Q&A: Waging War on Nation's Demand for Drugs
Herbert D. Kleber
Last month, the Senate confirmed Herbert D. Kleber, a professor of psychiatry and a drug-treatment specialist at Yale University, as the deputy director for demand reduction in the U.S. Office of National Drug Control Policy. In this position, Dr. Kleber will oversee the national effort to reduce the demand for drugs through drug education and treatment. Staff Writer Ellen Flax interviewed Dr. Kleber late last month.
Is the research base such that we can say with any certainty what works in drug education?
I don't think we have all the answers, certainly. There is evidence that certain approaches work. The one that has achieved a degree of notoriety recently is Project Star in Kansas City. What that has that differs from a number of education programs is: One, it is multifaceted; it wasn't just in- school education; it also involved aspects drawing in parents, the media, and the community. And two, very unusual, it had a control group. So you were able to see the impact of the intervention on the individual. There was a statistically significant difference between the control group and the experimental group.
Is there a particular personality or set of circumstances that makes it more likely for teenagers to use or abuse drugs?
Increasingly, it seems to me, if prevention is going to be effective, it needs to be targeted. It is a waste of money to use the same drug-education and prevention format for everybody.
There are a number of ways to decide how to segment. Let me just give you one example: Say that there are four groups; there are high-risk and low-risk youngsters, and there are those living in high-crime and low-crime areas. Now the high-risk, high-crime individuals are who we usually4think of as youngsters who grow up in inner cities. But there are also low-risk individuals growing up in inner cities. What many people forget is that most poor people don't use drugs, and most people who use drugs aren't poor. So you may need different kinds of interventions for the high-risk youngsters in the high-crime areas than you do for the low-risk youngsters in the high-crime areas.
And, likewise, you might need a different approach for high-risk youngsters in the low-crime areas. They're often the ones that we think of as having psychological problems, those who come from dysfunctional families, those who come from families with a history of substance abuse, youngsters with attention-deficit disorders.
There is recent interesting work by Sheppard Kellam, [chairman of the department of mental hygiene at Johns Hopkins' School of Public Health]. He's been doing work on what factors among 3rd-graders might predict drug use when these children grow up. For example, he divides youngsters into four groups: the shy-aggressive, that is, the individual who is sort of a bully but also a loner; the aggressive; the shy; and the normal. And he finds that, in terms of the likelihood of abusing drugs 10 years later, the most likely are the shy-aggressives; the second are the aggressives; the third,8normals; and the least likely, the shy. So you might want a very different kind of intervention based on that. I think that everyone should probably get certain common elements, and then we need to go beyond those core common elements and target.
If we can indeed see in 3rd grade, or elementary school, who is likely to become an abuser later on, do we now target to help these kids?
Probably not. That's one of the reasons why I like Project Star, because it looks like they did segment. They did try different kinds of interventions, and often those were the out-of-school interventions to deal with the individuals who were in different segments.
What do you think about the 'Just Say No' appeals? Do you think that approach is effective, or is it just preaching to the converted?
There is a certain segment of the population for whom a very simple message like that could be very effective. So I don't think it is just preaching to the converted. You are creating a climate. There certainly are youngsters who are on the fence, and, to the extent that that message is a very clear one, those youngsters could be helped to get off the fence on the right side.
It is also clear that 'Just Say No' is not for everyone. You need other kinds of drug education targeted to other groups. And no other approach is effective for everyone either.
What do you think of the evaluation efforts we have had to date?
I'm not adequately familiar with that. I would probably say that, generically, they're probably insufficient, because that has been my experience with much of the work that has been done across the whole drug field, including the supply side.
Would you agree with the statement: "Behind every drug problem there is a serious psychological problem?"
No. Absolutely not. The more addictive the drug, the less necessary it is to have the major psychological or psycho-social or socioeconomic problems associated with addiction. So with cocaine, which is probably the most addictive of all, you will find many people addicted who do not have either socioeconomic problems or psychological problems. With alcohol, which is a drug of relatively low addictiveness, you're more likely to find individuals who have either genetic or psychological propensities toward alcholism or problems that may lead to alcoholism. In between would be heroin and marijuana.
What do we know about drug treatment programs for teenagers?
Before I took this position, I was on a task force at the Institute of Medicine that was charged by the Congress with developing guidelines for how substance-abuse treatment should be paid for. And one of the discouraging things I found out as part of that task force was how little there is out there in terms of adequate adolescent treatment and how even less there is of adequate evaluation of such programs.
Are there enough spots for these kids?
Probably not. And certainly there should be an increase. But, at the same time, there needs to be more attention paid to what works. My understanding now is that most of the adolescent treatment programs are expensive, residential in-patient programs. It's not clear to me that that's necessary in many of the cases. We certainly need more cost-effective alternatives, so I would not want to see additional drug monies simply going into expensive in-patient residential slots.