sledgehammer. Police found the 25-year-old Hawkes in the family room, naked, stained with blood and spattered with brain matter, listening to instrumental music at full volume.
    The slayings stand today as a gruesome reminder of all that is unwell with Maryland's mental health system. Beyond the struggling of outpatient clinics, several of which have closed in the past year, the state has drastically scaled back its coverage for outpatient care. That has put emergency rooms on the front lines of mental health care, even though many are ill-equipped -- or unwilling -- to handle the most difficult cases. "The denial of treatment is putting the most severely disabled mentally ill patients at risk," said Herbert Cromwell, executive director of the Community Behavioral Health Association of Maryland. "The system is being squeezed."
    In the first half of 2001, hospital emergency rooms had a 17 percent increase in psychiatric cases from the same period in 2000, according to numbers still being analyzed by state health officials. Pegeen Townsend, a lobbyist for the Maryland Hospital Association, said the influx has been unmistakable. "Around the state, I'm hearing ERs are being inundated by folks with mental illness, and they are finding it very difficult to find a place to put them," she said.
    At the root of the mental health crisis are money problems that have plagued Maryland's mental health program since 1997, when the state changed the way it reimburses clinics and hospitals for the care they give uninsured and Medicaid patients. This year, budget analysts estimate the system faces a $20 million deficit, one that won't be solved easily given the current budget shortfall.
    Maryland's crisis mirrors troubles in dozens of states that have experimented with managed care to pay mental health costs, according to Michael J. Fitzpatrick, director of state policy for the National Alliance for the Mentally Ill. "What we're seeing out there is varying degrees of chaos," he said. "Look at the percentage of people with mental illness in jails or in the homeless population, and you realize this system is struggling." For the past two years, Maryland mental health officials have acknowledged their state's crisis but have repeatedly insisted, even as clinics close, that the shortfall is not affecting patient care. But there is mounting evidence that patients are suffering.
    The squeeze is being felt by such patients as Craig Ellington, 23, a Hyattsville man who has been treated in Maryland for bipolar disorder since he was 13. For years, Ellington traveled daily by bus from his aunt's home to a rehabilitation clinic in Rockville, where he was given medication and therapy and learned such skills as counting money and telling time so he could survive in the outside world. In October, the clinic received word from the state's managed care contractor, Maryland Health Partners, that Ellington's treatment was no longer covered. "Everything he had, the stability of a daily schedule, the certainty he would take his medication, it was cut off," said Lisa Coakley, 41, Ellington's aunt and primary caretaker. "All of his services were denied."
    The clinic, Affiliated Sante Group, sent three pages of documentation appealing Maryland Health Partners' decision, to no avail. Without money to pay for his care, Coakley, a real estate agent, was forced to leave Ellington at home all day, locked in her house, where he would watch television or sleep. Within weeks, Ellington became noticeably more agitated, she said. "He started losing sleep. He would babble and talk incoherently, and then he tried to break out of the house," she said. One night in November, he became so menacing that Coakley drove him to the Johns Hopkins Hospital emergency room in Baltimore. She went there, she said, because the ER had a history of admitting patients.
    While hospitalized, Ellington showed bursts of violence, at one point injuring five staff members as they tried to restrain him. On Dec. 20, though, he was discharged with a recommendation that he resume the treatment in Rockville -- the very same care that had been discontinued two months earlier. "The whole cycle he went through was unnecessary and cruel," said Jeff Carswell, Affiliated Sante's director. "And he was not the only one to go through this."
    Officials at Maryland Health Partners said they could not comment on a specific case, but they acknowledged that this summer was a turning point for patients like Ellington. At the request of state health officials, Maryland Health Partners began in July to change the way it approved or denied treatment requests from patients. They began what Maryland Health Partners President Damian Briggs called "aggressively managing care." Coverage for such services as therapy, life skills training and medication management is now carefully scrutinized.
    Oscar Morgan, director of the state's Mental Hygiene Administration, said, "We told MHP we need to make sure people are getting the right level of care." Briggs said that in response to Morgan's request, his screeners asked clinics for more frequent reports justifying each patient's care, and they then began looking for ways to scale back. Briggs said patients have not been denied care they need, only the care that went beyond the patients' needs. Clinics and hospitals, he said, have become accustomed to asking for more than what's needed, because no one was telling them no. "I believe it's been a little behavior modification, and the providers are slowly accepting the new process," Briggs said. "It's just taking time."
    The results, from a cost-cutting standpoint, have been remarkable. Since July, Morgan said, the state has saved about $15 million by reducing care. But the caregivers have bristled at the sudden rush of denials. Since July, they have filed more than twice the number of appeals of Maryland Health Partners care decisions as in the previous six months. Lori Doyle, vice president of Revisions Behavioral Health Systems in Baltimore County, said she has filed several appeals for her patients, including clients who were denied care despite histories of suicide attempts and repeated hospitalizations. "Cost containment is happening on the backs of people in dire need," Doyle said. "These are the folks who could kill themselves. These are the folks who hospitalize themselves as a last resort. To just say they don't need these services is putting their lives at risk."
    Some clinics, unwilling to deny care to their patients, simply treat them for free. But as the clinics lose money, more patients are turned away. And as their cases become acute, they head to the nearest emergency room. Under law, emergency physicians cannot deny care to the patients, even if they lack insurance. But the rates hospitals get paid for psychiatric patients don't come close to covering the costs, especially in difficult cases. Some mental health advocates believe this has proved a disincentive for hospitals to admit patients. The hospitals say patients are suffering delays in getting admitted because they are short of beds for psychiatric care. Between 1999 and 2000, the number of beds available declined in Maryland by more than 1,800 -- to about 6,800. The shortage may be cost-related, since the rates set by the state don't make the beds profitable.
    Michael J. Kaminsky, clinical director of the Johns Hopkins University department of Psychiatry, said hospitals have engaged in "active avoidance" when faced with difficult cases. "Clearly," he wrote in a letter to the Maryland Health Care Commission, "something is broken in a system that, almost on a monthly basis, leaves patients in our Emergency Department for 24 to 72 hours awaiting placement."
    Emergency physicians have been meeting periodically since May to try to work around the bed shortage and reduce the risks posed by delaying care. One solution would use computers to track the location of every available bed in the state, so patients can be sent for treatment immediately. "The ER physicians are very concerned about the lack of space to put these patients, especially children and adolescents, who are extremely difficult to place," said Barbara Brocado, a lobbyist in Annapolis for the American College of Emergency Physicians. "But there's no magic solution. I wish there was."
    Howard County General Hospital officials said all the normal procedures were followed when Benjamin Hawkes entered their emergency room Feb. 10. He had spent the previous night at a party, muttering to himself and at one point pulling his pants down. Records show he told the admitting nurse that he had not slept, that he felt depressed and that he "had difficulty thinking." During his 30-minute examination, the psychiatrist who treated Hawkes noted a previous diagnosis of schizophrenia. But this time, the diagnosis was anxiety. He was given a mild sedative and advised to make an appointment at a clinic. At 3:15 a.m. Feb. 12, Hawkes was back at the hospital, this time in handcuffs. He urinated on a cot and flinched when he was offered water. Voices, he said, had urged him to kill, and he had listened. A Howard County judge has since found Hawkes legally insane. At Clifton T. Perkins, the state's facility for the criminally insane, he is finally getting the treatment he needed.

Teen Suicide Pilot Saw Sept. 11 'Justified'
Reuters, 2/7/2002

TAMPA - A 15-year-old student pilot who crashed a plane into a Tampa office building last month was not a terrorist, despite a note he left praising Osama bin Laden and supporting the Sept. 11 attacks on the United States, Tampa police said yesterday. Ending their investigation into an incident that some saw as a grim echo of the airliner assaults on the World Trade Center and Pentagon, Tampa police said Charles Bishop acted alone when he intentionally flew a stolen, single-engine Cessna into the Bank of America building in Tampa. Bishop died on Jan. 5 after he took the plane from a St. Petersburg airport where he had been taking flying lessons and crashed into the 28th floor of the 42-story tower. No one else was injured.
    ''Based on information obtained during this exhaustive investigation, there is no indication the plane crash was in any way an act of terrorism. Authorities further concluded the incident appears to have been an intentional act on the part of the pilot, Charles Bishop,'' the Tampa police statement said. The joint investigation was conducted by the Tampa police, the FBI and other federal, local and state agencies.
    For the first time, investigators released the full text of the two-page handwritten letter found in the wreckage of the plane. Police had summarized the letter in the days after the crash, saying it expressed support for bin Laden, the Al Qaeda leader believed responsible for the Sept. 11 attacks, which killed 3,000 people.
    Bishop wrote, ''I have prepared this statement in regards to the terrorist acts I am about to commit.'' The word terrorist was then crossed out. ''First of all, Osama bin Laden is absolutely justified in the terror he has caused on 9-11,'' the note continued. ''He has brought a mighty nation to its knees! God blesses him and the others who helped make September 11 happen. ''The US will have to face the consequences for its horrific actions against the Palestinian people and Iraqis by its allegiance with the monstrous Israelis who want nothing short of world domination. ''You will pay - God help you - and I will (underlined) make you pay. ''There will be more coming! Al Qaeda and other organizations have met with me several times to discuss the option of me joining. I didn't. ''This is an operation done by me only. I had no other help, although I am acting on their behalf. ''Osama bin Laden is planning on blowing up the Super Bowl with an antiquated nuclear bomb left over from the 1967 Israeli-Syrian war,'' the unsigned note concluded.
    Bishop's mother released a statement shortly after the crash calling her son a boy who loved his country. Students and teachers who knew him said he never said anything in support of bid Laden or the Sept. 11 attacks.

