Top Doc

By Zachary Block '99 / November / December 2003
June 21st, 2007
By the time Terry Horton steps out of the Brooklyn subway station, it’s just after 8:30 a.m. He’s already been awake for more than three hours, having risen before dawn for the commute, via Amtrak and the New York City subway system, from his home in Wilmington, Delaware. Once a magnet for drug dealers and other parasites, this subway station used to be known as “the pit” by New York City cops. The surrounding neighborhood, Dumbo—Down Under the Manhattan Bridge Overpass—is a former industrial area that’s been transformed into one of New York’s hipster havens, with artists crammed into cafes and warehouse lofts. From the subway station it’s only a short walk to the former paint factory that is now the Phoenix Career Academy, a cutting-edge drug-treatment center that is part of Phoenix House, the nation’s largest—and, in the view of many experts, the most effective—nonprofit drug-treatment program.

“Are you a visitor?” a young woman asks Horton as he approaches the front desk in the vaulted-brick entryway.

“No,” he says. “I’m the medical director here.”

Horton smiles. He doesn’t seem to be offended by the lack of recognition. Baby-faced, with brown eyes squinting through round, wireless eyeglasses, Horton does not look like a veteran of the drug wars or a doctor who has spent more than fifteen years caring for crackheads, dope fiends, mainliners, pill poppers, and every other class of drug addict. But this is a place where people may not be what they appear. The receptionist, for example, is a twenty-four-year-old mother of two toddlers who has wasted years drunk and high. She is a Phoenix House client, and giving her the responsibility of a job is one of the ways the program is rebuilding the lives of even the most hopeless cases.

For Horton, Phoenix House also represents a personal mission. In part, he became a doctor after seeing several childhood friends end up in jail on drug charges. One of them died of an overdose. “There was no treatment,” he says. “What would have happened if they had gotten treatment sooner? If the schools had figured it out? If their families had figured it out?”

FOUNDED IN 1967 by six recovering heroin addicts in a New York City tenement, Phoenix House now runs 100 treatment programs in nine states, serving 6,000 adults and adolescents through a range of residential, prison, and outpatient programs. Phoenix House programs provide counseling, job training, and medical and dental services, all in the belief that effective drug treatment requires not only detoxification but self-discipline, vocational training, and psychological and medical care. “I think they’re the best,” says Judge Alex Calabrese, who presides over Brooklyn’s Red Hook Community Justice Center and who often mandates treatment at Phoenix House to addicts in trouble with the law. “When I place someone at Phoenix House, I really think I’m placing them somewhere where they can change their lives.” Between June 2002 and June 2003,Calabrese sent seventy adults to Phoenix House. “I like their approach,” he says. “It’s a tough approach. It’s not easy to be in Phoenix House, but I think addicts need an abrupt change.”

As the program’s “top doc,” Horton oversees the medical care of every Phoenix House resident, helping to implement a holistic treatment method that’s not without controversy. The expense alone prohibits most treatment centers from adopting it. Ironically, though, some experts maintain that Phoenix House’s approach, while costly up front, may actually save money in the long run. According to a May 2000 U.S. Justice Department–funded study written by addiction researchers Douglas Lipton, Frank S. Pearson, and Harry K. Wexler, “the quickest and most cost-effective method to reduce the demand for drugs of abuse is to treat chronic, hardcore substance abusers. These are the persons who consume the most drugs, do it most frequently, commit the most crimes, and burden the health care system to the largest extent. Without treatment these hardcore users continue to use drugs and engage in criminal acts, and when arrested, they typically continue their drug use upon release and return to criminal activity.”

Later in the day, Horton and Ed Barnett, the Career Academy’s counseling director, introduce a reporter to three such hardcore abusers, all of them Phoenix House residents. The group gathers around a wood table in a second-floor conference room. Abstract paintings hang on the walls. As the residents, two men and a woman, tell their individual stories, they bring to life the painful, complicated reality of drug addiction.

