UCLA Professor M. Douglas Anglin is one of the most respected addiction and treatment researchers in the United States. Anglin was the Founding Director of the UCLA Drug Abuse Research Center and an Associate Director of the Integrated Substance Abuse Programs (ISAP) from 1998 to 2010. He is currently a Senior Advisor in the Department of Psychiatry and Biobehavioral Sciences at UCLA.
Anglin has been conducting research on substance abuse since 1972. He has been the principal investigator on more than 25 federally funded research studies. Anglin is also one of the longest surviving HIV positive patients with active AIDS in the country.
This interview was aided by Professor Michael Prendergast, the Director of the Criminal Justice Research Group at UCLA ISAP. Prendergast has directed numerous projects studying drug treatment strategies in the criminal justice system and has been principal investigator of evaluations of treatment programs in correctional settings in California. His research work includes treatment and policy, issues in coerced treatment, and treatment effectiveness for drug-abusing offenders.
In 1994, you were part of a study that showed drug abuse programs to be truly cost-effective. The study estimated that $1.5 billion in savings resulted from the $209 million the state spent on treatment between October 1991 and September 1992. Fewer crimes committed by those in treatment resulted in the majority of the savings. The rest was largely due to a drop in health care expenses for the users. The Los Angeles Times reported your perspective on this success when you said: “This is the first time that I’ve seen the return on the investment so clearly laid out… Now, we can really be confident when we pound on our lecterns and say treatment works.” Has this and other such studies led to the implementation of cost-effective alternatives in the criminal justice system?
Anglin: The use of the criminal justice system to deal with drug users has been pervasive since the beginning of the 20th century. It began in 1914 with the Harrison Narcotics Act. In the 1930s, there were federal hospitals at Lexington and Fort Worth that were among the first to take criminalized populations and try to treat their drug addiction problems. But this didn’t last.
The next big phase was the War on Drugs that was initiated by President Nixon in 1968. That was the time I was a graduate student at the UCLA Department of Psychology, and I started to work with Professor Bill McGlothlin in addiction studies. I went from a relatively naïve small-town Arkansas boy to studying heroin addiction in one fell swoop.
At that time, I got involved with the Civil Addict Program that had been established by the State of California in the early 1960s. The idea was to take drug offenders and get them inpatient treatment at minimal security prisons. After the treatment, they would be paroled with specialized parole agents who would test them and try to keep them away from the further use of drugs. If they relapsed, they would be sent back to the California Rehabilitation Center for three to nine months for additional treatment, then released again.
The Civil Commitment Procedures had a good understanding of the pervasiveness and longevity of drug abuse once established. The Civil Addict Period was seven years, reflecting an understanding of the entrenched nature of drug addiction. The initial few years for addicts in the program seemed to always have a consistently high rate of incarceration at the California Rehabilitation Center.
The opportunity to study that program developed into a natural experiment. Many of the heroin addicts in the program ended up being released on Writs of Habeas Corpus due to inadequate court processing. Bill McGlothlin got a grant from the National Institute of Mental Health – they were in charge of drug abuse studies in those years – and we took a matched sample of those released on these writs to compare on follow-up with those who remained in the program. We found that program to be effective, particularly from a cost perspective.
Prendergast: I should note that the early years of the Civil Addict Program were successful, but after the 80’s and 90’s, the treatment became more lax and the effectiveness of the program dropped off. Although the Civil Addict Program is still on the books, it no longer has any real impact. The California Department of Corrections has moved on to providing treatment in prisons, primarily therapeutic communities and occasionally cognitive behavioral treatment. The Civil Addict Program is just not used very much anymore
In 1998, you were interviewed by the City Journal about the relatively new innovation of drug courts. You said, “The data are not yet available to indicate whether the drug court phenomenon as it has been variously implemented is an adjudication fad or provides, at least in some areas, the elements of a substantive intervention.” Sixteen years later, would you call it a fad or a substantive intervention? Do drug courts work?
Anglin: Rather than being a fad, it was really a jurisprudence movement. There are still a thousand or so drug courts in the U.S. and I believe they operate now in practically every state. The evaluations have been equivocal even as drug courts vary in terms of exactly what they do. The majority of drug courts steer drug offenders to treatment options and anonymous programs, particularly Alcoholics Anonymous, as an alternative to sentencing and prison. Even now, the results are mixed, the court is still out and no final verdict has been given. There is a Drug Court Association (the National Association of Drug Court Professionals), and they have standards of best practices. The drug courts that choose to abide by those standards tend to have a reasonable effect.