Michigan Sheriff Says Mentally Ill Prisoners Need Better Care
Ben Schmitt, Detroit Free Press- 2/7/2002

Macomb County Sheriff Mark Hackel is about to campaign to make some changes at the county jail, where there have been five suicides since July 2000. Hackel wants to expand a wing for inmates who appear to have mental health problems, are suicidal or are in detoxification. The addition would include 24-hour surveillance with security cameras. The changes could mean reorganization and remodeling of the jail and reassigning inmates. The closing of most state psychiatric hospitals has shifted the burden of caring for many mentally ill people to jails and prisons.
    "Mental health in the jail is an extremely big concern for me right now," Hackel said. "The housing area we have for mental health patients is inadequate. I've got to have them. There's nowhere else to put the people." A mental health wing, run by the jail's health-care provider, Correctional Medical Services, houses about 35 inmates. The jail houses 1,400 inmates. Eventually, Hackel also wants to make the jail a central intake facility for those arrested in Macomb County, which could mean the demise of police lockups. "Every person arrested in the county would come here, be booked, processed and held here until they are classified," Hackel said. Another possible option would be building a satellite jail in the southern portion of the county to run hand-in-hand with the main jail in Mt. Clemens, Hackel said. Both ideas are very preliminary, he said. Funding hasn't been discussed and other police departments would have to sign on.
    Warren Police Chief James Vohs said he would have to learn more about Hackel's proposals before assessing them.  "A southern jail would help, but I'm not sure if doing away with all police lockups is feasible," he said. Hackel's efforts toward dealing with mental health problems in jail caught the eye of Michigan Protection and Advocacy, a disability-rights agency investigating how county jails and police lockups in metro Detroit deal with suicidal and mentally ill prisoners. Yvonne Fleener, the group's director of advocacy services, said one of the main issues is identifying those prisoners who need mental health treatment. "Macomb County has struggled with being able to identify people who have mental health problems," Fleener said. "Having a special wing could be helpful for people they have identified, but if they don't identify them well, then that really doesn't help." Fleener said she hopes the unit is set up as a therapeutic place, instead of a punitive one. "Given the right factors, it could be a positive step for Macomb County," she said.
    A Free Press investigation published in August found that 55 prisoners died in metro Detroit jails since January 1998 -- many from medical neglect, foreseeable suicides and suspicious circumstances. Most of the deaths were investigated in-house and few resulted in disciplinary action. By month's end, Hackel plans to have a consultant from the National Institute of Corrections come to Macomb County to examine the criminal justice system. The National Institute of Corrections is an agency within the U.S. Department of Justice, Federal Bureau of Prisons.  Hackel said that's when the county's board of commissioners will "be made aware of where we're headed" and what may be required financially, Hackel said.

Data Reflect Many Abandoned Teens
Alan Elsner, Reuters- 2/7/2002

DUNN LORING, Va. - Each year, tens of thousands of US teenagers are kicked out of their homes by parents who no longer want them. The federal government officially classifies them as ''thrownaway children.'' ''The police find them under bridges. We have kids who bounce around the foster care system, kids who are fighting with their parents, kids who run away for a few days and then find their parents don't want them back,'' said Judith Dittman, director of Alternative House, a temporary shelter for teenagers in a wealthy Virginia suburb of Washington.
    A 1991 survey sponsored by the Justice Department found 127,100 ''thrownaways'' at that time. Most were 16 or 17, and almost half had been asked or forced to leave their homes. ''What we often see is intense and escalating family conflict leading to a crisis. We see parental abuse or incompetence where the kids get the message they are not wanted any more,'' said David Finkelhor of the University of New Hampshire, one of the study's authors. ''Sometimes a teenager runs away for a day or two and comes back to find the locks have been changed at home,'' he said.
    One girl who spent time at Alternative House had traveled from Connecticut to Virginia to meet an Internet pen pal, who sexually abused her. Dittman contacted her mother, but she did not want the girl back. Although more than half of ''thrownaways'' eventually find their way back home, some 60,000 had no secure place to stay when they were on their own, Finkelhor said.
    Alternative House provides housing and therapy for teenagers, and tries to find them a safe place to live or attempts to get them back with their parents. Its therapists say the number of cases, even in one of the most affluent counties in the nation, points to a deep social problem. ''A lot of cases happen when a single parent marries or a divorced parent remarries and their new partners are not interested in having the children around. Sometimes they actively abuse them,'' said Stephanie Herman, clinical director of Alternative House. ''If the child is seen as problematic in the new relationship the parent is trying to build, that parent does not always act in the child's best interests.''
    The statistics show that only 19 percent of ''thrownaways'' came from two-parent families. About 80 percent of the teenagers who wind up at Alternative House are clinically depressed, and many use drugs and engage in dangerous sexual behavior.

Doctor Charged in OxyContin Deaths Testifies He Didn't Know
Bill Kaczor, Associated Press- 2/7/2002

MILTON, Fla. -- A doctor on trial for the deaths of four patients who overdosed on OxyContin testified Thursday that he had no idea the patients had been abusing the drug. Dr. James Graves said he had to trust that his patients were telling the truth when they complained of pain. ''It is a risk you have to accept when treating these patients,'' Graves said. ''They are deserving of treatment of their pain.'' Prosecutors contend Graves was running an illegal ''pill mill'' for addicts and dealers who paid him hundreds of thousands of dollars for prescriptions of OxyContin and other drugs.
    Graves, 54, maintained Thursday that OxyContin was an appropriate treatment for the pain his patients claimed to be suffering, and said he prescribed the drugs on the basis of his examinations, X-rays and MRI testing. ''On a safety and efficacy basis, I felt OxyContin, at the time I was practicing pain medicine, was probably the best alternative available on the market,'' Graves said.
    Graves is being tried on four counts of manslaughter, five counts of unlawful delivery of a controlled substance and a racketeering charge. If convicted on all counts, he could face up to 30 years in prison. Pharmacists have testified they stopped filling his multi-drug prescriptions, which some nicknamed the ''Graves cocktail.'' Some doctors have called the prescriptions unsafe or irresponsible.
    Graves said he prescribed two strengths of OxyContin to give patients a stronger dose at night and combined it with Lortab for short-term pain. He said he also prescribed the tranquilizer Xanax for anxiety caused by the pain. Graves also acknowledged he had been fired from jobs at a state prison and a Pensacola pain clinic before going into private practice.

Boston Archdiocese Names 22 More Priests Accused of Sexual Misconduct
Robert O'Neill, Associated Press- 2/8/2002

BOSTON --The Boston Archdiocese forwarded to prosecutors the names of at least 22 more priests accused of sexual misconduct with minors, including six priests suspended from active duty. With the number of accused priests now standing at least 60, the archdiocese also was hit by two new lawsuits alleging the church knew of the abuse but failed to stop it.
    A lawsuit filed in Middlesex Superior Court charged Cardinal Bernard F. Law with negligence by failing to protect a boy from abuse by now defrocked priest John J. Geoghan. Meanwhile, a lawsuit filed in Suffolk Superior Court on behalf of four former altar boys accuses the Rev. Paul W. Desilets of molesting them when he was assigned to Assumption Parish in Bellingham and the archdiocese of failing to protect them. Earlier this week, two other former altar boys filed a separate lawsuit against Desilets, now 78, with similar allegations. Desilets said in an interview Wednesday those allegations were ''exaggerated''
    Last month, Law announced a new policy of reporting even past allegations of abuse by priests after documents in the Geoghan case showed some archdiocese officials knew of the accusations. At the time, Law assured the public that all known sexual molesters had been removed from assignments. The suspensions announced Thursday, follows the suspensions of two other priests Saturday.
    The six priests suspended Thursday were: the Rev. James F. Power, 71, who worked at St. James the Great in Wellesley; the Rev. David C. Murphy, 65, chaplain at Brockton Hospital since 1997; the Rev. Robert A. Ward, 55, who worked at the archdiocese's development office; the Rev. Thomas P. Forry, 60, unassigned priest who provided assistance during absences of other priests; the Rev. Gerald J. Hickey, 64, and unassigned priest who was assisting at St. Helen Parish in Norwell when he was suspended; and the Rev. Richard A. Buntel, 56, employed in a non-ministerial position as a business manager at St. Thomas of Villanova parish in Wilmington. Their names, together with other accused priests who had served in the archdiocese over the past 40 years, were forwarded to prosecutors.
    On Thursday, Middlesex County prosecutors received 14 names, Norfolk County prosecutors received three names and Plymouth County prosecutors received five names. Suffolk County prosecutors said they received information from the archdiocese's law firm late Thursday and had not yet reviewed it.
    Prosecutors in Middlesex, Norfolk and Plymouth counties said they would be requesting additional information from the archdiocese, including the names of the alleged victims. ''We have not seen the name of a single victim yet,'' said David Traub, a spokesman for the Norfolk County District Attorney's office.
    In the suit naming Law, Christopher T. Fulchino, now 25 and living in Maine, alleges he was abused by Geoghan in 1989 when he was 13. Fulchino and his parents charge the cardinal Law knew or should have known Geoghan was sexually abusing children at parishes before being moved to St. Julia's in Weston in 1984. The lawsuits claims Geoghan was not removed from St. Julia's following further allegations, but instead was placed on ''sick leave,'' and then allowed to return and placed in charge of minors. Fulchino claims it was then that Geoghan molested him.
    Law is also charged with using ''a veil of silence to interfere with Fulchino's rights.'' Geoghan, who was recently convicted of sexual abuse, faces 80 civil lawsuits and two more criminal cases. The archdiocese is facing other lawsuits by people alleging abuse by Geoghan, and the victims of former church worker Christopher Reardon, who was sentenced to 40 to 50 years after pleading guilty last year to molesting 24 boys.

Top DUI Cop Was Drunk When He Died
Jerry Lawrence, Chicago Tribune- 2/8/2002

One of the top drunken-driving enforcement officers with the Lake County Sheriff's Office had nearly three times the legal level of alcohol in his blood when he died in a one-car accident last year, officials said Thursday. Sheriff's Deputy Philip John Santucci, who was a member of the sheriff's accident-investigations unit, was driving about 30 m.p.h. over the speed limit and was not wearing a seat belt when he died Dec. 19. Toxicology reports released Thursday at a coroner's inquest showed that Santucci had a blood-alcohol content of 0.225 percent, said Lake County Coroner Barbara Richardson. The legal level for drivers in Illinois is 0.08 percent.
    Lake County Sheriff Gary Del Re said Thursday that Santucci was the department's top drunken-driving enforcement officer, and credited Santucci with keeping the Lake County Sheriff's Office ahead of other agencies in Illinois for DUI arrests during the past three years. Deputy Chief Richard Eckenstahler said Santucci had been recognized by Mothers Against Drunk Driving, the Alliance Against Intoxicated Motorists and the Northern Illinois Council on Alcoholism and Substance Abuse for his DUI arrests.
    Santucci, 39, a father of two who joined the Sheriff's Office in 1997, was off duty when he was killed. Del Re said an internal investigation found that Santucci had been drinking with off-duty sheriff's deputies and other police officers at more than one bar before the early-morning accident, in which Santucci lost control of his 1998 Oldsmobile Intrigue on Wadsworth Road. "There were several parties going on that night at several drinking establishments," Del Re said. Richardson said the blood-alcohol content of Santucci's urine was higher than that of his blood, which indicated that he had stopped drinking before the crash.
    At the inquest, Sheriff's Lt. John Jansky said Santucci lost control of his car about 2 a.m. on Wadsworth Road, about a mile west of Green Bay Road in Newport Township. Santucci's car drifted onto the shoulder, Jansky said. Santucci overcorrected by steering sharply to get back on the road, which threw his car into a sideways skid across oncoming lanes, Jansky said. Jansky said skid marks indicated that Santucci's car was traveling about 73 m.p.h. on a stretch of road with a speed limit of 45 m.p.h. Santucci's car slid up an embankment at about 60 m.p.h. and hit a series of trees, Jansky said. Santucci was not wearing a seat belt. He was pronounced dead at the scene by the coroner's office. Jansky said a seat belt could have saved Santucci's life. "I can only hope that something like this will help officers use common sense and keep each other from driving if they believe someone has had too much to drink," Del Re said.
    Del Re and Eckenstahler both described Santucci as a model police officer and said that his level of intoxication was a surprise to everyone who knew him. "If he had a beer or two at an event, that was unusual. This was a very big surprise," Eckenstahler said. Santucci was one of the best sheriff's deputies Eckenstahler said he ever had seen. "I'm not good with poetic words, but I will say that we all learned a lot from Phil Santucci in life," Eckenstahler said. "Unfortunately, we learned even more in his death."

