Treating addicts whether they can pay - or not

A LOT has changed since the summer of love. There's hardly a trace of the hippie culture that flowered in psychedelic bloom in the summer of 1967, when young people from all across America trekked here in the name of peace, free love, and hallucinogenic drugs.

Today, this once run-down Victorian neighborhood is a model of gentrified chic - lined with restored gingerbread houses, arty caf'es, and funky boutiques.

But there is one place on a quiet residential block just off Haight Street that has endured through it all: the Haight Ashbury Free Medical Clinic. Whether it was ``talking down'' kids on bad LSD trips 20 years ago or counseling cocaine abusers today, the clinic's drug-treatment program has run on an unchanging philosophy: Help whoever shows up at the door, even if a person cannot pay one dime toward covering the treatment.

It's a concept that set the clinic apart when it first opened, and it's one that continues to hold special relevance, especially today as the issue of who gets treatment, and who pays for it, is coming into focus as the nation wages its war on drugs.

``One of the things that's become real clear is that this has become a class issue, so that those who have, get the ultimate (in treatment), and those who don't have, don't get,'' says Dr. Margaret Gregory, medical director of the clinic's Drug Detoxification, Rehabilitation, and Aftercare Project.

``Very often the person who's in the late stage of the disease is in the most need of ... the intensive things,'' she continues. ``And because they're in the late stage, they have lost their jobs, they have lost their support systems, they have lost their money. Therefore they don't qualify for those kinds of treatments that are available to the employed, monied person.''

The Haight Ashbury clinic is one of 5,900 programs across the United States that are at least partly funded by state or local governments, and help provide services for people who can't afford private treatment, according to the National Association of State Alcohol and Drug Abuse Directors.

The challenge for these programs, explains Nancy Record, the association's director of public policy, is that ``they're filled and they're putting people on waiting lists.''

At the Haight Ashbury clinic alone, for example, some 600 people a month are treated by staff doctors and counselors. But every month 400 more people are placed on waiting lists because there is no room for them.

On the other hand, Ms. Record notes, ``if you have the ability to pay, there's always going to be some [private program] that'll take you.'' In fact, in the past decade there's been a boom in private, for-profit alcohol and drug-addiction treatment programs.

That growth is due in part to a need for treatment facilities, but also in large measure to the fact that in the 1970s providers of private treatment persuaded many insurance groups to define addiction as a disease, and therefore to include treatment costs as part of major health-care-benefit packages.

Generally, however, only costs for inpatient hospital programs are completely covered; costs for nonhospital residential programs or outpatient treatment, such as visits to a private psychotherapist, are covered only in part, if at all.

Although numbers are hard to pin down (private programs do not have to report to government agencies), the National Institute on Drug Abuse says there are more than 4,000 private programs in operation across the country. Costs can run as high as $5,000 or more per person for one week in such a program, and insurance companies often pick up the tab.

Some treatment professionals agree that some people find help in these high-priced hospital programs. But critics contend that the private, for-profit operations are all too often interested in making money. Many ex-addicts or their families have stories to tell about programs where patients were dropped after their insurance money ran out, or about expensive clinics that are run in a ``country club'' atmosphere, where patients are well fed and well cared for, but may be released without really being free from drugs.

``You have to ask yourself, `What's the commitment of a culture that is willing to pay all this money for people to go and essentially be entertained?''' says Elaine Resnick, a clinical social worker and an expert on drug abuse.

Other critics even argue about how effective treatment programs really are. Craig Reinarman, a professor of sociology at Northeastern University and an expert on the history of drug abuse, says that although some people are helped through treatment, many users quit on their own. In fact, he says, ``there are probably more people who quit without treatment'' than those who quit as a result of treatment.

The whole treatment dilemma - who gets what treatment, who pays for it, what is effective - grows out of the fact that the addiction treatment field is still a relatively new one. It's also one that's been somewhat ignored in recent years, especially under the Reagan administration, which, before announcing its war on drugs in September, had actually cut funds for drug and alcohol treatment research during the first six years of the President's tenure.

But Dr. Gregory of the Haight Ashbury clinic says she thinks her field is finally beginning to gain some legitimacy. ``At least I can get on the phone and talk to other people who are capable of recognizing an alcoholic,'' she says. ``There is more than one person out there. I can talk addiction disease and use the term and not get challenged.

``I no longer get questioned as often as to why I like to work with these people,'' she says. ``I no longer have to feel apologetic for wanting to work in this field.''

Just as it has for the past 20 years, the clinic runs on a policy of offering its services not only for free (although donations are encouraged), but in a nonjudgmental way. Patients are not forced to give their names and are not lectured on their life styles.

``The very first thing you have to do is establish yourself as a safe person that they can be with,'' says Carol Chapman, a substance-abuse counselor and director of internships and volunteers. ``Through the process of listening to them, they will begin to believe they can trust you and that you're OK, and that they feel good about coming into treatment.

``Remember, we're on an outpatient basis where people come in voluntarily,'' she adds. ``After you have some basic trust things set up, then you can start helping with some decisionmaking skills and you can start setting some ground rules.''

Although the clinic has seen a rise in cocaine abusers recently, Ms. Chapman describes the nature of drug abuse over the years by simply drawing a circle in the air with her finger.

``It's just circular,'' she says. ``Sometimes they look different. ... Right now it's fairly fashionable to talk about the stimulant abuse epidemic that's happening across the country. But it hasn't been too long since it was a downer epidemic of heroin.

``The people sound the same, although maybe they look a little different,'' she continues. ``When a person comes in with a drug abuse problem you can sense the despair in their lives, you can sense the confusion, and you can sense the tragedy. Those are the things that you work with....

``You really address the tragedy of what's happening in that person's life right now and how to help them make something different of their own lives. That crosses race, it crosses sex, it crosses economics. And it's the same.''

Like her colleague Gregory, Chapman says she believes that substance abuse will continue to be a problem for society, and that treatment will continue to be a necessity.

But she also believes that society at large needs to reconsider its own agenda, and to take a longer range view of its actions.

``Drug deaths don't come anywhere near the impact of deaths related to alcohol and nicotine,'' she says. ``I think we're still underaddressing the severity of the two main legal drugs that we have. ... I think we need to address addiction to everything.''

For example, she adds, ``more and more states are legalizing lotteries. A facet of the mentality of today's society is that we don't have a clear, long-range look at what a lottery does. I'm not going to say that lotteries are bad, or that everything pleasurable is addicting.

``But,'' she insists, ``we don't look at the long-range impact of what we are doing in terms of creating a society that is addicted to a number of things.''

Third in an occasional series. Others ran Dec. 4 and 10.