"Nothing Is Magical"

Victor Capoccia, director of OSI’s Initiative to Close the Addiction Treatment Gap, discusses his search for a drug treatment model, but warns that there are no easy answers in this Baltimore Sun interview.

Victor Capoccia says he got into the drug treatment arena "sideways."

Recently named director of a drug addiction program of the Baltimore-based Open Society Institute, Capoccia was teaching planning and community organizing at Boston College's school of social work when he got involved in health planning programs for the Boston area in 1979.

That work took him to the Boston Department of Health and Hospitals, working on HIV and AIDS programs, which eventually led to running a community-based drug and alcohol treatment program.

When the time came to decide between remaining with that program or returning to academia, Capoccia stayed in the community, running the program for the next decade.

"I loved it," he says. "Essentially, what I loved about it was that the people there were ready for change and committed to the work they were doing."

Capoccia, 64, who became the head of the addiction prevention and treatment team at the Robert Wood Johnson Foundation in 2001, blends altruism and pragmatism in his approach to drug treatment.

"I came from the health care field," he says. "If you follow the principles available in that field, you can build strong, relevant treatment organizations."

As the George Soros-funded Open Society Institute program seeks to find a model that can work nationwide, one of the places it will be studying is Baltimore.

"From what I've seen, the two communities that stand out as local governments that had the most focus and concern and movement on the drug problem are Baltimore and San Francisco," Capoccia says.

"There were concerted efforts in both instances from leadership, both political and administrative, from health departments that focused on the issue and helped build a sense of collaboration and interdependence among health care organizations and between health and law enforcement in really positive ways," he says.

What is the most basic thing that people need to know about drug addiction?

At its root, addiction is a health issue. Treatment is not here to address the messy effects of addiction; we are here to treat all the different dimensions of alcohol and drug abuse that have been demonized, to say that people with a health condition ought to have that condition treated. They should not be jailed or shunned or put aside until their condition is so acute that they are a hopeless case. Like any other health condition, their condition should be addressed.

My experience in the health department shows that if you treat addiction, you have all these other spillover effects, not just on crime, but on HIV rates, on hospitalizations, on emergency room visits. In Boston, something like 30 percent of the calls that came in for emergency medical services involved either mental health or addiction-related issues. They are brought to emergency rooms, which is an incredible inefficiency and waste. Imagine if someday the EMS system could accurately triage people and take those needing it to the mental health or addiction treatment systems.

But isn't it true that treating addiction is not like treating an upset stomach, that people try and fail to kick these habits, that it is a matter of will, not just of medicine?

That is true of diabetes, it is true of hypertension, and a lot of chronic diseases. A person with hypertension can think, "Wow, that steak and french fries look good. I'll have some," even though if he takes his blood pressure after that meal, he can watch it go up. Or the diabetic thinking, "Damn, I ought to get up and exercise. Maybe tomorrow." Actively ingesting drugs is the same thing. People are choosing a set of lifestyle behaviors that are negatively impacting them just as those with diabetes or hypertension or other chronic conditions often do.

Using that chronic illness framework, you realize that this is a condition you have to learn to manage. It is not a case of finding a cure, that it's here today and gone tomorrow. It is a process of mitigation, of reducing the harmful effects, reducing the behaviors associated with those harmful effects.

The pattern is pretty clear: For the behavior to change, it takes multiple interventions with longer intervals between them, leading to prolonged if not permanent periods of being alcohol- and drug-free. So you cannot look at relapses as failures, just an expected part of the treatment pattern, as with so many chronic diseases associated with lifestyle behaviors.

But it seems so hit-and-miss. Do we know what works, which drug treatment programs do the job better than others?

The clinical approach to any health care issue ought to be based on some empirical research that says, for instance, we've tested and demonstrated that exercise relative to diabetes is a good thing, or that certain medicines have positive effects on hypertension.

I would say that in the addiction field, when I became involved in it in 1989, large parts of it were based more on belief than science. Even though at the time there were some medications, like methadone, around, there were still these strong belief systems that really turned into myths. They would say things like you have to hit bottom before you can do anything, with no empirical evidence to back that up.

Or you have these spa-like places that say you have to go there for 30 days, or 60 days, or, for some reason, the magical number of 28 days.

Look, we know that to get the chemical and physical interaction stable takes three to five days for most drugs. Then you begin to understand some of the dynamics and nature of the condition. For a lot of people, doing that in a structured residential setting makes sense. But that is not the case for everybody. Nothing is magical.

What you need is to be sufficiently stable chemically going into a reasonably stable environment. That is tough for a lot of people. Maybe they are homeless. They are in an environment that really has control over drug and alcohol abuse, because the notion of triggers is very real and strong. You can't do a residential rehab program for the rest of your life. So perhaps you are in one as long as it takes to get to the next step of stability in daily living, then you think about some sort of aftercare, outpatient work, other forms of self-help.

The point is that it should be a system of care organized to address a chronic condition, that helps you manage it over a long period of time. Again, one of the myths is that one size fits all, that there is one magic bullet. That's a lot of baloney. It's like there is no one medication to deal with hypertension; doctors are always fiddling and fiddling with different combinations depending on the patient's particular set of circumstances. That's true of addiction as well.

Overall, it is important to remember that this is a chronic condition, so people need to understand that measures of success have to do with periods of non-use, not with absolute sobriety. Also, as a chronic condition, we need to have service delivered in a variety of styles. Treatment programs should be organized that way. We don't have that.

Are there types of treatment programs that you would hope to avoid?

In the late '60s and early '70s, there were residential programs saying that the only way to get off drugs was breaking people down, then building them back up, blah blah blah. A year ago, I was at a meeting that was held at a treatment facility, a very regimented residential program. The clients, the consumers, the patients were helping out. This one guy has a piece of twine around his neck holding a cardboard sign that says, "My name is John and I need to learn responsibility."

That has been seared into my brain. It represented the worst of the myth-based, not science-based, treatments. I don't even call it treatment. It's part of the our-approach-works, everyone-is-the-same kind of thing. The lack of dignity represented by that sign showed an inability to respond to what that person needed.

Fundamentally, what is this Soros-funded program trying to accomplish?

At the core, Soros recognizes that we have a pretty shameful and unbelievably unreasonable situation in this country, that only one in 10 people with this health condition can get treatment because the resources are not there. Imagine any health condition, name any one, and then say, but we are only to make the resources available to treat 10 percent of the people with it.

And this is a condition that accounts for something like 14 percent of acute admissions to hospitals, so it covers a significant part of our health care costs. It is related to something like 70 percent of people incarcerated with all the associated costs of the justice system. It has all these impacts, yet we decide to provide the resources so only one in 10 gets help. It's laughable.

So what we have to do is increase the resources and begin to use the resources we have now more effectively. You begin to see that in places like Baltimore, where there is coordination using Medicaid funds, foundation money, federal block grants, child welfare programs and community correctional dollars. If those are used in a "siloed" way, they will be duplicative and inefficient. But used together, they can help build a system to care for this chronic condition. We need more money, but we can treat more people with the money we have.

You can throw out all the good ideas you want, but unless you have the operational end in place, they are not going to happen. I want there to be more quality services out there. I don't want to work to get more cardboard signs around anyone's neck.

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