Houston Schools Seeing Xanax Abuse Rise
Cindy Horswell & Salatheia Bryant, Houston Chronicle- 2/8/2002

When Nelda Cruz arrived at Baytown's Gentry Junior School, she found her 13-year-old daughter sitting limply in a wheelchair. Veronica's legs could no longer support her 120-pound body, her eyes had a dead stare and her speech was slurred. "All I could do was cry when I saw her," said Cruz. Officials in Baytown's Goose Creek school district later determined that the girl was one of six students there who bought -- on campus -- Xanax, a highly addictive, anti-anxiety prescription drug that is starting to invade schools in the Houston area. In less than two weeks, more than a dozen students in three area school districts have been linked to the drug, including some who were hospitalized and others accused of selling it. The Harris County Precinct 3 Constable's Office is investigating the incident at Gentry. Sgt. Jack Hagee said a student has admitted to school officials that he sold the drug, and felony charges of delivery of a controlled substance are expected. And in another recent incident in the Goose Creek district, a student at Robert E. Lee High School was arrested for peddling the drug to another student.
    Known as footballs, handlebars, or Z-bars, Xanax is the latest in a line of prescription drugs students are abusing, following Ritalin, Prozac and Valium. Xanax comes in white, tan and blue. In at least one district, each pill sells for $4 to $5. Adverse reactions to the drug can include drowsiness, confusion, loss of blood pressure, palpitations and muscle tremors. Users can also experience nightmares, manic symptoms and self-mutilation impulses. The drug recently attracted headlines when Florida Gov. Jeb Bush's 24-year-old daughter, Noelle, was arrested at a pharmacy drive-through window on charges of trying to buy Xanax with a fraudulent prescription.
    The drug's popularity is enough to make one veteran school police chief declare war on it. J.L. Campbell of the Fort Bend schools expects to launch on Monday a plan through the school's Crime Stoppers program that pays students $100 for information leading to any Xanax confiscation or arrests. It's a desperate measure for a district that has been hit hard by the drug. Two years ago, the district had no reported cases of Xanax. Last school year the district's police department worked 19 cases and this year the district is on target to surpass that figure with 12 cases to date.
    "We're starting to get a couple cases a week. It's just really mushrooming here," said Campbell. "We've made some cases where they've had 40 or 50 tablets, where they have been packaged for sale." "Kids aren't just carrying it around to look cool. They are taking it," said Campbell. In the HISD, four students at Black Middle School were taken to the hospital after showing signs of being dazed. Two other students were accused of selling the drug.
    Of 90 drug reports worked by the district this school year, only one other involved Xanax, according to the district's police chief. But even in districts where Xanax hasn't appeared, police are aware of its popularity. "Kids have always found ways to abuse prescription drugs. We're hearing about it. It's the new drug on the scene," said Spring Branch Police Chief Chuck Brawner. "We haven't had a case yet, but it doesn't mean it's not out there." Not only is it out there, says Kathy Clausen with Goose Greek, but it's readily available.  "This is happening in lots of area school districts because kids can buy it right off the Internet, without a doctor's prescription, from foreign companies," said Clausen, the district's spokeswoman. "All they need is a credit card."
    One Web site for an international pharmacy club offered an array of prescription drugs, including Xanax, at a 70 percent discount if the buyer pays an $80 membership fee. The site states: "You, as a citizen of the United States, have the right to buy your prescription drugs from international pharmacies for your own personal use, without being forced to pay overpriced physicians for their signatures." It stresses the convenience of buying drugs in "the comfort and privacy of your own home!" Clausen, however, said certain drugs are controlled and illegal to buy this way.
    Since the drug hit Fort Bend schools, Campbell has gotten a quick education, including learning that many students are taking the drug to counter the effects of another drug. He's learned that many students hide the pills in the casings of a pen or highlighter marker. Some pills come from home medicine cabinets, and some come from the black market. Fort Bend school officer Michael Rios can easily recognize a student under the influence of Xanax. He's seen it enough times. Sluggish, droopy eyelids and slurred speech are his clues. "You can spot them walking down the hallway," Rios said. "Sometimes they get to the point where they will actually fall out."
    At Gentry Junior School, Cruz said her daughter had taken four .25 mg tablets, or four times the recommended dose for adults. The drug is not recommended for anyone under 18. It was too late to pump her stomach, Cruz said, so her doctor said to let her sleep it off. Veronica awoke the next morning feeling jittery and with a splitting headache, but her mother said the eighth-grader was lucky, because an overdose can be fatal. "They need to stop this somehow," Cruz said. "It is hurting our children."

Increase in College Students Disciplined for Drug/Alcohol Violations
Associated Press, 2/8/2002

BOSTON -- The number of students disciplined for drug violations at the University of Massachusetts at Amherst more than tripled between 1998 and 2000, while at Tufts students reported for violating the school's alcohol policies nearly doubled during the same period, according to statistics released by federal education officials. The statistics show a similarly high increase across the country, The Boston Globe reported Saturday, Between 1998 and 2000, the most recent period for which figures are available, the number of students reported for violating drug laws increased nearly 80 percent nationally, while alcohol violations rose 25 percent.
    Colleges and education officials say the figures, compiled following a congressional mandate last year, are the result of more aggressive reporting of violations. Around the country, 6,270 educational institutions began reporting crime date to the U.S. Department of Education. ''My interpretation is that the campuses are taking a much more active role in reporting and taking action against students involved in activities that violate drug and alcohol law,'' said David Bergeron, chief of policy of post-secondary education at the Education Department. ''I think they're now aware their institutions are being scrutinized.''
    At UMass, officials said that the statistics have in part been boosted by the inclusion of students disciplined for possessing drug paraphernalia. ''What really increased our number was the possession of drug paraphernalia,'' said Paul Vasconcellos, dean of students. At Northeastern University, which saw arrests for alcohol violations triple, officials said they are now including even minor violations, even when they occur off campus. ''For us that's really the main difference,'' said Northeastern spokesman Ed Klotzbier.
    Public health officials say the rise in numbers also reflects relaxed attitudes toward drugs among students coming into colleges. Throughout the 1990s, ''programs and funds for the drug war decreased and the percentage of young people who viewed drugs as dangerous dropped,'' said Henry Wechsler, principal investigator of the Harvard School of Public Health's annual college alcohol study, which found nearly half of college students binge drink. Reports by the Harvard School of Public Health show the use of drugs like marijuana and ecstasy on student campuses jumped during the 1990s.

Second Marriages Up, U. S. Census Says
Genaro C. Armas, Associated Press- 2/8/2002

WASHINGTON -- Divorce rates are up, but so are second marriages. Divorcees who do remarry usually wait three years before saying "I do" again. Having an older wife is becoming more common, especially among younger men in their first marriages. Although these statistics came from a 1996 survey, the Census Bureau report released Thursday provides the most comprehensive look in years at marriage and divorce in America, University of Michigan sociologist Pamela Smock said. "It confirms the things that American people are well aware of," Smock said. The pre-1950s family pattern of Mom, Dad and kids living under the same roof is now "an aberration." The Bush administration wants to change the 1996 welfare overhaul, which must be renewed this year, to encourage women on welfare to get married. President Bush's 2003 budget proposal included $100 million for experimental programs to do that.
    Much of the census report reinforced long-running trends about marital status. For instance:
*Roughly half of first marriages for people younger than 45 end in divorce. First marriages that end in divorce typically last about 8 years.
*Younger generations of Americans are delaying marriage until later in life. "Marriage still is something that many people want to do and expect to do, but these statistics show that they are spending a lot of time unmarried," said Marshall Miller, co-founder of the Boston-based Alternatives to Marriage Project. "People no longer feel they have to rush down the aisle," Miller said.
*More educated people are more likely to marry and stay married, the report found. Miller's rationale: they are more mature when they tie the knot, and presumably have spent more time courting their future spouses. In the fall of 1996, 92 out of 1,000 never-married men age 25 to 44 with bachelor's degrees got married within that past year, compared with 59 out of 1,000 men of the same age with just high school degrees. Women who graduated from college were less likely to divorce in the previous year than those who had only high school educations.
    Long-held models of family makeup are slowly dissolving, said David Popenoe of the National Marriage Project, a think tank at Rutgers University. The group studies marriage trends and ways of strengthening marriage. "In the past, guys would look for a stay-at-home housewife," Popenoe said. "Young guys today are looking for someone with some money, and that requires an education." Roughly 9 out of 10 Americans were expected to marry in their lifetimes, the report projected. While still high, it's a change from the 1950s, when everyone was expected to get married, said Thomas Coleman, executive director of the Los Angeles-based American Association of Single People.
    Other highlights:
*11 percent of men born between 1925 and 1934 were married at least twice by age 40, compared with 22 percent of men born between 1945 and 1954. There was a similar increase among women.
*About 38 percent of women in their first marriage who married between 1945 and 1964 were the same age as or older than their husbands, compared with 48 percent of women who tied the knot between 1970 and 1989.
    On the Net: Census Bureau: http://www.census.gov

Marriages Tested by Changing Attitudes
Wendy Wendland-Bowyer, Detroit Free Press- 2/9/2002

