New York City is the heroin capital of the United States. Some 200,000 of the country's estimated 800,000 heroin addicts live here. The city is likewise the nation's methadone capital, home to about 36,000 of the 115,000 Americans who receive the substance. In all, the city has 122 methadone programs, most run by private nonprofit organizations. The largest is the Beth Israel Medical Center, which, with 21 sites serving 7,500 people, dispenses more daily doses of methadone than any other institution in the country.
New York is also home to methadone's most prominent critic. Rudolph Giuliani's surprise attack on methadone last summer made headlines across the country, and the echoes continue to resound. In August, the five clinics under the city's control adopted a new policy that makes abstinence the main goal of treatment. Meanwhile, the city's private providers -- long accustomed to laboring in the shadows -- continue to bask in the praise they've received from the news media and from other treatment providers.
Overlooked amid all the controversy, however, has been the really critical question of how well the city's methadone programs are actually performing. The mayor's outburst diverted attention from the fact that while methadone itself is of proven value in treating heroin addiction, the city's methadone providers -- grown lax over the years -- have in some cases become too protective of their own needs at the expense of their clients'.
For the most part, the issue has played out as a high-stakes political squabble, pitting the mayor against the nation's drug czar. In his two-plus years as director of the Office of National Drug Control Policy, Barry R. McCaffrey has not been known for boldness. Yet, within days of Giuliani's attack on methadone, the retired four-star general and Persian Gulf War hero issued a stinging rebuke, saying the mayor's comments were "at odds with the conclusions of the nation's scientific and medical community." The problem, McCaffrey declared, "isn't that there are too many methadone programs; in fact, there are too few."
To drive the point home, McCaffrey in late September came to New York to attend the national conference of the American Methadone Treatment Association. Representing 675 providers nationwide, the AMTA meets every eighteen months, and this year the site happened to be in Rudy Giuliani's backyard. The day before he was scheduled to speak, McCaffrey visited the Lower Eastside Service Center, a methadone clinic located on East Broadway, on the edge of Chinatown. Sitting in a circle with six clients as reporters looked on, the trim, gray-haired general listened attentively as the group described how methadone had helped turn their lives around.
The next day, McCaffrey, speaking to a standing-room-only crowd at the Marriott Marquis, led what amounted to a pep rally. Noting that heroin addicts "don't have a lot of friends," he told the assembled providers and counselors that "the good you do is incredible." Bemoaning the "stigma and fear" surrounding methadone, McCaffrey announced his support for proposed changes in federal regulations that for the first time in 25 years would allow methadone to be dispensed not just in clinics but also in doctors' offices. "We're going to try to do this before we leave office," McCaffrey said to a standing ovation.
Rudy Giuliani has many detractors, but it is unusual to find a highly decorated general among them. The mayor refused to retreat, however. McCaffrey, he declared, "has surrendered. Essentially, what he'd like to do is deal with heroin addiction by making people addicted to methadone, which maybe even is a worse addiction."
Giuliani's comments on methadone were so fierce and excessive as to prompt much speculation about their source. The New York Observer detected the hidden hand of Dr. Mitchell S. Rosenthal, the suave, politically well connected president of Phoenix House. Rosenthal, the Observer noted, is a leading proponent of the therapeutic-community approach to drug treatment, with its stress on discipline, self-reliance, and abstinence -- all things the mayor likes. Yet the newspaper offered no hard evidence that Rosenthal had actually spoken to the mayor about methadone, and Rosenthal himself told me that he had no input whatsoever into Giuliani's decision. While he questioned some features of the city's methadone programs, Rosenthal said, he does not believe that they should be phased out. He called the Observer piece a case of "creative writing." "I am not part of the mayor's drug cabinet," Rosenthal said. "He has formed his own beliefs about what is right."