On the well-trodden paths of the national drug debate, Barry R. McCaffrey likes to surprise his audiences, undermining stereotypes and shattering assumptions.
He tells them, for instance, that the rate of illegal drug use among African-Americans younger than 30 is lower than that for white Americans. That casual drug use peaked in 1979, when 14 percent of Americans had used an illegal drug in the preceding month; the number now is 6 percent.
He informs them that the United States consumes less than 4 percent of the heroin produced in the world; Pakistan has more than twice as many heroin addicts. That, in his opinion, "the worst drug ever to come to the United States" is not heroin or crack cocaine but methamphetamine, which has become the dominant drug used in many Western U.S. cities.
And that he long ago watched a huge community become devastated by drug use and then bounce back to nearly eradicate the problem. That was the U.S. Army, where he served for 36 years and achieved the rank of four-star general before President Clinton appointed him director of the White House Office of National Drug Control Policy four years ago.
"I've had four combat tours," says McCaffrey, who spoke to The Sun during a visit to Baltimore last week. "I've never seen greater suffering in warfare than I've seen in substance abuse in this country."
McCaffrey, 57, is far from a drug libertarian. He has pushed hard recently for military aid to the government of Colombia for its fight against drug-running guerrillas. He opposes needle-exchange programs and roundly rejects the idea of drug decriminalization, once urged by former Baltimore Mayor Kurt L. Schmoke and currently by New Mexico's Republican governor, Gary E. Johnson. He argues that such talk is pernicious, partly because it mutes the anti-drug message to middle-school children, whose behavior will determine the future of drug use.
But in other ways, McCaffrey has defied the expectations that face a general who becomes drug czar. In a nation with little enthusiasm for spending tax dollars on drug addicts, he has become the most prominent advocate for treatment. And his strongest advocacy has been for the most controversial form of treatment: methadone for heroin addicts.
When New York Mayor Rudolph W. Giuliani astonished drug-use experts last year by saying he wanted to phase out methadone programs, McCaffrey took him on.
"Ultimately the general entered into a very public debate at considerable political risk, because methadone is not overwhelmingly popular with all of Congress," says Mark W. Parrino, president of the American Methadone Treatment Association. "This man has made a tremendous contribution."
McCaffrey has pushed to move methadone from restricted status in heavily policed programs into the mainstream of medicine. Federal regulations proposed in July would make it easier for stable methadone patients to receive take-home supplies of the drug from their doctors.
"This is the most widely studied, documented drug in the annals of American medicine," McCaffrey says. "Clearly it's a dangerous drug. But so's morphine. So's heart medicine."
Though the country has almost 900,000 chronic heroin addicts, he says, only 179,000 people are on methadone, a number he believes is far below the need. Though methadone has been widely used since the 1970s, eight states have laws or policies effectively preventing its use, he says.
Opponents of methadone incorrectly think of it as "just another addiction," he says. Instead, it should be seen as a well-proven treatment for a disease that has severe consequences not only for the patient but for the community, he says.
"Every day I'm on methadone I'm not going to break into your car and steal your purse," he says. "Every day I'm on methadone I'm not going to get infected with HIV."
McCaffrey, who knows plenty about warfare of the nonmetaphorical kind, says the notion of a "war on drugs" has done huge damage, suggesting that addicts are enemies and that total victory is possible.
He prefers a medical analogy. Cancer is an illness that, like drug addiction, can be caused by behavior (smoking or diet) and in which relapse is common.
"If you want to fight cancer, you focus on prevention," he says. "But you know some people will get cancer anyway. And when they do, you expect five years of treatment and you don't say to your grandmother, 'You got surgery already, and it didn't cure you, so that's it.'"
McCaffrey says that while casual drug use has generally been declining since the 1970s, many U.S. communities are severely affected by chronic addiction. Methamphetamine, smoked or injected, has ravaged cities and towns all over the Western United States and in Hawaii, even in locations such as Boise, Idaho. Eastern cities like Baltimore have made little progress against hard-core addiction and the street markets for heroin and cocaine they create.
"It is incredible to me that we will tolerate the most abject misery and open lawlessness in parts of America, when not for a minute would we tolerate it where I live" in the Washington suburbs, he says.
The suburbs are a big part of the cities' drug problem, he says, noting the steady stream of suburbanites who visit cities, including Baltimore, to buy their drugs. "It has to be a regional approach," he says.
For those who despair over the scale of drug abuse, McCaffrey has a lesson from history.
"In the mid-'70s, I'd say a third of the U.S. Army was regularly using illegal drugs, and another third when they could get their hands on them," he says. "We opened treatment centers in every hospital in Germany. There was a huge treatment and prevention program. In 10 years, we went from a disaster to a drug-free Army, almost. Now they get 1 percent, 2 percent positive rates on drug tests."
Even outside the controlled atmosphere of the military, drug use should not be an impossible challenge, McCaffrey says.
"If I was the czar to deal with racism or poverty, I'd have a real challenge," he says. "The drug problem's pretty simple. We know the problem. We know what works. We have treatment protocols for drug addiction that are more effective than many of the protocols for cancer treatment."