Dorothy Keith was 16 when she met her future husband. He remembers the day well. They were introduced by a friend at a high school football game. "She had a lovely smile," said Rudolph Keith, 83. Together they weathered World War II, raised two daughters and survived a big move from Alabama to Taylor, where they now live. She stayed home with the kids; he brought home the bacon. And after 60 years together -- they celebrated their anniversary Dec. 25 -- their feelings are as strong as ever. "We are very in love with each other," Dorothy Keith, 79, said Friday.
    If that sentiment seems quaint, it may be. According to data released Friday by the U.S. Census Bureau, long-lasting marriages like the Keiths' are as old-fashioned as antimacassars. Americans are marrying later and divorcing more often. About half of today's first-time marriages end in divorce, the government says. That's a reflection of changing attitudes, said David Popenoe, a sociology professor and codirector of the National Marriage Project at Rutgers University in New Jersey. For the World War II generation, marriage was a partnership for battling life. Now, Popenoe said, marriage is almost completely tied to feelings. "But the problem with feelings is they are notoriously changeable," he said.
    Expectations also change. Women still desire to marry someone who earns a decent income, he said. But now, so do men. "Many men want a wife who will earn money . . . but they also want this woman to do the laundry and cooking. The whole area of marriage gender roles is still in a state of flux and up for negotiation," he said.
    The Census Bureau is calling its new report, based on data collected in fall 1996, the most complete look at marriage and divorce in a decade. The release of the report is timely. Marriage initiatives are cropping up in state legislatures -- including Michigan's, where a lawmaker wants to establish a Marriage and Fatherhood Commission -- and in Washington, D.C., where marriage is expected to figure into the debate as the nation's welfare law comes up for reauthorization this year.
    The report shows that among men born between 1925 and 1934, 15 percent were divorced by age 40. But among men born between 1945 and 1954, 31 percent were divorced by that age. People also are marrying later, the report says. While women married in the early 1940s averaged age 21, by the late 1980s it was 25.
    The fact that more people are living together tends to delay marriage, said Pamela Smock, associate professor of sociology at the University of Michigan. Smock recently completed research that shows more than half of all couples who married in 1994 lived together. In 1965, just 10 percent of couples who married tried cohabitation first.   "Young people I talk to say they wouldn't even imagine getting married without cohabitating first, so things have really changed," Smock said.  Henry Baskin, a Birmingham lawyer who has specialized in divorce cases for 30 years, said he has even heard of parents who encourage their children to live together before tying the knot. Many end up divorced anyway, he said.
    Many counselors and psychologists say the reasons people divorce have not changed, and there are steps couples can take to stick together.  Robert Erard, a psychologist at the Psychological Institutes of Michigan in Franklin, said money, in-laws and sex are prime culprits in arguments that lead to breakups. But it's the little things that warn of trouble ahead, he said.  When couples no longer spend time talking to each other, going out alone together, surprising each other with little things, or being physically intimate, problems can quickly arise, he said. When couples see warning signs like going weeks or months without physical intimacy, not making up after fights or making up without addressing the cause of the fight, or speaking about the partner in a disparaging way, they should get counseling, Erard said.  Eric Nordquist, a counselor at Perspectives of Troy, said he believes today's instant-gratification society makes people think their marital problems can be solved in a flash. "The good news is, people who do seek counseling are oftentimes able to reconcile . . . it does work," Nordquist said. "But the sooner people seek help, the more effective counseling is."

Reports of Priests' Abuse Enrage Boston Catholics
Elizabeth Mehren, Los Angeles Times- 2/9/2002

BOSTON -- Among Catholics here, the floodgates of rage and disappointment poured open this week. On radio talk shows, in chatter at convenience stores and in emergency "listening sessions" convened hastily by the Archdiocese of Boston, the faithful vented anger and frustration over daily disclosures that scores of pedophile priests worked in the region with the full knowledge of church officials. As the number of implicated clergy members soared to 80, the crisis grew so deep that nearly half the Roman Catholics polled said Cardinal Bernard Law should resign. The turmoil over what church officials knew, when they knew it and what they did or did not do to protect themselves and their parishioners has rocked a region that is more than 50% Catholic. "This is our Sept. 11," Boston College professor Thomas H. Groome said Friday.
    By week's end, the archdiocese had given law enforcement authorities the names of at least 80 priests accused of sexual misconduct with minors over the last 20 or more years. The archdiocese also announced Thursday that six more priests had been suspended. Earlier in the week, the archdiocese relieved two other priests of duties, also following accusations that they had sexual relations with children. Both actions came days after Law publicly insisted that all priests in his jurisdiction who were suspected of sexually abusing children had been removed from their duties.
    In the poll of 800 adults taken by the Boston Globe and WBZ-TV, 51% of those surveyed were critical of the cardinal and how he has handled the growing scandal. The displeasure was aimed specifically at Law, the 70-year-old archbishop of Boston. In the same poll, only 16% of respondents had an unfavorable view of Pope John Paul II, and just 4% had adverse opinions of their own parish priests. The survey found that 64% said church leaders care more about protecting the accused priests than helping the victims.
    "I think for a long time people have known that the church has been aware of these problems and has not acted expeditiously," said Lisa Cahill, a professor of moral theology at Boston College, a Jesuit institution. "Part of what's appalling," she continued, "is the extensiveness of the problem, based just on the number of these priests that keep surfacing in New England. Every day, you hear about six more cases."
    Recently, the archdiocese said it had settled so many child sexual abuse claims against it that a multimillion-dollar insurance fund was running dry. Scandals involving pedophile priests have hit parishes across America--and indeed, around the world--in recent decades. Thousands of adults have come forward to say they were abused as children and many priests have been sent to jail.
    At first, accusations against Father James Geoghan seemed no different. The 66-year-old defrocked priest was charged in three separate criminal sexual abuse cases dating from the 1980s and 1990s. More than 130 people have claimed they were fondled or molested by Geoghan, who also is a defendant in 84 civil lawsuits. But in the course of the Geoghan investigation, Law was forced to tell prosecutors that the priest's pattern of pedophilia was no secret in the local Catholic hierarchy.
    Law abruptly promised to supply law enforcement agencies with names of priests suspected of such behavior. He organized a panel including medical experts to look into sexual abuse within the church. The cardinal also appealed for public understanding, urging Catholics to pray for him as he faced this difficult situation. On Jan. 25, he vowed, "There is no priest, or former priest, working in this archdiocese in any assignment whom we know to have been responsible for sexual abuse." Days later, he removed two more priests for alleged child molestation. The archdiocese did not respond to requests Friday for an interview with the cardinal. However, after returning from the Vatican, Law told local reporters at Logan International Airport: "Our intent is to do everything we possibly can to ensure the protection of children."
    Around the archdiocese, the scope of the scandal--and its growing momentum--continued to shock Catholics, who expressed grief, outrage and, most of all, a sense of betrayal. "You have an organization that is based on faith, and part of that faith derives from your confidence in the institution that houses that faith," said Paul Nace, a real estate developer in Newton who was raised Catholic. "When events happen that call into question that institution, at a very basic and moral level it also calls into question your faith," Nace said. As horrific as the spiraling number of clergy sexual abuse cases might be, "the most disturbing part is that it appears that decisions were made to protect the institution at the expense of the victims," Nace said. "You've got a head-on, loggerhead collision with everything that institution is supposed to stand for."
    Groome, a former priest and author of a new book called "What Makes Us Catholic," said that to Catholics, the church represents a vastly more important institution than in some other denominations. "We have obviously exaggerated the importance of the institution," he said. "Everybody has a priesthood, and everybody invests in their priesthood, but nobody in the Western world has invested in their priesthood the way Catholics have. This is why all of this is so desperately shattering."
    Mitchell Garabedian, an attorney representing 84 plaintiffs in civil suits against Geoghan, said his clients have had their faith ravaged by their experiences. "They cannot seek spiritual relief anywhere because of what has happened to them," Garabedian said. "The very entity they want to turn to has in a sense helped them to be molested. It is mind-boggling." Some of the claims he has looked into involving the Boston archdiocese date back more than 40 years, Garabedian said. Far from surprised that so many names of alleged predator priests have been put forward by the church, "I'd be surprised if more names were not revealed," he said. "There is a serious problem within the Archdiocese of Boston," Garabedian went on. "For decades they have been imprisoned by pedophiles and shackled by their own denial."
    The troubles at the archdiocese took a new turn late in the week when a family in which both a father and son were abused by priests filed a suit against Cardinal Law. The latest legal action--the first directed at the cardinal himself--claims Law "intentionally" and "recklessly" inflicted emotional damage on Thomas and Christopher Fulchino by knowingly assigning a pedophile priest to their parish. Law, archbishop of Boston since 1984, is the senior Roman Catholic prelate in America. Twice this year he has declared that he will not step down. "I do not believe that submitting my resignation to the Holy Father is the answer to the terrible scourge of sexual abuse of children by priests," he wrote in a Jan. 26 letter to area Catholics.
    The poll found that church attendance has not declined significantly because of the scandal. But 1 in 5 Catholics said they were contributing less money to the church as a result of the controversy. The archdiocese-wide survey was taken Monday through Wednesday and has a margin of sampling error of plus or minus 3 percentage points. Groome said "one of the reasons I like this church is it is full of sinners and I feel at home. But you make a distinction between sin and crime. The criminals you can't have in your chancery." As to whether the cardinal should resign, Groome said, "A month ago I said no, he should ride it out, clean up the mess. I did think a month ago he was capable of putting the thing back together. This morning, I am not so sure."

Drug Guidelines Often Written by Experts With Ties to Industry
New York Times, 2/9/2002

WASHINGTON -- A survey of medical experts who write guidelines for treating such varied conditions as heart disease, depression and diabetes has found that nearly nine of 10 have financial ties to drug makers, ties which are almost never disclosed. It has long been known that contact with the pharmaceutical industry can influence individual doctors' prescribing patterns and that financial support from drug manufacturers can affect the course of academic research.
    The survey, a relatively small study conducted by the University of Toronto, is the first to document the extent to which the industry may influence clinical practice guidelines. These voluntary guidelines, published in medical journals and endorsed by medical societies, set standards followed by countless doctors. "These clinical protocols should be seen by the public as unbiased," said Sheldon Krimsky, a health policy expert at Tufts University in Medford, Mass., who has written extensively on financial conflicts of interest.
    The survey, reported in last week's issue of The Journal of the American Medical Association, sought the opinions of 192 experts who participated in writing 44 sets of practice guidelines covering treatment for asthma, coronary artery disease, depression, diabetes, high cholesterol, pneumonia and other ailments. Of the 100 who responded, roughly nine out of 10 had some type of financial relationship with a drug manufacturer, including research funding and speaking, travel or consulting fees. About six out of 10 had financial ties to companies whose drugs were either considered or recommended in the guidelines they wrote.

