The two-way mirror can be merciless. Focus groups are notorious for exposing clients to consumer perspectives they might not expect—or want—to hear. In 2005, I was doing market research for the federal government’s anti-drug media campaign, and I wanted to find out where regular Americans ranked substance abuse on their list of national priorities. Their top concerns were not surprising: terrorism, Iraq, the economy, health care. Then they’d think a bit and get to education, crime, taxes, Social Security, and immigration. For most people, “drugs” didn’t show up on the list until the mid- to late-teens, ranking behind “housing prices” but ahead of “killer asteroids.”
But a funny thing happened when we changed just one part of the question. Then we switched the wording from “What do you think are the most serious issues facing the nation?” to “What are the most serious issues facing your family and community?” Instantly, drugs and addiction rocketed into the top five. For every group, in every demographic category.
Most Americans recognize drug use and addiction as a serious threat to those around them. But they seem less inclined to view it as a pressing matter of national policy. There are a number of reasons people might feel this way.
One is a widespread misapprehension that “nothing works” in combating drugs (despite the fact that usage rates have gone up and down dramatically over the past 30 years—obviously something causes those changes). Another is a sense that drug use is merely a personal lifestyle choice. Many others believe that addiction is a form of moral failure or weakness, and thus the sole responsibility or choice of the user. (Recent advances in brain imaging are fundamentally changing our understanding of this phenomenon. As Andrea Barthwell, CEO of the tony Two Dreams Outer Banks treatment center and past president of the American Society of Addiction Medicine, explains, “Drug use is a preventable behavior. Drug addiction is a disease of the brain.”) And some people have come to the conclusion, from personal observation or exhaustion, that addiction is just too complicated, too messy, and too intractable to grapple with productively.
The Epicenter of Dysfunction
Donors are eager to apply their ingenuity and resources to fix failing schools, feed the hungry, and reduce homelessness. But often there’s a reluctance to focus on addiction—which may actually be the engine driving many of those other social problems. “There are many donors who support the homeless,” remarks Mary Scullion, a Catholic nun who co-founded Project H.O.M.E. in Philadelphia, “but very few who give specifically to the addiction that so often underlies it.”
The numbers show that substance abuse and addiction are massive social problems—probably larger in scope than most people realize. According to the National Institute on Drug Abuse, the economic, health, and public safety costs of substance abuse in America are over $400 billion per year. That doesn’t count the larger opportunity costs of wasted years and stunted educational achievement. And, if anything, that total undercounts even the true criminal justice costs. The fact is, more than half of all arrestees now test positive for drugs. That’s not half of the persons picked up for drug crimes. Of all the individuals arrested for any crime, most of them have illegal drugs in their system.
And substance abuse is itself a killer: Nearly 40,000 Americans die every year from overdoses (including combinations of prescription drugs), and many more die from the health and safety consequences that come from their use: diabetes, infections, heart disease, accidents.
Of course, addicts don’t just harm themselves. They become vectors of dysfunction and chaos, careening through families, schools, workplaces, and communities. And the costs of the mayhem they create increase as the severity of their addiction progresses. Shrinking America’s addiction problem would have large and rapid salutary effects on many of the indicators donors care about: educational attainment, public health, community stability, workplace safety, domestic violence, long-term employment, housing, out-of-wedlock births, and intergenerational poverty.
When it comes to addiction, why do many philanthropists either look the other way or throw up their hands, even though it so strongly affects many of the things they fund? Some view drug problems as primarily the government’s responsibility. That’s understandable, given the significant government expenditures in this area. Certainly the supply-control and law enforcement side is squarely within the government’s purview. But what about the many promising opportunities for donors on the treatment and prevention side?
“If you made a matrix lining up the biggest societal problems, matched up against philanthropic funding, to my mind the biggest mismatch would be substance abuse,” observes Rick Ohrstrom, a board member of the Ohrstrom Foundation and chairman of C4 Recovery Solutions. He contends that the real reason some donors shy away from addiction is stigma. It’s an unglamorous cause without the smiling faces and community recognition associated with, say, giving to benefactions such as K–12 education or the symphony. “If we could just educate enough donors to love their local drug addict, the problem would go away,” says Ohrstrom wryly. “The thing is, people are never going to learn to love their local drug addict.”
Advocates and development professionals for the treatment of other diseases have learned to rally victims and their family members as public spokesmen and donors. That doesn’t work as well for addiction. As Andrea Barthwell explains, “often the family members have looked away and enabled the behavior—or in many cases are users themselves. You often don’t have the family mobilization that you might get with cancer or other diseases because the family is—at best—beleaguered by the addict’s behavior.”
Moreover, she adds, many people in recovery are looking to put that phase of their life behind them. “They want to put some distance between themselves and the disease,” which may well put a damper on their enthusiasm for publicly raising or donating money.
Not surprisingly, many of the donors who do fund substance abuse programs are, like Ohrstrom, in recovery themselves. But this kind of insight cuts both ways: While people who are in recovery themselves are far more likely to “get it” and want to help others suffering from the same disease, they also might feel like they have more to lose by going public with their support.