Deborah, at forty-five, is a well-dressed nurse and mother of four who started smoking crack after being sexually abused by her father and beaten by boyfriends. “I tried to escape life,” she says. “I did that. I try to commit suicide.” Tyrone, thirty-five, a former New York City Housing Authority worker with an easy smile, says he begged a judge to send him to Phoenix House after police found cocaine, pot, and bullets stuffed in the cushions of his couch. “I have an addictive personality,” he says. “Sex. Money. I see that.”

“My addiction was selling drugs all my life,” says a man named Louis. “All my life that’s all I know how to do. I could never hold a job too long.” Beads of sweat roll down Louis’s brown, freckled forehead. The moisture sends his outsized tortoise-shell glasses sliding down to the tip of his nose. He shreds a clump of tissues in his hand, squeezing the pieces back together in his fist. Born and raised on Manhattan’s Lower East Side, Louis is thirty-six years old. He has abused and dealt drugs for more than two decades. Today he wears a white button-down shirt, a geometrically patterned tie, and a blue blazer with a Phoenix House patch. Louis has survived three months at Phoenix House and is now at the critical stage when treatment, if it has a prayer of succeeding, should begin to take effect. Only 60 percent of addicts who enter Phoenix House make it this far.

Louis talks about his father, who left the family when he was three, and his mother, an IV-drug user and dealer. He tells of being kidnapped with his mother and sister by drug dealers. The ordeal lasted three weeks. “I see my mother getting raped during that time,” he says. “They put guns to my head.”

By the age of twelve, Louis was snorting cocaine. By the time he was twenty-one, he was shooting heroin. He Ping-Ponged between the street and jail, selling drugs, joining gangs, acting tough. After his latest arrest, Louis petitioned the judge to send him to Phoenix House. If he can complete his treatment, his guilty plea will be erased. If not, he’ll serve a longer sentence than he would have received for settling his case. “I was just tired of keeping on going to jail,” he says. “Come out and keep on doin’ the same thing again and again.”

Louis’s background is typical of Phoenix House residents, 85 percent of whom have had some contact with the criminal-justice system. Many have tried treatment before and failed. All have lost years, often decades, to drugs. Phoenix House is often their last shot to get clean and avoid the inevitable: jail or death, or both. “Chills went up my spine when I heard [Louis’s] story,” Horton says later. “I remember reading his file. This guy would be your worst nightmare on the streets, in a dark alley.”

Life for Louis and for all Phoenix House residents in New York begins anew in Long Island City, Queens, in a converted nursing home alongside the East River. The building’s light-green tile and drab wooden furniture give it an institutional feel. On the top floor is the induction unit, where new residents—seventy-four men and women on a day in mid-May—spend most of their time. The space is crowded and loud but surprisingly calm. It’s here that incoming addicts are introduced to the therapeutic community, the heart of treatment at Phoenix House, in which the group acts as the main healing agent, dispensing a powerful prescription of tough love and accountability. Peer pressure and confrontations are aimed at changing an addict’s behavior, at socializing a person whose every cell once churned for drugs.

The daily routine in Phoenix House is strictly regulated. Residents must adhere to rigid rules that govern every aspect of their lives. They are told when to wake up, when to shower, when to eat, and when to sleep. They are shown how to make their beds and clean their rooms. Urine tests, house meetings, and counseling sessions are required. Residents learn responsibility by holding jobs within the community, starting with the most menial tasks. As the residents gain “time on the pop,” they move from cleaning kitchens and bathrooms to serving as hall monitors, chaperones, or crew leaders. “It’s a hard program,” says Andrew, a thirty-seven-year-old cocaine addict. “People tell you when to go outside, when to see your kids.”

Clients spend all day together, monitoring one another’s behavior and challenging each other in therapy sessions. A resident who breaks a rule, cops an attitude, or skimps on chores can be reported by his or her peers, who are encouraged to write them up, or “drop a slip on them.” Counselors, many of whom are Phoenix House graduates, provide hope for the possibility of recovery.