Psychiatrist Says Detained Airliner Passenger May Have Had Panic Attack
Associated Press, 2/9/2002

MIAMI -- A passenger accused of trying to break into an airliner cockpit during a flight to Argentina had been depressed and may have suffered a panic attack, according to relatives and a psychiatrist who treated the man during the flight. Pablo Moreira Mosca, 29, a bank employee from Uruguay, was arrested Thursday on a United Airlines flight from Miami to Buenos Aires with 157 people on board. He allegedly crashed into a reinforced cockpit door, getting his upper body into the cockpit, before a crew member hit him with the blunt end of an ax and fellow passengers helped subdue him.
    Dr. Maria del Carmen Pirez Vargas, an Uruguayan psychiatrist on the flight, told The Miami Herald she treated Moreira with an anti-anxiety drug. ''At the moment of the incident, the patient broke with reality and with the present,'' Pirez wrote in a medical report she gave to the newspaper. ''He experienced a clastic crisis (mental breakdown), with aggressiveness and a great lack of control.'' Pirez quoted another passenger who had just attended a marketing seminar with Moreira as saying: ''Pablo was under great stress just prior to the flight. He was in a state of shock for 24 hours before boarding the plane.'' The passenger said Moriera seemed depressed ''because he spent a whole day without saying a word.''
    Moreira's sister, Montevideo journalist Gimena Moreira, told the Herald that his boss had asked their brother to meet Moreira when the flight reached Buenos Aires. Gimena Moreira said her brother ''gets panicky when he flies, especially when there is turbulence.'' She recalled an earlier trip when they were traveling together and their plane flew through turbulence: ''Pablo gripped the arm rests so hard that they came off.''
    Moreira was unconscious and bleeding from a scalp wound when Pirez reached him during Thursday's flight. She said she gave him the anti-anxiety medication Loxitane. As Moreira gained more awareness, he told her he worked at a Montevideo bank and had been married for two years, she said. Other family members said Moreira's outburst was completely out of character, describing him as a mature and intelligent person who tutored students and enjoyed playing soccer. ''Pablo is an excellent person,'' Maria Balsa, Moreira's sister-in-law, told the South Florida Sun-Sentinel. ''He is an absolutely normal person.'' Moreira was returned to Miami on Friday to face federal charges of interfering with a flight crew. If convicted, he could face up to 20 years in prison and a $250,000 fine. A bail hearing was scheduled for Tuesday.

Exploring an Enron-Related Suicide
Paul Duggan & Lois Romano, Washington Post, 2/10/2002

WASHINGTON - Before he was found dead on Jan. 25, the former Enron Corp. vice chairman, J. Clifford Baxter, was ''obsessed'' with worries that the scandal surrounding Enron's collapse would forever tarnish his reputation, and that private investigators were rummaging through his mail and trash, according to a lawyer in whom Baxter confided. Texas authorities, who have ruled Baxter's death a suicide, have declined to release the contents of a note he left, and little has been reported publicly about his state of mind in the days before his death.  Baxter was named as one who ''complained mightily'' about the off-the-books partnerships at the heart of the company's failure in the memo that an Enron manager, Sherron Watkins, wrote in August to the chairman, Kenneth L. Lay. In it, she warned that the company could implode in an accounting scandal.
    A Houston lawyer, J.C. Nickens, who represented Baxter and who spoke frequently with him in the weeks before his death, said in an interview that he does not believe that Baxter, 43, had taken damaging Enron secrets to his grave. He also said that Baxter had not been deeply troubled by the prospect of having to testify before Congress, and that he had not feared being held criminally culpable for the company's demise. Rather, Nickens described Baxter as having become agitated about being a watched man. ''Cliff expressed to me his belief that people were going through his mail, that they were going through his garbage, that people were showing up at his home late at night, and making phone calls that were unwelcome,'' Nickens said. ''He felt his intention to spend more time with his family was going to be frustrated, and that he might be unemployable for the rest of his life over something that, from his point of view, he had no information about.''
    Nickens said he had no sense that Baxter might take his own life. He agreed with the recollection of Jeffrey Skilling, a former Enron chief executive, in testimony Thursday before a House subcommittee. In a conversation about a week before the suicide, Skilling said, Baxter had told him that he feared the taint to his reputation would ''never wash off.'' ''Why did he do it? That's a psychiatric question that I can't answer,'' Nickens said. ''If I had seen this coming, I might have been able to do something about it. And I don't like that feeling.''
    Several former colleagues recalled Baxter as being passionately loyal to his friends at the company, which is why some surmise that he was so troubled in the last weeks of his life. ''He was an honorable guy, and his loyalty went way beyond friendship,'' said an acquaintance, who asked not to be identified. ''If he thought he would have to testify against his friends, it would have eaten at him.'' Nickens, however, said that was not a major worry for Baxter, because he would not have been an important witness. ''Yes, testifying was a concern for him, because he didn't want the hassle,'' Nickens said. ''But the speculation that he was going have to reveal some secret or he was going to have to implicate some of his friends - that just was not the case.''
    Before shooting himself in the right temple with a .38-caliber pistol, police said, Baxter wrote a note. Authorities are waiting for an opinion from the Texas attorney general's office on whether the note can be released, pursuant to the state's open-records law. One non-police source, who reports having been told about its contents, said it mentions Enron. But the note is largely a personal message from Baxter to his family, the source said. ''I'm told he left it in a place where he expected only his wife would read it,'' said Nickens, adding that he does not know details of the contents. ''It's certainly our hope that it doesn't become public.''
    Baxter was one of 29 past or current Enron officials named as defendants in lawsuits by shareholders who lost billions of dollars when Enron went bankrupt. The lawsuits allege that the defendants concealed Enron's deteriorating financial condition while selling hundreds of millions of dollars in stock. Baxter lived in the affluent Houston suburb of Sugar Land with his wife, Carol, and their two children. He sold $35.2 million in stock over three years before he resigned from Enron last May, according to the lawsuits. ''Cliff had a saying about working for Enron,'' Nickens recalled. ''He said he felt like he'd been drinking water from a firehose for 10 years. ... He said to me that that he'd missed 10 years of his kids growing up and that he had done very well and could afford to just go home.''

Coke, Crack Making Return to Massachusetts
Associated Press, 2/10/2002

BOSTON -- Cocaine and crack, the substance that fueled an epidemic of violence a decade ago, are reappearing in Massachusetts. Directors of detox centers, residential and outpatient drug-treatment clinics and probation offices report seeing increasing numbers of people using cocaine or crack in the past several months. ''We're expecting heroin, and we start to see cocaine showing up and it's throwing us a little bit,'' Bob Manion, chief probation officer in South Boston District Court, told the Boston Herald.
    State Department of Public Health figures show that cocaine use in Massachusetts steadily declined during the 1990s as heroin addictions surged. But the latest numbers, based on drug seizures from police departments statewide, show the percentage of cocaine hauled in since last summer on the rise for the first time in eight years.
    Just before Christmas, undercover agents made the largest cocaine seizure ever in state history about 600 pounds worth $20.8 million that was smuggled in a truck from Arizona to New Bedford. ''There is some concern over the fact that such a large shipment was destined for Massachusetts and New Bedford, which is a key source area,'' said Diane Brackett, special agent with the federal Drug Enforcement Administration's New England office. ''Certainly that's indicative of a customer base to support that shipment.'' The seizure followed raids that rounded up 19 alleged members of another cocaine ring that, documents show, may have moved as much as 400 pounds of cocaine into the Boston area in previous months.
    ''Heroin has tapered off and now we're starting to see cocaine,'' said Manion. ''Something is happening and we don't know yet quite what it is. DPH data also indicate that even as the latest cocaine numbers jumped, crack seizures from police departments continued to decline. But anecdotal reports suggest the potent substance a cheaper and more powerful ''rock'' form of cocaine smoked for an instant high is popping up more frequently in some areas.  ''We have noticed an increase in people who are coming in with cocaine as part of a (multiple drug) addiction history, and crack is becoming more prevalent,'' said Christine Hickey, program director at the South Middlesex Opportunity Council's Framingham detox facility.
    At the Albany Street shelter in Cambridge, which houses men and women with alcohol and drug problems, director Win Poor said clients have told him the streets are ''flooded'' with cocaine. The agency's admissions data show the number of clients with cocaine and crack problems spiked in September and October, and again in January, while heroin use declined. Directors of drug-treatment facilities said calls and admissions to their programs jumped after Sept. 11. Directors say they don't know if the increase was because more people were using drugs or just seeking treatment, but regardless, the percentage of cocaine users stands out.
    It's also unclear whether Massachusetts' increase in cocaine is an aberration or a signal of a new trend. Either way, it's an issue that demands careful monitoring, experts say. ''The behavior implications are considerable,'' said Thomas Clark, a Boston-based researcher who tracks drug trends for the federal government's National Institute on Drug Abuse. ''If cocaine should come back, we could face once again in uptick in violence related to the drug.''

Staying Clean: Does Rehab Really Work?
Peggy Orenstein, New York Times Magazine- 2/10/2002