Prendergast: The main issue with drug courts is that they are quite restricted in terms of whom they accept. That means that the total population of drug users they serve is relatively small. Although they are an important part of the treatment system, they are a relatively minor component when compared to the size of the drug using population among offenders.
In a 1989 interview with The Desert News, you spoke about how drug abuse is unusual among older adults. You said, “With illicit drug abuse, there’s an aging-out effect because it’s a young person’s game in terms of the hustle to obtain drugs.” Is this still the case? Can you describe this aging-out effect?
Anglin: The aging out effect, broadly referred to as natural recovery, happens to most drug users. As years pass, the numbers drop precipitously for people who have used drugs less than ten times. Somewhere between 6 and 10% of people who try drugs ever get involved in a protracted period of heavy use. Most of those do age out relatively quickly.
There has been some pattern of change in the age relationship given certain circumstances. First, the baby boomers that went through the 1960s had a different perspective that tended to last longer. Many people went through that era exploratory when it came to recreational drug use and many continue to use recreationally. More recently, the huge increase in the use of diverted prescription drugs, mainly opiates, has changed the pattern. Prescription drugs have a flatter age range than the more illicit drugs.
In 2001, in your continuing Civil Addict Program study that we touched on before, you looked at an aging population of heroin addicts. That study revealed the importance of early interventions. Here are details of the report from an article in Health Day News entitled, “Heroin Use Leaves Trail of Troubles”:
“The study, published this week in the Archives of General Psychiatry, included a third look at 242 of 581 male heroin addicts admitted to the California Civil Addicts Program in the early 1960s; 284 addicts in the original program had already died. The median age of the addicts this time was 57.4 years. Of those left, 20.7 percent tested positive for heroin use, 9.5 percent refused testing, and 14 percent were in prison and couldn’t be tested. The bad news didn’t stop there… Of the many who reported illegal drug use in the previous year, 40.5 percent had used heroin, 35.5 percent had used marijuana, 19.4 percent had used cocaine, 10.3 percent had used crack cocaine and 11.6 percent had used amphetamines.”
Are such results conclusive proof that early intervention by offering treatment to first-time offenders is no longer a choice, but a conclusive necessity if the American judicial system is going to effectively stem the tide of illegal drug addiction?
Anglin: It should be the first option, the second option and the third option. The Civil Addict Program recognized that given long-term drug abuse and the entrenchment of the addict lifestyle, relapse is to be expected. You needed to swoop in and provide more substantive interventions in the face of relapse as opposed to more punishment. Although the rhetoric has been well accepted by the criminal justice system, the money is still focused on punitive measures. Today, the budget for criminal justice is 70% as compared to 30% for treatment options and interventions, and that’s the best it has ever been for the many decades that I’ve been working in this field.
The number of offenders treated in prison is still only 12 to 15%. California did establish an entire prison exclusively for drug offenders called the Substance Abuse Treatment Facility, but I am not sure if it’s still in operation.
Prendergast: The California Substance Abuse Treatment Facility and State Prison in Corcoran is still in operation, but it is not totally devoted to treatment anymore; it still serves a large population of drug offenders, but small when compared to the number of drug offenders in the entire prison population.
Anglin: In other words, it’s still a drop in a bucket. From your studies, you found that coerced treatment actually is as effective as voluntary treatment. Such a finding goes against the belief of most rehab counselors and recovery clinicians who believe that personal motivation for treatment is critical. Why is there such a gap between your findings and the perceptions of professionals in the treatment field?
Anglin: That’s partly due to the pervasiveness of the concept of hitting bottom where an addict absolutely encounters so many problems that recovery is there only way out. They have to choose it as a way to survive or, at least, survive outside of the criminal justice system. The whole AA and NA movement was in part predicated on this idea of hitting bottom. Coerced treatment seems counter-intuitive in that culture, but, when you look at the actual facts, coerced treatment was as effective and, in some cases, even more effective than voluntary treatment.