Some addicts have never lived a structured life before coming to Phoenix House. For them the program is not rehabilitation but habilitation—learning for the first time the behaviors, attitudes, and values associated with being part of mainstream society. Horton describes the process as a “substitute adolescence.”

Throughout it all, egos and attitudes are broken down. Memories of incestuous stepfathers, absentee parents, and abandoned children are confronted. “We’re about psychological clarification,” Phoenix House president Mitchell S. Rosenthal says. “We’re about self-understanding. We’re about behavioral change. We’re about changing lifestyles.”

After a month at Phoenix House, new residents join others who are farther along the recovery road. Now life becomes a steady stream of individual and group counseling sessions and weekly seminars on stress management, family issues, life skills, pre-employment training, and personal finance. Every day begins and ends with a house meeting, which is run by a rotating group of residents.

Adults in Phoenix House can take remedial education classes or earn their general-equivalency diploma. All are expected to learn a trade. The Phoenix Career Academy offers courses in cooking, carpentry, construction, computers, and drug counseling in on-site classrooms and labs. Residents also have access to medical, dental, and eye care. If addicts are to stay off drugs, Horton says, it’s vital to treat their physical problems and minimize their discomfort. Life on the streets and years of drug abuse ravage addicts’ bodies. When they get sick or feel pain, he explains, they are accustomed to self-medicating. Many suffer from tuberculosis, diabetes, asthma, and disfiguring dental problems. Eight percent of Phoenix House residents are H.I.V.-positive. Benefits like dental care, Horton emphasizes, have an important practical purpose: residents’ job interviews are likely to be more successful, he says, “when they open their mouth and it isn’t full of holes.”

“It’s really very unique,” says Frances Levin ’81, a psychiatrist with Columbia-Presbyterian Medical Center’s division of substance abuse. “Most drug-treatment programs aren’t able to offer those kind of services to their patients.” But providing them isn’t cheap. A year at Phoenix House costs anywhere from $20,000—the average cost of a year in prison—to $50,000. In New York, Medicaid pays for treatment and medical services for 1,300 Phoenix House clients. Nationwide, contracts with federal, state, and local government agencies, along with welfare and food-stamp benefits, cover the bulk of treatment. Donations pay for the rest, but the September 11 terrorist attacks and the stumbling stock market have made it increasingly difficult for the agency to attract fundraising support. Between 2001 and 2002 unrestricted donations to Phoenix House fell 50 percent. Public funding for drug treatment is also likely to drop in coming years, as state governments scramble to balance their budgets. Among the states that trimmed treatment dollars this year were Oregon and Massachusetts. Many others have proposed similar cuts. “States are deciding they are going to cut back on areas where there is the least political energy to support them,” American Society of Addiction Medicine president Lawrence Brown says.

HORTON JOINED PHOENIX HOUSE in 1993 after two years on the medical staff of the Tombs, the New York City jail that houses prisoners awaiting trial or sentencing. After seeing the same prisoners return again and again, Horton began to question his faith in the ability of individuals to overcome anything. “The people on the subway,” he says, “started looking like people in jail.” He needed a switch. During an interview for the Phoenix House job, he was given a tour by a resident who had passed through the Tombs. “But he spoke differently,” Horton recalls, “and he wanted to improve himself. It just resonated with me.” Phoenix House was Horton’s salvation.

In 1993, Phoenix House’s medical service was little more than a student-nursing program. “I didn’t even have a secretary,” Horton says. “It took me over an hour to open my mail.” Horton set out to professionalize and expand Phoenix House’s medical care. He began by instituting medical evaluations of all new residents and overseeing the renovation of Phoenix House clinics. He opened dental labs and optometry suites.

