Book Review

The Fix

N Engl J Med 2000; 342:140January 13, 2000

Article

The Fix
By Michael Massing. 335 pp. New York, Simon & Schuster, 1999. $25. ISBN: 0-684-80960-5

Substance abuse is one of the most serious and debilitating yet treatable chronic diseases in the United States today. Use of illicit drugs alone is estimated to cause approximately 20,000 deaths per year. Fortunately, there is a large body of evidence that treatment for substance abuse and addiction is highly effective and that it can save lives and money. Furthermore, treatment has repeatedly been shown to be far more cost effective than legal measures in reducing drug consumption.

Given these facts, one might expect strong support for treatment among political leaders and the general public alike. Yet few issues generate more spirited debate than national drug-control policies. Too frequently, the result of such debate has been ever more strident calls for stricter laws and mandatory jail sentences for drug offenders and a relative devaluing of programs to prevent and treat drug abuse. A tragic consequence of this orientation is that addicts who want and need treatment are often unable to get it. Meanwhile, drug traffickers, lured by the huge profits that can be made in the illegal-drug trade, find ways to negotiate legal hurdles to replenish the drug pipeline. At the same time, our prison populations swell with drug offenders, who, in 1996, accounted for over 60 percent of federal prisoners.

Against this backdrop, Michael Massing, in his provocative and meticulously researched book, contrasts the reality of addiction to illegal drugs with the gyrations of U.S. drug policy, from the Nixon administration to the present. Along the way, he describes the tremendous barriers addicts who want treatment encounter when they try to obtain it. He also chronicles how U.S. drug policy has moved away from demand-reduction programs, which emphasize treatment for addicts, and toward law enforcement and interdiction of drugs at their source.

Massing's surprising conclusion is that we should adopt a national drug-control strategy similar to that which existed during the Nixon administration, when activities to reduce demand were considered to be at least as important as programs to reduce supply and were funded accordingly. Providing the reader with an engaging view of the inner workings of the Nixon White House, Massing describes how the Nixon administration — motivated by the need to deal with returning Vietnam veterans who were addicted to heroin and with violent crime in the nation's cities — enlisted the aid of Dr. Jerome Jaffe, one of the most respected specialists on addiction in the country. Dr. Jaffe quickly established a testing and treatment program for returning veterans as well as a national treatment network for drug addicts, which was similar to one he had established in Illinois. In short order, this initiative curtailed the heroin-addiction epidemic among returning Vietnam veterans and substantially reduced both waiting lists for drug treatment and crime rates throughout the United States.

Massing goes on to detail how, in the wake of the Watergate scandal and the subsequent resignation of Richard Nixon and his senior staff, this treatment system was gradually dismantled as the nation's drug-control priorities tilted toward funding the “war on drugs.” He particularly takes aim at the Office of National Drug Control Policy, characterizing it as ineffectual and blasting the succession of “drug czars” for their lack of experience in drug treatment.

The first-person accounts of drug addiction Massing provides are no less compelling than the historical account of drug-control policies in the United States. Through the real-life stories of individual drug addicts, who are guided through the maze of treatment options in and around New York City by dedicated and street-wise outreach workers, the reader can feel their growing sense of urgency and frustration as treatment slots fill and the window of opportunity for placing increasingly dysphoric addicts in a treatment program begins to close. The reader is also given an inside view of the devastating personal and social costs of drug addiction, including broken homes, addicted children, crime, unemployment, and wasted lives.

The Fix is not without its shortcomings. By emphasizing treatment for “chronic” drug addicts, Massing tends to underemphasize the roles of prevention and brief intervention programs for less severely addicted persons. Each of these approaches is critical if we are to reduce the impact of drug abuse and addiction on public health and the number of people who become severely addicted to illegal drugs. However, given his focus on reducing the social costs of drug addiction, including criminal activity, Massing's emphasis on treatment for severely addicted persons is not surprising or inappropriate. In addition, as Massing states, the book is based on “political and street reporting”; it is not a scientific work. As such, there is some risk of overgeneralization on the basis of the experience of the few persons profiled in the book. There is also a tendency to impute relations of cause and effect between, for example, the availability of drug treatment and crime rates, without considering other factors that could also influence this outcome.

Nonetheless, these shortcomings do not detract from a core message of the book: that we need to modify our national drug-control policies so that we can at least achieve parity in terms of funding between demand-reduction and supply-reduction programs. Were we to follow this wise counsel, there is ample evidence that we could reduce the personal and social costs of drug addiction and ensure that those who desperately need and want treatment services are able to receive them.

Robert D. Brewer, M.D., M.S.P.H.
Lincoln, NE 68506