Coerced individuals would enter treatment at a somewhat earlier age, and they would stay in treatment a bit longer. One consistent truth we have learned about treatment is that the longer you stay, the better you eventually do. Coerced treatment removes the self-selection phenomena of those who are willing to stay longer because they lack the power to make that decision. Of course, the treatment options provided need to be effective as well.
This opens the door for a question I have for Professor Prendergast. As an investigator of treatment programs, can you briefly explain your findings of how evaluations can be used to improve program implementation and lead to better results?
Prendergast: New programs and new techniques do need to be evaluated to determine whether they are effective. Just because somebody says that I have the latest treatment doesn’t mean that it’s going to work. You need rigorous research to determine whether a particular treatment approach is effective. The problem then becomes making sure that that treatment is implemented with some sort of fidelity. That is to say that the clinicians who provide the treatment are adequately trained and, more or less, follow the protocol of the treatment approach or technique. In the absence of that, you don’t know whether the treatment is effective. Evaluations – not necessarily rigorous NIDA-like evaluations – but even evaluations performed by the staff of the program to see whether their outcomes are what they expected is an important means of maintaining or even improving programs.
There is a whole new area of research called implementation research, which is designed to develop methods for introducing new treatments and sustaining those treatments over time. We are doing some of that research now at UCLA. But in the absence of evaluations of both new treatments and existing treatments, we don’t know whether they are in fact working or what is necessary to try to ensure that they continue to be effective. It is very easy for programs to become complacent, particularly with funding problems. Continuous evaluation of treatment programs is an important component of ensuring that they maintain their effectiveness and hopefully even improve their effectiveness.
In 2007, you told the Prison Legal News that, “Although American corrections officials have generally resisted drug therapy, the high cost of recidivism among abusers is forcing a re-evaluation. About 85% of all incarcerated people have had substance-abuse problems at some point.”
In the early 1990s, only about 5% of inmates received substance-abuse treatment, compared to about 15% today. But you described such an increase as minor when you said, “that’s still a drop in the bucket.” Are drug treatment options for offenders the key to reducing the prison population in this country?
Anglin: Decriminalization of use is affecting more and more people with drug issues. Our recent research with California’s Substance Abuse And Crime Conviction Act found it to be very cost effective, particularly in terms of significantly reducing incarceration costs with only moderate increases in treatment costs. Once again, cost effective studies fall very heavily on the side of alternative interventions. With prison overcrowding, alternative interventions are being pressed more and more upon the criminal justice system.
Still, it has responded too slowly. But it has made a distinct difference. The rhetoric has been followed by some action and that action has proven to be definitely constructive.
I quote again from the 2007 Prison Legal News article:
“’Various epidemics of drugs’ over the years — from LSD and heroin to cocaine, crack cocaine and methamphetamines — combined with increased emphasis on penalizing drug use, ‘effectively criminalized whole generations of black people and now, increasingly, Hispanics,’ Anglin says….
In 2003, more than 20 percent of sentenced inmates were imprisoned for drug offenses. Offense rates varied by race, however, with 24 percent of black inmates and 23 percent of Hispanics serving time for drug offenses, compared to 14 percent of white inmates.”
Given such findings, what is the connection between illegal drug abuse and race? Is it based in race or is it a socioeconomic problem that brings out a form of institutionalized racism?
Anglin: Well, it’s certainly a socioeconomic issue because it has been shown that minority communities that traffic in drugs do so because of a lack of access to legitimate sources of income. Even though the use rate among Africans-Americans and Hispanics is no more, sometimes even less, than in the white population, socioeconomic difficulties lead directly to these minority populations becoming involved with distribution, and thus into the focus of law enforcement.
The socioeconomic is inextricably linked with racial disparity. Although it might appear on the surface to be a racial issue, the main cause is socioeconomic.
When it comes to treating drug addiction and handling the problem of illegal drug abuse in society, you developed the idea of “return on investment” as a way to make progress in the policy arena. What does “return on investment” mean specifically in this context?
Anglin: I thought return on investment would be an intuitively obvious concept for government officials to see – whatever resources you put into an intervention, you gain back in terms of lowering costs. Hence, it was a good buy for taxpayer dollars to expand rehabilitation and offer treatment as opposed to just locking people up and building more prisons. The prevention approach showed its greatest savings in reduced incarceration costs.