Patrick T. is prone to citing Oscar Wilde and the physicist Michio Kaku. He's so well spoken, his manner polished to such a high gloss, that--aside from the fact that he's been a methamphetamine addict and career criminal since age 13 whose only formal education is a high school degree earned in juvenile detention--he could blend easily into a gathering of witty young professionals. Certainly he is equally engaged by his work. Until recently, Patrick often earned his living robbing drug dealers and the occasional small business. "There's a lot of thought and energy that goes into getting loaded and planning a crime," he explains. "It's dramatic--the excitement, the carefree feeling that comes when you succeed. That's not something that happens in the monotone of everyday life. That's why for me, feeding my mind and spirit will be as important as anything I do in terms of abstaining. Because if I get bored . . . " He lets the threat hang, unspoken.
    Patrick is 30, tall and rangy, with sandy, short-cropped hair and a neatly trimmed goatee. He and I are in the small library of Center Point, a substance-abuse treatment facility in San Rafael, California, about half an hour north of San Francisco, where he is enrolled in a six-month residential program. Patrick is a "retread": This is his second time through here in a year, initially in exchange for a suspended sentence on charges of possessing drugs and stolen property. He completed the program last June and got a job restoring boats in Sausalito, convinced that his own ship had finally come in. But within five weeks he had moved from swallowing pain pills for a bad back to downing a couple of beers with his older brother. Then he started lighting up a few joints. In less than two months, he headed to San Francisco on a meth binge. He had planned to stay high until his money ran out, he was arrested for violating probation or he died. But one night, holed up in a transient hotel with an old crime partner and a prostitute, Patrick had a revelation. "I was suddenly disgusted with the whole scene," he recalls. "I had this thought--or this thought was given to me--that I just couldn't do it anymore. I just couldn't." He called Center Point and said he needed help. Within 24 hours he was back.
    As Patrick talks, members of "the family," as the 40 clients here call one another, drift in and out, browsing through the self-help books that line one of the room's walls or--since the program frowns on privacy--listening to our conversation. A disheveled heroin addict who has been through six treatment programs in 11 years comes in to sharpen a pencil. After he leaves, Patrick says, "What scares me are people like him, who are intelligent. That can be one of the biggest obstacles. You substitute intellectual understanding for actual change." I ask Patrick what odds he give himself this round for staying off drugs. "Fifty-fifty at best," he says, evenly. "But anyone who'd give their chances as being any better than that is practicing self-deception."
    Patrick is one of thousands of addicts in this country who are doing exactly what the new conventional wisdom says they should: going through treatment and probation rather than jail (or in exchange for a lighter sentence) with the promise of a better outcome. It's the latest salvo in America's other war--the one on drugs--which many would acknowledge we've been losing for years. Consider: The federal government spends about two-thirds of its $19.2 billion drug budget on law enforcement and interdiction. A result has been a skyrocketing prison population--it has tripled in the last two decades--with at least 60 percent of inmates reporting a history of substance abuse. The cost of warehousing nonviolent drug offenders is more than twice as great as treating them. Meanwhile, a study by the RAND corporation's drug policy center found that for every dollar spent on treatment, taxpayers save more than seven in other services, largely through reduced crime and medical fees and increased productivity. A visit to the emergency room, for instance, costs as much as a month in rehab, and more than 70,000 heroin addicts are admitted to ER's annually.
    Those facts, along with an enormously successful campaign by the National Institute on Drug Abuse (NIDA) to portray addiction as a disease rather than a moral weakness, have already persuaded Californians and Arizonans to pass voter initiatives requiring nonviolent drug offenders to be offered treatment with probation in lieu of jail. Similar measures are being targeted for November ballots in Michigan, Florida and Ohio. By 2003, systemic changes in the New York courts are expected to divert 10,000 nonviolent drug addicts to rehab annually. And Senators Barbara Boxer and Orrin G. Hatch, hardly ideological soul mates, have proposed bills to increase federal funds for treatment, although they differ considerably in details.
    As the call to treat drug offenders grows--an ABC News poll showed that more than two-thirds of Americans favor treatment over jail for first- and second-time offenses--one of the thorniest questions will be how to define success. Because the truth is, Patrick's estimation of his own chances is about right. Center Point, which was established in 1971, runs one of the oldest and largest treatment networks in California and has what are considered excellent success rates. Still, one-third of its clients leave without completing the program, even if that means going directly to jail. Nationally, dropping out of treatment is the rule. Among those who do finish, few maintain the gold standard of total abstinence for long: a Congressionally mandated study showed that more than half of cocaine addicts and nearly two-thirds of those addicted to both heroin and cocaine were using drugs within a year.
    Center Point's adult program house sits at the nexus of the business and residential districts in downtown San Rafael. Bland, dorm-style bedrooms line three halls, each room containing two single beds, two dressers, two night stands, two lamps. Out back, beyond the TV room (which is off-limits most of the time), there is a concrete slab for smoking breaks. Clients spend much of their day in a large central room that, depending on the configuration of chairs and folding tables, serves as dining room, therapy space or study hall. Its only décor are two small handmade signs: one reads, "And the day came when the need to remain closed became more painful that the risk of being open." The other, the map of a land called re-entry, highlights the Ten Concepts--initiative, effort, completion, etc.--that are the backbone of Center Point's program, the precepts upon which clients are supposed to build their new lives.
   The 40 family members file in and sit silently in a circle on straightbacked chairs. They are mostly white and mostly male, many with prison tattoos covering their forearms. Most are in their 30's, which is typical in treatment. They place their hands in their laps, feet on the floor, and look straight ahead in what is called "group protocol." When anyone deviates, a brother or sister corrects him. He may not talk back. When anyone deviates, a brother or sister corrects him. Women and men sit on opposite sides of the room and may not speak unchaperoned. When anyone deviates, a brother or sister corrects him.
    Strict adherence to what to an outsider can sometimes seem like arbitrary rules is integral to the therapeutic-community method: a self-help-based approach to addiction that most of the large drug-treatment franchises employ. At the heart of the method is the belief that daily interactions within the family - a kind of round-the-clock peer pressure - are the main agent of change. Drug use is viewed as symptomatic of a "whole person" disorder. If, through resocialization, an individual's attitudes, values and lifestyle are transformed, the addiction will take care of itself. Governing everything from how long clients can shower to what they can drink (no coffee, for example), the rules are supposed to instill self-control and provide structure for those who may never have had it. The idea is that if you sweat the small stuff, the big stuff, like not stealing or not using drugs, will follow.
    Instilling a work ethic is also essential to a therapeutic community. Everyone helps maintain the house, doing laundry, cooking, cleaning. New clients are assigned a "big brother" or "big sister" who accompanies them everywhere, even to the bathroom. As they participate in the family, write essays exploring such issues as their attraction to drugs, memorize the Concepts and generally behave themselves, they move up in "status," earning rewards that are both tangible and affirming, like receiving mail. After three months, clients ease into the real world by finding a full-time job, some for the first time. After six, they either move to transitional housing or home, cautioned to attend "continuing care" or 12-step meetings for at least a half-year.
    Each day at Center Point is punctuated by group therapy sessions guided by a counselor, in which a client brings up an issue - past sexual abuse, a craving for drugs - and the rest of the family responds, sometimes bluntly, with opinions and advice. The feedback is supposed to break through calcified defenses and challenge ingrained thinking, helping clients recognize the need for change. Today is "grief and loss" group, and Micky Wickersham, a blond, ponytailed counselor who is leading the session, asks Sharon A., 32, if she has anything to share. Sharon is addicted to a volatile combination of meth and pain pills. She was ordered to treatment by the Child Protection Program under the threat of losing her 23-month-old daughter. (She also has an 8-year-old son.) "I'm drawing a blank," Sharon responds, smiling appeasingly. Wickersham, a 33-year-old recovering alcoholic and meth addict herself, eyes Sharon, who has been here for several weeks sliding by, evading attention. Like most clients, Sharon resists kicking up the murk of an unhappy life. It's time to give her a little push. "No problem," the counselor says, turning to the family for inspiration. Hands shoot up. One brother tells Sharon that she acts detached from her own experience, as if it happened to someone else. A sister begs her to "open up" for her own sake, then bursts into tears. "Let us help you, Sharon," she says.
    Patrick goes on the attack. "You want to put things out in a pretty package so everything will sound good," he snaps. "Forget sounding good. Sound real." Wickersham lets that thought hang for a moment. "We could unwrap that pretty package right now," she says, sweetly ominous. "Do you know what it looks like on the outside?" Sharon shakes her head almost imperceptibly, looking dazed. "You like to present yourself as a middle-class white woman with a little drug and alcohol problem who some stuff happened to and now you're here to get your life back." "No," Sharon says softly. "I don't mean to." "Do you know what's inside that box?" Sharon shakes her head again. "Because I'm going to tell you," Wickersham continues. "You are a homeless dope fiend with no education who chose drugs over your kids." Wickersham goes on to say Sharon could become the woman she pretends to be by dedicating herself to the program. She could take advantage of Center Point's G.E.D. tutoring and vocational training. She could learn a new values system. She could get her children back. "Do you want this program?" Wickersham asks. "Yes," Sharon says. "Let me hear you say it." "I want this program." "Again." "I want this program." "Choose four men and four women," Wickersham says. "Look into their eyes and say, `I need your help because I want this program.' " Sharon steps across the circle to a brother who is addicted to crack and meth. "I need your help because I want this program," she says softly. "Sharon, I need your help because I want this program," he replies. She moves on to three more men, then to the women, who cry and hug her. Finally Sharon stands before Wickersham, unexpectedly grabs the counselor by both hands and yanks her to her feet. "I need your help because I want this program," she says, a tear rolling down her cheek.
    It's a poignant, triumphant moment. Sharon has admitted her problem. She has allied herself with the group. She has bonded with her counselor. And she has been offered hope that, with diligence, she can turn her life around. On other visits, I would watch a prison-hardened man weep like a little boy over the death of his father. I'd witness a woman mourn over neglecting her children. I'd listen to a brother grieve years of molestation by a coach. The family would confront or cajole, console or criticize: As moving as it all was, I wondered: can such catharsis, or even a series of them, keep an addict clean?
    "Of course it can't," says Sushma D. Taylor, a clinical psychologist and Center Point's C.E.O. "But they're related. Our clients are seeking emotional sanctuary, especially the many who have suffered abuse. The only way you can grieve the things that have been done to you is to cry in a place where you know the tears are going to get mopped up and somebody is going to put you back together and say we love you, where no matter how ugly the past is, it can be viewed within the context of being a therapeutic issue." Realistically, the groups can't resolve past traumas in six months, Taylor says. They are just a step toward self-awareness, toward learning healthier ways of coping with pain.
    Later, when Sharon is cleaning the bathrooms, I ask her how the attention felt. "I wanted to hide in a corner while it was happening," she says. "But afterward I felt exhilarated. It really did feel like something had lifted off of me." She sighs. "I still fear I won't be able to open up, though. They say doing jail time is easier than treatment, and I think that's true. This is not easy."
    In July, when California enacted Proposition 36, which diverts drug offenders to a variety of treatment programs (depending on availability), Mike T was just the sort of addict whom the public had in mind. He is affable, nonviolent and employable, and he has never been in treatment. Mike pleaded guilty to possession and has one other charge pending-he tried to draw on a forged check at a bank, a crime largely influenced by his drug use. Mike is a natural athlete, a former ski instructor, but two years of daily methamphetamine use has ravaged his body and destroyed his stamina. While other members of the family play basketball in a nearby park, he takes a break on the sidelines. It's a rare time outdoors, an hour away from the relentlessness of 40 personalities rubbing up against one another in the cramped public rooms of the house. Mike is dressed for the game in sweat pants with an American-flag motif. Other days, he sports an Old Glory T shirt or tie. The patriotism is a legacy of his father, a retired Air Force colonel who considers addiction "a weakness." Mike's not sure what he thinks. As ;a teenager he watched his mother drinking herself to death. He used to water down her wine, but, he says, "she always caught me, and it just made things worse."
