The Real Methadone Problem

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.”

Those beliefs are no mystery. Ever since his days as an ardent young prosecutor in Manhattan, the mayor has viewed the drug issue in starkly moral terms. Giuliani fully subscribes to the zero-tolerance, just-say-no, drug-free-America school, and skepticism about methadone has long been part of it. As to timing, some have cited Giuliani’s political ambitions. Should he seek the Republican nomination for president in 2000, his tolerant views on abortion and gay rights could make him vulnerable to attack from the right; going after methadone offers one means of deflecting it. On a swing through Iowa late last summer, Giuliani proudly cited his anti-methadone campaign – and was heartily applauded.

But the mayor’s crusade cannot be put down to simple political calculation. Nor can it be dismissed as a sudden eruption of ideological fervor. Rather, it grew out of an analysis begun the previous year by an administration disturbed by methadone’s seeming tendency to keep people off heroin but still out of work and on welfare.

Whether public or private, the city’s methadone programs all operate in roughly the same manner: Six days a week, clients show up for their daily dose of the synthetic narcotic, taking it orally with orange juice or some other liquid to mask the bitter flavor. Methadone acts on the same endorphin brain receptors as heroin, but because it is slower-acting, it has a longer, more even effect. (As a treatment for addiction, methadone is available only to heroin addicts; users of cocaine, crack, and other drugs must seek other types of treatment, such as residential programs.) At the right dose, methadone does not make users high; instead, it blocks the craving for heroin, and those taking it no longer have to spend every waking hour thinking about where to get their next fix.

The five clinics run by the city are administered by the Health and Hospitals Corporation (HHC). Its president since 1995, Dr. Luis R. Marcos, has strong views on methadone, as I learned during a visit to his office at 125 Worth Street, near City Hall. A 55-year-old native of Spain, Marcos has worked as a policy-maker in the city bureaucracy since 1981, but he is trained as a psychiatrist, and in 1973, after completing his residency at Bellevue Hospital, he went to work at a city-run methadone clinic in Kings County Hospital Center in Brooklyn. Marcos has some fond memories from that period, especially of the many patients he got to know, but the program itself had many troubling features. For one thing, counselors gave patients all the methadone they wanted. They also dispensed many pills, such as Elavil and other antidepressants. “You would see patients lying outside the clinic, sedated,” said Marcos, a soft-spoken, mild-mannered man with gray-flecked curly hair and gold-rimmed glasses.

What Marcos most vividly remembers, however, is how determined the staff was to keep people in the program. “The clinic at Kings County always had a waiting list,” he said. “When it began to shorten, the staff would get nervous.” And when anyone expressed an interest in getting off methadone, the staff would try to discourage him. The reason, Marcos said, was job security. If too many patients left the program, the staff’s own positions would be threatened.

Such self-interest, Marcos believes, remains a problem to this day. “Methadone is a big business,” he told me. “Each patient who is detoxed is one patient less for that program. It has to find another patient to take that slot, or it will experience a drop in revenue. I challenge you to find any incentive, explicit or implicit, to have this addicted patient withdrawn from methadone. Everything in these clinics is geared to methadone maintenance.

Listening to Marcos talk about methadone, I found his assessment unduly severe. He made no mention of the hundreds of studies that have shown the narcotic to be a safe and effective treatment for heroin addiction. Recently, for instance, the federal government, in a survey of more than 700 people entering methadone clinics, found that the number using heroin went from 89 percent before treatment to 28 percent after. Similarly, the proportion saying they had engaged in illegal activities declined from 29 percent to 14 percent. Other studies have shown that heroin users in methadone programs have lower rates of HIV than those on the street. In 1997, the National Institutes of Health issued a consensus statement from a panel of experts calling for greater access to methadone based on the drug’s demonstrated ability to reduce drug use, death, and crime.

On the matter of methadone and detox, however, I thought Marcos had a point. Of the 122 programs in the city, a mere handful set abstinence as their ultimate goal. All the rest are maintenance programs, in which patients are expected to remain on methadone indefinitely – even when they are desperate to get off. And there are many who fall into this category. For the methadone routine can be very wearying. Every day but Sunday, patients must show up at clinics to get their medication. (On Saturdays, most get a take-home dose for the next day.) Clinics tend to open late and close early – a serious inconvenience. In addition, many clients simply grow tired of being dependent on a powerful narcotic. And so they decide to detox, a process in which their dose is gradually reduced over a period of weeks or months.