Prendergast: Yes, and as budgets of state and county agencies have decreased or, at least, flattened, officials want to know that the money they invest in whatever service is being offered returns at least as much in benefits and hopefully more. Our studies of criminal justice interventions often include a cost component to see whether the benefit-cost ratio is favorable. If you invest a dollar in treatment, you want to show that you can get two dollars in benefits.
Anglin: That’s a great stock market return.
Prendergast: The problem is that let’s say the Department of Corrections provides treatment and pays for treatment. If there is a reduction in recidivism, then normally they benefit. On the other hand, if there is no reduction in recidivism, but there is an increase in employment as a result of the program, that’s still a good thing, and you could say that it’s cost effective. But the money does not come back to the Department of Corrections. The savings are in other parts of society.
Although these agencies want to know a program is both effective and cost-effective, they also want to have those specific savings come back to them as opposed to some other agency or to society in general. As a result, it can be a little tricky sometimes.
Reminds me of that line from the Tom Cruise movie Jerry Maguire – “Show Me The Money!”
Anglin: Right. What matters is not that you are saving money and it’s cost effective, but whose pocket does the money end up in.
You were a pioneer in examining the natural history of drug abuse. Can you explain this concept and how it applies to addiction research?
Anglin: A natural history timeline shows, either for individuals or groups or both, how they get involved with drugs, how they become substantively involved, and how they manage to maintain their drug use over time. Beyond the addiction, a natural history shows what patterns occur with interventions, including criminal justice and treatment and otherwise like the aging out effect. We [cut] our teeth on the heroin addicts in the Civil Addict Program, but as cocaine, crack and methamphetamine use became much more prevalent, we looked at those populations as well.
There are really a lot of commonalities between these natural histories regardless of the drug of choice. The consistent effects are the aging effect, their criminal careers and interactions with the criminal justice system, and, of course, the history of their treatment careers because most addicts tend to be in and out of treatment. We would correlate all of these factors over time and how they differentiate between sub-groups like gender, age, race, socioeconomic strata and so on. As a result, you get a robust picture of these life cycles and can do comparative research.
With the original McGlothlin study, after ten years, our second follow-up simply turned into a natural history study. The entire study lasted for 33 years. Taking that model of a natural history of addiction that began with heroin, we applied it to cocaine in the 80s, crack cocaine in the late 80s, and methamphetamine use in the 90s. We applied the same treatment intervention methodologies to these different drugs of choice and consistently found the same results. We were able to see both the epidemiology and etiology by using this method to see that treatment interventions consistently worked when applied to the criminal justice system. That does not mean, however, that it changed the criminal justice system.
So a natural history of drug addiction is like mapping out someone’s addictive history and their treatment history as well in order to find patterns and extrapolate from those patterns to develop more effective prevention strategies and possible treatment options.
Anglin: Correct. That’s it.
You were diagnosed with HIV in 1985 and with AIDS in 1993. As one of the longest living survivors of this brutal virus, what have you learned and what lessons would you want to pass on to the world? What do you see as your legacy?
Anglin: In 1985, the time window on survival after diagnosis was about three years. There were no effective interventions. With my diagnosis in 1985, I didn’t tell anyone because I didn’t want to burden my friends. I also felt like my legacy should be a sustainable drug abuse research center, I was afraid that the news of my diagnosis might effect peer review groups on my grants and agency funders.
God, it was twenty years before I really came out again about the disease. In those first fifteen years, I kept expecting this three-year window to close. I was lucky enough to be here at UCLA so I got into the earliest trials of AZT. As other drugs became available, I would sequentially shift over to them, which unfortunately led to my virus becoming very drug resistant. This was before multi-drug cocktail therapy was conceptualized. In the early 2000s, I had staved off use of the old drugs as I waited for at least three new drugs to become available. I started all of them simultaneously and the results were incredible because I reached an undetectable viral level. I have been undetectable for the last ten years or so. It actually looks like I might live long enough to die of something else.
That’s just wonderful news.
Anglin: I do feel like I have established my legacy because of my role as the Founding Director of the UCLA Drug Abuse Research Center. We have become one of the go to places for effective drug abuse research and training. I feel like my legacy has been very well established and will be sustained by the folks I helped bring into the field. And, of course, I have fifteen thousand hits if you Google me. I guess that’s a legacy of some sort.
John Lavitt is a regular contributor to The Fix. He last wrote about Robin Williams and Dylan Brody.