"Crack Is Whack": The Hierarchy of Addiction

Wednesday, August 11, 2010

Last week the Seattle P-I publicized the fact that Seattle's University District needle exchange, privately funded and operated by the People's Harm Reduction Alliance, had added clean crack pipes to its arsenal of disease-prevention weapons.  KING 5 News picked up the story, as did KIRO Radio.

Many of the reader comments posted to the stories reflect the expected divide in public opinion about needle exchange programs.  On the one hand are those who understand that certain strategies focused on reducing the societal and personal harms of drug abuse not only "meet addicts where they are" and provide a compassionate link to treatment and recovery, they also save tax dollars that would otherwise be spent on emergency rooms, hospitalization, and uninsured treatment of Hepatitis C, HIV, and AIDS.  On the other are those who think harm reduction strategies simply enable addiction, and addicts would be better served by a dose of "tough love" - or simply left to die from overdose or the diseases they contract.

The surprising comments are those like this from "screwybruce""needle I can live with, crack pipes no way. let them poke holes in pepsi cans to kill themselves, no way should money be spent on supporting crack users."

I'm reminded of Whitney Houston's status-conscious insistence that crack was too low-brow a drug for her:  "Crack is cheap.  I make too much money to ever smoke crack.  Let's get that straight."

I'm also reminded of the choice Congress made when crack first arrived in inner-city communities on the heels of heavy loss of industrial jobs that had provided employment for blue collar urban families.  Congress could have decided to invest in those communities, which might have reduced demand for crack and provided better employment options than selling it.  Instead, Congress invested in incarceration - by making crack a political football in the "tough on crime" game.  Five- and ten-year mandatory minimum sentences and a 1:100 sentencing disparity between crack and powder cocaine are just two examples of policies adopted in the 1980s that have devastated generations of American families and entire communities more effectively than crack ever could.  At least one senator saw the travesty for what it was:

If we blame crime on crack, our politicians are off the hook.  Forgotten are the failed schools, the malign welfare programs, the desolate neighborhoods, the wasted years.  Only crack is to blame.  One is tempted to think that if crack did not exist, someone somewhere would have received a federal grant to develop it.

If Ms. Houston and "screwybruce" are any indication, we're still suffering from the 1980s media campaign that faciliated those terrible decisions by framing crack as a wildly different drug than powder cocaine, one associated more explicitly with violence, poverty, and moral degeneration (ever heard of a "powder ho"?). 

Science certainly doesn't support the distinction.  Crack is simply a different form of cocaine, not an entirely different drug.  The way that crack is ingested - most commonly heated to produce a vapor that is inhaled into the lungs - delivers cocaine to the bloodstream more quickly than intranasal use (snorting).  The increased efficiency results in a faster and more intense delivery of the desired euphoria, but for a shorter duration.  As Nora D. Volkow, Director of the National Institute on Drug Abuse, explained last year to the U.S. Senate's Subcommittee on Crime and Drugs, "Cocaine, in any form, produces similar physiological and psychological effects once it reaches the brain."  The more efficient delivery route of crack smoking simply increases cocaine's reinforcing effects, which may be associated with increased risk of addiction.  While 3.4% of Americans report having tried crack cocaine at some point in their lives, only 0.1% report being current users.  Clearly, not everyone who tries it gets hooked.

Another important point that Dr. Volkow made in her testimony is that addiction to cocaine - whether crack or powder - can be treated:

Currently, the most effective treatments for cocaine addiction are behavioral therapies, which can be delivered in both residential and outpatient settings. Several approaches have shown efficacy in research-based and community programs, including (1) cognitive behavioral therapy, which helps patients recognize, avoid, and cope with situations in which they are most likely to abuse drugs; (2) motivational incentives, which use positive reinforcement, such as providing rewards or privileges, for staying drug free or for engaging in activities, such as attending and participating in counseling sessions, to encourage abstinence from drugs; and (3) motivational interviewing, which capitalizes on the readiness of individuals to change their behavior and enter treatment, performed at intake to enhance internal motivation to actively engage in treatment.

What's not mentioned as an effective treatment?  Punishment.  And punishment happens to be a lot more expensive than treatment, what with all the lawyers, judges, courtrooms, and prisons.  It also costs more than investing in our communities in ways that ensure adequate motivations for staying drug free exist, like good schools, jobs, and neighborhoods.

It's also expensive to deny crack users the same types of street outreach services we offer heroin addicts or alcoholics.  Making a connection with someone who cares about you is an essential first step toward recovery and away from hospital emergency rooms.

Sure, "crack is whack" (as Ms. Houston remarked in an interview with Diane Sawyer).  But continuing to marginalize crack users is just plain dumb.  Bravo to the People's Harm Reduction Alliance for trying a new approach.