Just how much will Beilenson need to make treatment-on-request a reality? He suggests $30 million to $35 million, on top of the current budget of $32 million. But a precise figure is impossible because no one knows how many people would seek treatment if it were easily, immediately available. Even the total number of addicts is unknown--60,000 is just the best guess. Finally, adding capacity to the existing system is only the beginning. At the Glenwood Life Counseling Center, which offers methadone and therapy for addicts, three positions went unfilled for months. The reason, says executive director Frank Satterfield, is that the starting salary for a job that requires a bachelor's degree and offers a slim chance of raises is only $21,000. Satterfield says he would need to pay $27,000 to be minimally competitive. Applied to treatment programs across the city, such salary increases would require $2.4 million. Even fully staffed, Glenwood can barely stay on top of administering 340 patients, soon to increase to about 500. With rare exceptions, therapy is done in groups. Vocational training, family counseling, good psychiatric care--these services, which Satterfield says he took for granted when he first entered the field in the early seventies, are not possible with his budget.

The irony is that these deeper needs will only become apparent once the first steps are taken. In other words, the further Baltimore moves down the path to "medicalization," the longer the path seems. And though political obstacles have so far been few--there is no Republican Party to speak of in Baltimore--that may change.

A hint of future conflict came last summer, when Beilenson expressed interest in a plan by Johns Hopkins researchers to conduct a trial in heroin maintenance. The idea was to replicate a now-legendary Switzerland study in which heroin addicts who had failed in repeated treatments were given injections of the drug in a clinical setting. The results were impressive (though not necessarily definitive): Many in the test group found housing and employment, and the percentage committing crimes went from 59 percent to 10 percent. In casual conversation about such a study in Baltimore, Beilenson told a Sun reporter--while they watched their kids play soccer--"It will be politically difficult, but I think it's going to happen." The Sun printed these remarks, and sharp criticism came quickly--from Governor Parris Glendening, City Council members and even the Mayor. "This administration has no intention of initiating a heroin maintenance program," Schmoke told the Sun. But in a recent interview, Schmoke struck a different tone. He had to rebuke Beilenson, he explained, because the commissioner floated a radical idea without building consensus. But, Schmoke continued, "if you ask me what should be a part of a good public health system to combat substance abuse, many different treatment options should be part of that system--plus this last one, medical distribution of certain drugs."

This puts Schmoke and Beilenson on a collision course with state officials, most notably Lieut. Gov. Kathleen Kennedy Townsend, who said such an idea "undermines [the] whole effort" of convincing young people that "heroin is bad."

Indeed, while city officials try to build a model program of treatment on demand, Townsend is staking her reputation on a different model: coerced treatment. Last year the legislature approved Townsend's proposal to administer twice-a-week drug tests to 25,000 people on probation or parole. Under the $2.9 million program, positive tests for cocaine, heroin or marijuana would trigger a series of escalating sanctions--for a midlevel offender, for example, the first failed test would lead to two days in jail, then five, ten, thirty, forty-five and finally a return to court for parole violation. "You don't have to want treatment for it to work," says Adam Gelb, Townsend's policy director.

Researchers and treatment providers have mixed opinions on coerced treatment. "If you have leverage, you ought to use it," says Dr. Robert Schwartz, who directs the University of Maryland School of Medicine's division of alcohol and drug abuse, and who consults with the Open Society Institute in Baltimore. Still, Schwartz urges that coerced treatment not squeeze out voluntary programs--which seems a real possibility were Townsend to get her way. Beilenson urges the state to spend more on both forms of treatment, arguing that the big savings will come from keeping people out of the criminal justice system in the first place.

The idea that drug users belong in prison has in the past few decades been carved deeply into US politics and won't be easy to change. In New York, for example, a recent study found that the state spends $680 million a year to lock up nonviolent drug offenders, and yet the legislature has stalled on even modest reforms of its draconian Rockefeller drug laws. Those laws, adopted in the early seventies, were quickly adopted by other states and by federal officials. Now, the damage is apparent even to many hawks. "We have a failed social policy, and it has to be re-evaluated," national drug policy director Gen. Barry McCaffrey said this year. "Otherwise, we're going to bankrupt ourselves."

Of course McCaffrey won't propose the next logical step, which would be to eliminate mandatory minimums and other harsh measures and redirect that money into treatment. During his 1992 campaign, Bill Clinton pledged to enact "treatment on demand." He quickly abandoned the promise, not just because it would be expensive but because it runs contrary to a winning political formula: more arrests, longer sentences, more jails.

The experiment in Baltimore challenges that formula. Officials there are driven by the basic instinct that drug users need help, not punishment. But they also believe the policy makes fiscal sense. And they know they'll have to support that view with hard numbers. That's why Beilenson contracted with a team of independent social scientists (from Johns Hopkins and two other universities) to measure the crime, health and income of three groups of addicts in Baltimore: those who get treatment immediately, those who have to wait and those who get no treatment at all. The results of the $2.8 million study are expected in 2001. If it confirms Beilenson's argument that "treatment saves money and treatment on request will save more," the study could turn an iconoclastic experiment into a model for other cities and states. Today, the idea of universal, immediate treatment on a national scale is hard to imagine. But then, so was Governor Nelson Rockefeller's idea that possession of two grams of cocaine deserved fifteen years in prison.

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