    Mike's own drug use started, as did nearly everyone's in the family, in junior high. He was a pothead, a party boy who added cocaine to his repertory in high school. In his 20's, he switched to methamphetamine (also called crystal meth, ice or crank), a cheaper, longer-lasting and easily made form of speed that has swept the West and Midwest and is quickly moving across the country; it's the dominant drug at Center Point. Meth can be snorted, shot or smoked. At first, Mike says, the draw was the extra staying power during sex. Eventually, though, he was doing several "blasts" a day. A college dropout, he supported himself when he could by trimming trees or working construction. When he was on a run, he'd rely on unemployment, petty dealing, cashing bad checks and mooching off friends. By the time he was arrested in August for a small-time sale (a charge that was later knocked down to possession), his family had cut him off financially. He lost his apartment, hocked all his belongings and was living in his truck.
    Mike says he feels "blessed" by the opportunity he has been given, both because he has avoided prison, the threat of which terrifies him, and because it has helped him kick meth. "Meth did nothing but destroy me physically, mentally, emotionally, the whole nine yards," he says. Even so, Mike won't rule out going back on the drug once he's off probation ("Aug. 31, 2004," he repeats like a mantra). "I know myself well enough to know I may use," he says. "I don't know for sure. I like the lifestyle I'm living now I look forward to getting something better than what I have in life. But who's to say what will happen?"
    To be a drug addict is to engage in a perpetual internal dialogue about whether you truly have a problem, whether you really belong in treatment. While acknowledging his meth addiction, for instance, Mike doesn't see why he should stop his daily marijuana use - even though smoking pot after treatment triples the chances of a return to harder drugs. "So every day I ask myself: am I wasting a seat here? Is there somebody that needs to be here to save their life, who is sick and tired of what they're doing and wants to get help? Because part of me says: I'm 34 years old and I'm healthy and if my choice is to smoke my pot and use drugs, then that's what I'm going to do."
    Mike often suggests that he'll leave Center Point, that he'll head up to Tahoe and get a job on the ski slopes. Of course, the more likely result of walking away is jail. "I know," he says, his eyes skimming the action on the basketball court. "In my heart I know I have to stay. If I walked out of here now I'd go right back to where I was. I'd end up living in the back of my truck." He turns toward me, leaning forward intently. "But I still think about how to get high every day. And that's the part of my addiction that eats me alive."
    A few days later, Mike stops me in the hallway, asking me to define addiction. Maybe, he says, his father is right and it's simply a failure of will. "I didn't smoke pot until I was 12," he reasons. "I had a choice then. And I still have a choice every day. So what does `addiction' mean?" He has every reason to be confused. Is addiction a spiritual disease? A physiological illness? A character flaw? A sin? Genetics, in part, explain why, when two people who are equally curious first try a mood-altering drug, one walks away with a shrug and the other finds salvation. But environment plays a role as well: economic disadvantage and family dysfunction can drive the need to self-medicate (according to NIDA, an arm of the National Institutes of Health, there are actually 72 separate risk factors for drug abuse). Hanging around druggie friends has an impact, too, as does boredom.
    Drug use, of course, is not the same as addiction. The former is clearly a choice. But over the last decade, scientists have begun to see the latter as something else: a chronic, relapsing brain disease. At some point (when, precisely, is unclear) the neurochemistry and receptor sites of a user's brain change radically, causing drug-seeking to become as biologically driven as hunger, sex or breathing. Long after the addict quits, some of those brain changes remain, creating a vulnerability to relapse. The implications for the criminal-justice system are profound, reinforcing the need for treatment: it would be ineffective, not to mention inhumane, simply to punish someone for an illness without helping to heal him.
    Some researchers, however, call the brain-disease model little more than a gimmick, one that undercuts the role of choice and personal accountability. "I'm not disputing the fact that certain areas of the brain light up when an addict thinks about or uses cocaine," says Sally Satel, staff psychiatrist at the Oasis Drug Treatment Clinic in Washington and a fellow at the American Enterprise Institute. "But it conveys the message that addiction is as biological a condition as Multiple Sclerosis. True brain diseases have no volitional component." Casting addiction as a brain disease rather than a behavioral disorder, Satel says, gives addicts an easy excuse for relapse. It also suggests that the remedy is primarily pharmacological, which has not, so far, proved true. "The search for a magic-bullet cocaine vaccine has been under way for 10 years, and I'm skeptical anything will come of it," she says. "The only way to get better is to harness free will. Ask any addict; they'll tell you."
    Alan I. Leshner, under whose leadership NIDA aggressively promoted the brain-disease concept, agrees that addicts should not be let off the hook. "The danger in calling addiction a brain disease is people think that makes you a hapless victim," he says. "But it doesn't. For one thing, since it begins with a voluntary behavior, you do, in effect, give it to yourself." Nor does biology trump responsibility. "Just like any other disease, you have to participate in your own treatment and recovery," he says. Still, he doesn't like the moral tenor of Satel's argument. "What about people with high cholesterol who keep eating French fries? Do we say a disease is not biological because it's influenced by behavior? No one starts out hoping to become an addict; they just like drugs. No one starts out hoping for a heart attack; they just like fried chicken. How much energy and anger do we want to waste on the fact that people gave it to themselves? It can be a brain disease and you can have given it to yourself and you personally have to do something about treating it."
    In art therapy the clients are drawing one of the five elements in pastels, after which they will explain their choice to the group. Patrick is halfheartedly crayoning the ocean while describing the sculptures he used to make in jail from bits of leftover soap. "My proudest achievement was a giant Oakland Raiders emblem," he says, holding his hands about a foot apart, "with big letters that said 'Commitment to Excellence.' "
    Patrick refers to himself as "institutionalized": he has spent so much time in prison that the prospect is no longer a deterrent. "I'm comfortable there," he explains. Patrick is pretty comfortable at Center Point too, perhaps too much so. He volunteers to speak in every group (though maybe because of that, he is rarely called on). He follows the rules meticulously and reprimands anyone he finds slacking. A few brothers call him "Center Pat" behind his back, saying he has just perfected rehab: once he leaves he'll surely relapse. Patrick is determined not to let that happen. "Last time I didn't extend myself," he explains. "I participated just enough to not be confronted by a counselor. And behind the scenes I ran my own deal. I got someone to sneak coffee into the house for me every day. I didn't respect `quiet time.' And those little things got bigger and bigger. "Honestly, a lot of the rules are petty, and I'd still just as soon not follow them," he continues. "But we agree to do that when we come here. Learning to keep that agreement, learning not to do what it is we feel like doing, those are important things. I don't want to be quiet. I don't want to not drink coffee. I don't want to do many of the things asked of us here." He shrugs. "But then, what I want to do has often times proven not to work."
    Responsibility. Self-worth. Community. Those are the things Patrick hopes to cultivate this round. That last piece is critical to any addict's treatment. Familiar cues - smells, places, people - can have a Pavlovian effect: a heroin addict who has been clean five years in prison may vomit on the ride home as the bus passes old haunts, instinctively anticipating a fix. An addict's best bet is to change environments entirely, but for Patrick, as for anyone, ditching old pals is painful, even frightening. "I have a history and fun memories of using with my friends," Patrick says. "I don't have a good sense of who I am outside drugs. I don't have much experience with real life."
    Later, during an evening therapy group, a middle-aged meth addict who is about to complete the program and move to transitional housing discusses the daily obstacle course of temptation he navigates on his way to work at a nearby supermarket. "I see the dope fiends, and I can smell it on them," he says. "It reminds me of old times, of making dope, using dope. I have heavy triggers. Any kind of chemical smell. At work I'm fortunate; I don't have any of those smells. But I've seen dope on the sidewalk and didn't mess with it. Or people leave their keys in their vehicles. One guy had one of those restored cars from the 50's with fins - he left the keys in and the motor running while he ran into the market. I'm a dope fiend. I have sleazy thoughts. But I don't act on them. I carry the Ten Concepts in my pocket, and I read them in the street. That's how I work my way through it." Dennis Labogin, the program manager who is leading the group, smiles. "Eleven years later I can still spot the perfect robbery" he says. "That's who we are. No matter where we are these thoughts will drag us down. And the only people who will understand is us."
    Not all people with a drug or alcohol problem will self-destruct the way Patrick and Mike and Sharon did. In fact many, like President George W Bush, will quit spontaneously before their lives unravel. Others do well (at less taxpayer expense than treatment) on probation with contingencies: rewards for abstinence and sanctions for testing positive for drugs. Those tend to be lighter-weight users with more to lose. Have they not yet contracted the brain disease? Or has it not progressed as far? Or, as Satel might say, have they merely harnessed their free will?
    Both sides of the brain-disease debate agree on one thing: a significant subset of addicts do need help, which jail alone can't provide. "I'd be happy with incarceration if it were effective," says A. Thomas McLellan, director of the Treatment Research Institute and professor of psychiatry at the University of Pennsylvania. "Here's what happens now They go to jail. Why? They've broken the law, and we're going to teach them a lesson. They'll realize it's bad, and they'll stop. Then they leave jail and go into the parole system. The parole officer has a caseload of up to 1,000 people. The individual is not monitored or only monitored briefly. And, anyway, he was supposed to have learned his lesson. What happens is relapse."
    McLellan and James W Cornish undertook a study comparing punishment in conjunction with treatment to stricter punish without treatment, to see which was more effective in reducing crime. They found that opiate addicts who were forced to increase the number of times they met with their probation officers were twice as likely to be rearrested or reincarcerated within a year as those who received only standard probation but with therapy and naltrexone, a drug that blocks their high.
    The question remains, however: Just how effective is rehab? The treatment system, which evolved as a piecemeal, grass roots movement, has been subject more to faith than to scrutiny. In many states, like California, the rehab industry remains largely unregulated, with lax licensure and few standards for quality or effectiveness. Since conventional wisdom blames the addict for his relapse, if the courts are involved only the addict is sanctioned: judges rarely ask whether programs delivered the services promised.
    As public interest in treatment grows, though, researchers have been taking a closer look at traditional methods to tease out the strengths and limits. "For many counselors the litmus test of good treatment is whether you can get the patient to cry," says Richard Rawson, associate director of the Integrated Substance Abuse Programs at U.C.L.A. "If you look at the data, there's not a lot to support a causal relationship between talking about feelings and not using drugs and alcohol. I'm not suggesting it should be ignored. Having a safe place to process that material is an important element. It's the other half of the equation: `O.K., so we've done therapy. What do I do next?' "
    One answer, Rawson says, is to incorporate techniques that have been proved in clinical trials. Medications like naltrexone, along with counseling, work well with heroin addicts. Meth and cocaine addicts, particularly males, respond to cognitive behavior therapy. Used primarily in outpatient programs, cognitive therapy does not focus much on the psychological causes of addiction. Instead, therapists act more like coaches, teaching addicts why they develop cravings and working on coping skills, like planning in microscopic detail how to get from today until Wednesday without using. For less severe addicts motivational enhancement therapy peels away resistance to change through positive reinforcement rather than confronting an addict with his denial.
    Those methods are slow to gain ground in a field wary of outside intervention. Counselors-whose only qualification is often that they, too, are in recovery- resist replacing entrenched, it-worked-for-me ideology. Consider the maxim that an addict has to be "ready" for treatment, that he has to "hit bottom." Thai idea gives providers a free pass when rehab fails. It's also a myth: addicts forced into treatment by the courts do surprisingly well. Apparently if you lead a horse to rehab he may indeed quit drinking.