“I used to sponsor four or five high-end finance guys, powerful guys, guys who could hire or fire 15,000 people with a stroke of the pen,” says Ohrstrom. “And those guys would pee in their pants if they thought it was going to come out publicly that they were in recovery. There’s a stigma to this issue that is pervasive. It’s a problem other causes don’t have.”
The stigma leads to the other unique characteristic of this field—the one that might best explain why innovative and committed donors get so little public attention: anonymity. Ask major national treatment nonprofits who their big donors are and they’ll tell you: mostly anonymous. (And then they’ll ask not to be quoted about it.)
But support for the individual addict is particularly valuable, according to Ohrstrom, because “almost all institutional funding, from government and the big foundations, is aimed at research and science. There is very little funding for people who are directly working with people on the street. Smart donors are interested in outcomes they can see: How do I help the individual addict? How do I get him into treatment? The problem for attracting new donors to the field is that they are told that treatment only ‘works’ one out of three times. That’s discouraging. But success can literally be life-saving. There are very good programs, but so few donors are interested that it gets frustrating. How long can you bang your head against a wall? The challenge is: how do you show donors that they are getting real value?”
The most successful programs demonstrate that addiction is a problem best approached on the immediate level—person to person. Two organizations that help donors connect with local nonprofits working on substance abuse are the National Council on Alcoholism and Drug Dependency and the Community Anti-Drug Coalitions of America.
Community coalitions can also be a good starting place. “The reality is that in every town there are heroes,” says Ohrstrom. “That’s what keeps me in this field. Go and see who’s doing things locally. Talk to the people who run the for-profit rehabs. They will know who is doing a good job on the nonprofit side. Don’t fall into the trap of only supporting pseudo-certified ‘evidence-based’ programs—believe your own eyes.”
Ohrstrom is particularly impressed with the Salvation Army. “They do an amazing amount of great work,” he notes. “I know a lot of people whose lives they have saved. They don’t get much mainstream attention but the reality is that they provide good service to a population that most people want to look away from. It’s a population with low statistical likelihoods of successful outcomes, and the Salvation Army keeps plugging away. They don’t waste a lot of money on overhead or fads.”
John Walters, the former director of the Office of National Drug Control Policy, agrees. “One of the things I saw in my travels was that there are people doing hard work in almost every community in this country. Find them and support them. They are probably in recovery themselves, and they probably aren’t very good at fundraising or PR.”
Funders who aren’t in recovery themselves—especially program officers and philanthropy professionals—might be hesitant to take chances on the edgier, relatively low-percentage but life-altering interventions offered by hands-on, faith-based problem-solvers like the Salvation Army. But, Walters contends, there are great opportunities out there. He points to local “fighters who are working where the gaps are—the late Pastor Freddie Garcia in San Antonio, Bob Coté at Step 13 in Denver, Bill Russell at Union Gospel Mission in Portland—these are people who have saved lives by focusing on the very people most of us had given up on.”
Walters is likewise impressed with the opportunities in what’s called SBIRT—an acronym for “screening, brief intervention, and referral to treatment,” which encourages healthcare providers to ask about and watch for evidence of incipient addiction among patients. Catching a problem before it develops into full-blown addiction is much more effective and cost-efficient. But addiction is usually only treated once something is “broken”—that is, after a student has been expelled (perhaps multiple times), there has been an overdose, or someone loses a job, or becomes entangled in the criminal justice system.
For Walters, prevention offers the most bang for the buck. He recognizes that young people’s attitudes and perceptions are critical. While some donors express concern that universal prevention campaigns are often “wasteful” since you are paying just as much to reach the significant percentage of teens who were not going to use anyway, there is abundant evidence that targeted and tested advertising works. In Montana, philanthropist Tom Siebel funded a successful meth-prevention marketing campaign. The efforts of the Partnership for a Drug Free America, which was extensively funded by the Robert Wood Johnson Foundation, also endure.
But, according to Walters, “screening is the best prevention tool available today. If you are really going to take the public-health model seriously—that addiction is a disease—then we should be employing the best public-health practices that we have learned from other diseases.” That means random student drug testing.
Today’s version of random student drug testing is preventive, not punitive, routing students who test positive into treatment rather than expelling them. In addition to the treatment benefits for students who are using, testing offers a halo effect of prevention for students who haven’t yet started. When students know that they may be subject to testing they are less likely to use, and have an easy social out to resist peer pressure (“I can’t—they test at my school”). Random student drug testing is being tried at more and more schools across the country. “This isn’t punishment. It’s epidemiology,” says Walters. “No teen looks at an addict and says, ‘I want to be like that guy.’ In real life, a teen looks at a peer who is using with no visible consequences, and thinks, ‘That looks okay.’” Testing is the means to intervene during the critical time before a teen’s drug use progresses into addiction.
It is easier for a donor to help implement drug testing at independent schools, but a number of public school districts, in New Jersey and elsewhere, have successfully implemented it and seen drug use, violence, and other distractions from learning decrease significantly. “Donors are influential in these institutions and can make a difference when they choose to,” says Walters.