Horton also hired another physician and Brown alumnus, Christopher Randolph ’74. Randolph, who was promoted to deputy medical director in 2002, now administers a promising new detoxification program that is among the first in the country to offer both rehabilitation and detox in the same facility. Having both under one roof, Horton says, allows Phoenix House to reverse a troubling trend: half the patients referred by detox clinics never show up, because they relapse before finding their way to treatment. The approach depends on a new drug called buprenorphine, which the Food and Drug Administration approved in 2002, and which may be the biggest breakthrough in heroin treatment in decades. “That’s a major accomplishment,” Lawrence Brown says of Phoenix House’s detox program. “It has a lot to do with Terry’s role. There are a lot more positive things about Phoenix House now that he’s there.” “Very few physicians devote their careers to drug treatment,” Levin adds. “He’s very innovative.”

While Phoenix House supporters celebrate its innovative services, they also acknowledge that the program isn’t for everyone. “There’s no one-size-fits-all approach and no cookie-cutter medicine,” Brown says. For more highly functioning addicts and for users with jobs and strong support networks—a cocaine-bingeing Wall Street trader, for example—drug-free outpatient programs are likely a better option. For many heroin addicts, more traditional methadone maintenance may suffice. There’s even some evidence that women don’t respond as well as men to the confrontational approach that is a hallmark of the Phoenix House model.

Others criticize Phoenix House for its close links to the judicial system. Nearly two-thirds of the adults and half of the adolescents at Phoenix House have been required to seek treatment. For them the choice is simple: complete treatment or go to jail. Because of this, Phoenix House has “made a pact with the devil,” says Ethan Nadelmann, executive director of the Drug Policy Alliance, a drug-reform advocacy group. This collaboration with the criminal-justice system, he argues, “throws patient confidentiality out the window, treats relapse as a criminal offense, and causes people to be locked up for far longer periods of time.” If addicts fail to stick with Phoenix House, Nadelmann says, the assumption is that they are at fault when in fact their treatment regime may be flawed or ill-suited to them. “It’s the one area of medicine,” he insists, “where the criminal justice system determines the outcome.”

Phoenix House residents typically spend from one to two years in treatment. In order to earn their Phoenix House diploma, they must not only stay clean, but save $2,500, line up a job, and find a place to live. After moving out of Phoenix House they also have to attend six months of outpatient aftercare. “People can’t imagine what takes so long,” Horton says. “But people come to us with really hardcore fundamental problems. They have never dealt with anything in life without drugs.”

Even with the threat of jail looming, most Phoenix House residents don’t make it. Only 40 percent complete a year of treatment. Even fewer graduate. But for those who do, the outlook is good. According to Phoenix House statistics, 75 percent of its graduates are employed, drug-free, and without a criminal record five years after graduation. By comparison, a May 2001 study of federally funded treatment programs found that only 50 percent of addicts were clean a year after treatment.

Horton is eager to pass on the results of his work to other doctors. A few years ago he created a partnership with Cornell Medical School to teach future physicians how to deal with drug-addicted patients. He has also conducted research with Columbia, NYU, and RAND and has worked as a liaison to the National Institute on Drug Abuse’s clinical trials network. “We’re trying to use science to figure out this black box,” he says. “There are clearly tools that work here. We’re trying to find out what those tools are and take them and move on.”

BACK AT THE PHOENIX CAREER ACADEMY, it’s late afternoon when Horton begins to see residents for checkups. A diabetic woman has swollen legs and feet. Another has suffered an asthma attack. Then there are two men, one complaining of numbness in his back, the other of excruciating pain in his knee. Horton pushes them to see if their symptoms are real or if the patients are faking to sneak out of their house duties. Another resident, a frequent visitor to the clinic, demands to be seen, but he’ll have to wait. Horton has a train to catch.

Three years ago, Horton and his wife returned to Wilmington, Delaware, to raise their son and twin daughters in the same working-class neighborhood where they’d grown up. The commute is long, but Horton uses it to work on a medical thriller—about a doctor who discovers a cure for drug addiction.

Zachary Block is the BAM’s staff writer.
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