    Beyond that, the newer remedies require extensive training. Though a counselor like Micky seems especially dedicated (and Center Point does integrate some science-based methods into its programs), nationally, the turnover rate among counselors is an estimated 50 percent. And with starting salaries around $18,000, the applicant pool is limited. "In many places you can work at McDonald's one day and be a drug counselor the next," Rawson says. "People you do train tend to go on to something else as soon as they get some skills. It's hard to develop a cadre of skilled people in those conditions."
    Another factor in successful rehab is matching a given addict to the program and services that will make him stick. Each approach will work for some, but none for all: the therapeutic community that clicks with a homeless crack addict who suffers from post-traumatic stress may not be appropriate for a medical resident who can't stop dipping into the morphine. With long waiting lists for treatment slots and pressure on programs, which are paid per client, to take whoever walks in the door, that has not been an easy task.
    While improving all these aspects of treatment may well lead to better outcomes, according to a study of more than 10,000 addicts in 96 programs, the single most important factor (assuming a program is well run) is the length of time an addict stays in it. And 90 days - not the managed-care-driven 28 or the brief 3-to-5-day detox that is the most common "treatment" in many cities - was the minimum for enduring benefits to manifest.
    Little of this was taken into account by California's Proposition 36. The state's 58 counties are applying the law in virtually 58 different ways. Since each county can decide how to allocate its funds among direct services, administrative costs and probation departments, some are still emphasizing punishment over treatment. Either way, while the $660 million over five and a half years is the state's biggest infusion of cash into treatment, it isn't enough to cover the cost of long-term care for all who will need it, whether for day or residential programs.
    Although it's too early to predict how the experiment will play out, even the staunchest supporters of treatment are skeptical, particularly as other states prepare to follow California's lead. "There is promise here," says M. Douglas Anglin, co-director of the U.C.L.A. Drug Abuse Research Center, a node of the National Drug Abuse Clinical Trials Network. "But there are also fears about a possible quagmire. The voters rammed Prop 36 down the throat of all the agencies involved. And at the end of it all, we may find no reduction in drug use or crime, and that treatment was received by fewer than intended and for a shorter period than intended. It will look like treatment doesn't work."
    At lunch, most of the men reflexively hunch over their plates, left arm slung around the top, shoveling in their food as if they're in prison. Mike, who works in the kitchen, stands at the front of the room wearing a paper hat on which he has written "Sinbad" in Magic Marker. I sit at a women's table with Sharon. It is "dress for success" day, so she's wearing a long flowered skirt, green sweater and elegant black heels, all salvaged from a local donations bin. Despite years of drug abuse and personal neglect, Sharon is a beauty with an easy smile. She's a caretaker too -- always concerned about whether I've had enough to eat or how far I have to drive after a long day of reporting -- but the brothers and sisters are right: she has the disconnected quality of someone who is treading water against a rising tide of panic. She speaks quickly, her words slurring together, and tends to finish her statements by asking, "Does that make any sense?"
    Sharon doesn't remember most of her past, but what she does recall is a shattering pastiche of rape, abuse and violence. Like Mike, she was homeless when she arrived at Center Point; since dropping out of school in eighth grade the closest she has come to having a legitimate job was when she provided in-home service for her elderly mother, a position she was relieved of when it was discovered she was filching pain pills. She is currently studying the Ten Concepts. It's no surprise that she's stuck on Trusting and Support. "They make no sense to me at all," she says.
    About half as many women as men enter treatment, but the ones who do are more than twice as likely to have additional mental disorders like anxiety, depression or post-traumatic stress disorder. Though estimates vary, perhaps as many as two-thirds, like Sharon, were raped or molested before substance abuse. At least half have been victims of domestic violence. Because victims of such traumas are more likely to become addicts, and because, according to the National Center on Addiction and Substance Abuse, addicts are more likely to abuse and neglect their children, breaking the cycle among that population takes on particular urgency. Yet women, perhaps in response to the aggressive, male-dominated nature of many programs, drop out of treatment at far higher rates than men. Most of the women at Center Point are in a separate, single-sex program with their small children. The seven in this house are either childless or have grown children, or their kids live with relatives. For that latter group, regaining custody is a preoccupation. One of Sharon's table mates shows me three marbles she carries with her: a clear blue one to represent her son, a green one representing her daughter and a clear marble for the mother she would like to become.
    Sharon's children are currently with their fathers. Her daughter's dad is also an addict, in a day program in another town. Her son's father is clean. As much as she wants to set a better example for her kids, Sharon would never have quit using drugs on her own: she likes, and needs, to be loaded too much. Even so, she's indignant over her predicament. She talks about leaving treatment to be with her daughter: But to be with her daughter, she needs to stay in treatment.
    Micky Wickersham, Sharon's counselor and a mother herself, had told me that the hardest thing for a female addict is to admit she has been a bad mother. Sharon is no exception, arguing with herself over what constitutes child abuse. "I love my children," she insists. "I've never done any of the stuff my mom did to us. I would never even conceive of doing that to a child. I wouldn't beat them. So in my eyes, I don't feel like I was a bad mother." She pauses a moment, considering. "But granted, there was drugs. I understand that. There was the drugs. But. ... " She breaks off again, looking at me helplessly. "Does that make any sense?"
    Sometimes Patrick's dreams seem locked in the amber of adolescence. He imagines being an actor someday or maybe a drummer. Other times, his goals are more practical. He'd like to be a good father to his 10-month-old daughter, a good partner to his girlfriend (who has been clean for more than three years). He'd like to go to college. He also fears that he is programmed for failure. "You know, everyone falls," he told me. "And some people don't get back up. It scares me to think that I wouldn't be able to stand up again. It wasn't easy for me to come back here. If I had to make that choice again, it would be harder still. I feel awfully concerned about that."
    On this night, however, Patrick is optimistic. He's about to move up in the family hierarchy, gaining freedom and privileges. Labogin is supposed to quiz him on one of the Ten Concepts, but instead Patrick opts to recite them all. He closes his eyes and begins. "Empathy," he says. "The ability to imagine how others feel." I glance around the room. Some of the brothers and sisters are leaning forward, eyes shut in concentration, whispering the words along with Patrick. Others, like Mike, stare straight ahead in silence. I wonder whether Mike will experience the epiphany in treatment that will allow him to make more permanent change. Or whether probation and the threat of random urine tests will, in fact, keep him clean until 2004. Maybe the day he's a free man he'll celebrate by lighting up a fatty. Then a week, a month, a year later, break out the crank. Or maybe, just maybe, he'll discover he likes looking at life without the scrim of a ganja buzz. Maybe Sharon will get clean for her kids -- or for herself -- and stay sober, at least for a while. Maybe Patrick will last four months this time or a year or 10 years. Or maybe staying clean in treatment is, for the moment, all he can manage. And though on the surface this may look discouraging, the opposite is true. Failure, even serial failure, can actually be a form of success.
    Though among heavy users, some will go through treatment once and remain clean indefinitely, most will cycle through repeatedly, just as some smokers need multiple tries to kick cigarettes or dieters try over and over to slim down. "Treatment catches up with you," says U.C.L.A.'s Douglas Anglin. "For heroin users with a five-year history of addiction, it may take 10 or 15 years to help them come out of it, but if you start when they're 25, by the time they're 40 they're pretty much rehabbed. If you don't, most of them burn out by 40, but they don't get clear until 55 or 60."
    Perhaps the epiphany Patrick experienced during his last binge in San Francisco, the one that may have saved his life, was a direct result of his last round of treatment. He thinks so. "I couldn't even enjoy being high with a pocketful of money," he recalls. "I hope I never forget how demoralized I felt." Or, as another brother who has been through treatment three times and is addicted to meth, crack and alcohol puts it, "All that recovery information ruins your high totally and completely. It's a conflict of interests to have that understanding and use."
    If treatment is conceived of as an ongoing process rather than as a cure, a different, more optimistic notion of success emerges. Although addicts may relapse, a year after treatment their drug use decreases by 50 percent, according to the National Treatment Improvement Evaluation Study, and their illegal activity drops as much as 80 percent. They are also less likely than before to engage in high-risk sexual behavior or to require emergency room care. Other studies have shown that they are less likely to be on welfare, and that their mental health improves.
    For chronic addicts like many of those at Center Point, it may be that treatment should never entirely end; it should just be tapered down. "You don't let a schizophrenic out of case management," argues the University of Pennsylvania's Thomas McLellan. "Your expectation is that there will be a relapse if they leave. Good practice would be to continue to monitor and support that person to see early signs of intensification. At that point you intensify treatment not to `cure' but allow them to remain in a state that maintains them and doesn't have an impact on society."
    Perhaps, then, Patrick clean, even for just the six months he's in a program, and Mike clean for three years, and Sharon clean for as long as the Child Protection Program breathes down her neck- or even Patrick, Mike and Sharon returning to treatment two, three, five times - while not optimal, may, for now, be good enough. If, that is, during that time they cost the taxpayers less, they work and pay taxes themselves and they do less harm to society, themselves and their children than they otherwise would have. Even as researchers push for reform in the system, that perspective may be the most pragmatic. "We expect too much from treatment," McLellan says. "The relapse rates are about the same as for hypertension, diabetes, asthma or any other chronic illness. At the same time, we're not asking the right questions. Treatment providers and researchers have been focused on whether someone uses drugs or alcohol after treatment. I don't care if you drink. I don't care if you use drugs. I do care if you're honest and not stealing from your employer or driving drunk or stealing from cash machines."
    On a late January evening, I visit Patrick, but not at Center Point. He left the treatment center on Thanksgiving Day, less than two months into his program. After accusing a young counselor (who eventually left) of abusing power, Patrick became the focus of rumors and suspicion himself. Nor was he entirely innocent: he had manipulated the counselor into sneaking him out of the house - a major taboo. As punishment, Patrick was assigned a series of essays on topics like criminal thinking; for two weeks, he also had to rise at 6:30 and clean the house. In the end, though, it was a petty argument that undid him: he threatened to pound another client, then stormed out of treatment. By the time he cooled down, it was too late to return; invoking violence is an unpardonable offense.
    At that moment, I would have put Patrick's odds of staying clean at around zero, but he surprised me. He went home to his girlfriend's, and he didn't use. When he was tempted by the wine at her family's holiday dinner, he left and went to an Alcoholics Anonymous meeting. Some friends from his first round at Center Point were there and helped him through; they still visit him regularly.
    Since the suspension of Patrick's jail sentence was contingent on his remaining in treatment (followed by six months of modified house arrest), after Thanksgiving he turned himself in. He is now serving three months at the county jail, where he requested placement in an in-house therapeutic community. "A better man would've stayed at Center Point," he says, looking stockier in his prison blues, the muscles of his face strung tight. "I didn't. I made a bad choice in leaving. But I realized that this time, I didn't have to keep on making bad choices."
    Patrick may have jumped, but through a combination of his own motivation and a multi-layered local treatment network, he fell right into a safety net. Jailhouse therapeutic communities have a lousy track record -- their recidivism rates are similar to incarceration alone. Unless, that is, they have a continuing care program. Patrick's does. After his release, he expects to enroll in it, to attend daily A.A. meetings, to find a pro bono therapist and embed himself in a clean and sober community. He already has a job lined up with a tree-trimming service and plans to look into grants for college. Those are exactly the steps experts would recommend for him. Still, he's uneasy. As a result of his free weekend, he and his girlfriend are expecting a second child. He worries that the pressures of fatherhood will overwhelm him. "I'm desperately scared about that," he admits.
    All along the Plexiglas between us, people have carved their names, striking a blow against anonymity, announcing that they were here and are now ... where? I study Patrick through the scratched pane and ask him one more time: How does he rate his chances of staying clean? "The same as they were when we first met," he replies. "About even." Then he smiles slightly and corrects himself. "Well, maybe now they're better than even."