So-called coerced treatment, whether initiated by concerned family members, schools, or even the criminal justice system, has a success rate roughly similar to voluntary treatment. Both rates are lower than one would like, but Walters says we have a responsibility to keep at it: “I was talking to a cardiologist friend recently, and he told me that after examining patients at risk for a heart attack he would tell them to change their behavior in specific ways. I asked him what percent actually did change their damaging behaviors. He said about 10 percent. Now we all know it would be foolish to draw from this that cardiology ‘doesn’t work.’”
“It’s the difference between seeing addiction as a lifestyle or a disease,” Walters explains. “If you take the disease model seriously, testing is the most rational—and effective—public-health action you can take.” He bristles at the suggestion that preventing teen drug use somehow restricts freedom: “Addiction is the thing that most completely strips away freedom or liberty.” Moreover, drug use “prevents a person from being an active and rational participant in a free society.”
Filling the Cracks
Private donors can make the biggest difference when they find and fill the spaces where people fall between the social services cracks—inmates coming back into society, women trying to break out of prostitution, people who need the human or spiritual touch in a way that government agencies, even if properly managed, simply cannot provide.
Yet there are donors who have done just that. In a field too often crowded with cynicism and heartbreak, Mel and Betty Sembler are two of the happiest and most positive people you could hope to meet. Mel’s can-do spirit helps explain his tremendous business success in real estate and finance, building up Florida’s Sembler Group (a developer of shopping centers) then serving stints as the U.S. Ambassador to Australia and later Italy. But it is Betty’s energy and determination, dressed at all times in Southern charm and graciousness, that have made her so effective, and allowed her to help so many people avoid or get free from addiction.
Why does she focus her philanthropy on addiction? “Because I love my country,” she explains. “I have three children, all in their 50s now, but back when they were teenagers I could tell that something was happening to the young people of that generation.” She discerned that drugs were the unseen mover behind many of the problems that teens of that era were having, and she decided to do something about it.
The Semblers started a treatment program, called Straight, that went on to help thousands of teens around the country. She has gone on to found many other prevention, treatment, and policy organizations, including the Drug Free America Foundation, of which she is board chair. “Nobody pushes back on this problem at the national level like the Semblers,” says Walters.
Betty Sembler has a long history of bringing donors into the field and showing them what works and what doesn’t. When asked what advice she would give to a new donor looking to get involved in this area, she laughs dismissively but politely. “That’s not how philanthropy works. I’ve never heard of anyone who said ‘What can I fund?’ They need to see how something is relevant and effective.” She argues that the reason more donors haven’t taken up this issue is that it hasn’t been made clear to them how connected it is to the other issues they care about.
Almost everybody has some connection to addiction,” she explains. “But every last person thinks his story is unique. People either think their tragedy was unique to them or that if things turned out well they were just lucky and you’re done with it. No, you’re not. This is a disease that is affecting us, and people around us, all the time, whether we choose to see it or not. We are all affected by it—and paying for it—in insurance costs, healthcare costs, safety, the economy. Pick up a newspaper and read any tragic story in it—about child abuse, a shooting on the street—and you can find substance abuse behind it. I can’t just shrug my shoulders and say that it’s someone else’s problem.”
“It’s hard to find young people interested in this field,” laments Rick Ohrstrom. “There are virtually no clinicians under 30. The credentialing process is arduous, the pay (compared to other fields) is terrible, and the professional field is swamped with cynicism.” Cynicism, many donors learn, is a real problem. For most fields, innovation and energy come from an infusion of young people. But there is no Teach For America for addiction. Betty Sembler sees a vital role for donors in attracting “creative young people” into the field, and herself sponsors scholarships, internships, and travel and conference opportunities for promising young people who might be future practitioners and advocates.
Kevin Sabet, assistant professor at the University of Florida and president of the Policy Solutions Group, which advises donors on drug prevention strategies, agrees. “One thing George Soros did that was very smart was to deliberately recruit young people to take up his pro-legalization cause. He realized—rightly so—that his long-term success would rely on smart young leaders articulating his message to their equally successful friends and peers. With the exception of the Semblers, the anti-drug side has no such strategy.”
Of course, George Soros is the philanthropist who has arguably invested the most money in the field. But the vast majority of his funding has been directed not toward prevention or treatment, but to drug policy advocacy, namely drug legalization, or as his spokesman puts it, “ending the drug war.” Whatever one thinks of the merits of this proposal, even its proponents acknowledge that it would make addictive drugs much cheaper and more easily available. Drug use—and thus addiction and the need for more treatment and prevention—would rise. If the country moves into a healthcare environment where costs of a “chronic relapsing condition” like addiction are underwritten by the federal government, it would entail large public expenses in addition to the human damage. The need for already-stretched services and programs would increase dramatically.
There are donors all across America who are working to make the disease of drug addiction rarer. They are dealing with a problem that often remains shrouded in secrecy, denial, stigma, and shame. Whether or not we choose to acknowledge addicts, they are out there, men and women with stubborn problems, on the street, in the shadows, rolling down the highway, in your workplace, school, or family. Fortunately there are philanthropists out there too, who are offering these troubled souls a measure of hope.
Contributing editor Tom Riley was associate director of the White House Office of National Drug Control Policy from 2001 to 2009.