Rarely, though, are they supported in that enterprise. “The counselors at most programs won’t help you get off methadone,” says Gina Neveloff, a 38-year-old resident of Spanish Harlem. I met Gina at the Lower Eastside Service Center, the clinic Barry McCaffrey visited. A heavyset woman with long brown hair and an animated manner, Gina said that she had begun doing drugs when she was 13 and had been in and out of programs ever since. And methadone, she said, had undeniably helped her to reduce her consumption of drugs over the years.

When I asked about detox, however, Gina frowned. A few years earlier, she recalled, she was progressing nicely in a program, working in a hospital while earning credits toward a college degree. She was doing so well, in fact, that she decided to detox. Her counselor strenuously objected. “If they see you’re working and trying to get your life together, they put up roadblocks to keep you from getting off,” Gina said between sips of coffee. “Instead of rooting for you, they become adversarial.” Eventually, she made up a story about moving to Florida so as to win her counselor’s consent.

In defending their opposition to detox, providers point to the large number of patients who, after leaving programs, eventually relapse to heroin use. One study of six programs in New York, Philadelphia, and Baltimore found that about 80 percent of those leaving methadone programs returned to IV-drug use within a year. Given that even one brush with a dirty needle can lead to hepatitis or HIV, most providers regard abstinence as too risky an option.

The risk is real. Nonetheless, the vehemence with which providers reject abstinence as an option suggests that something more is at work. During a break at the American Methadone Treatment Association conference, I found myself seated at a table with several top methadone experts, and the conversation quickly turned to the nature of addiction and methadone’s role in combating it. Heroin addiction, the researchers insisted, causes permanent changes in the chemistry of the brain – changes that require users to take methadone for life. Opiate addiction, they went on, is no different from diabetes or high blood pressure. Just as people suffering from these medical conditions must take insulin or beta blockers indefinitely, so must opiate addicts remain on methadone. When I observed that many heroin addicts do seem to get off drugs, I was dismissed as naïve. The researchers would not admit that addiction wasn’t necessarily a lifetime affliction, that some proportion of addicts do eventually get clean.

New York’s methadone providers are a curious lot. Many are highly dedicated, toiling in the trenches, battling stigma and public opprobrium to bring relief to the sick and disabled. As a result of such isolation, however, the field has grown somewhat insular and inflexible, and the belief in maintenance has, for some, congealed into a creed.

Luis Marcos wanted to change this. In the spring of 1997, he began exploring the idea of making abstinence, not maintenance, the prevailing goal at the city’s clinics. To help guide him, Marcos initiated a case-by-case assessment of HHC’s 2,100 clients. Fully 75 percent were judged capable of making the transition to abstinence in the short term (90 days to one year). The remaining 25 percent – a more debilitated group – were felt to need longer. Encouraged by these results, Marcos discussed with the mayor the idea of introducing an abstinence-based approach at HHC’s clinics. Giuliani was enthusiastic, and Marcos set about designing a new protocol.

Around the same time as Marcos was making his push, the city’s Human Resources Administration (HRA) was beginning to reassess methadone programs’ performance on another sensitive point – their ability to put people to work. Ever since methadone was introduced as a treatment for heroin addiction in the mid-sixties, providers have touted its ability to transform street addicts into productive citizens. But while methadone clearly helps reduce crime and illegal-drug use, it has not done a good job in fostering employment. According to New York State figures, just 10 percent of all methadone patients in the city derive their income mainly from wages or salary; 62 percent rely on public assistance. To a degree, this reflects the hard-core nature of methadone clients: Most come from disadvantaged backgrounds, are poorly educated, have spotty work records, and are physically or psychologically impaired. Moreover, methadone, like drug treatment in general, is severely underfunded, and counselor caseloads tend to be so high (averaging 50 clients per counselor) that patients are rarely able to get the attention they need. Vocational training and job placement are in particularly short supply.

That said, methadone programs themselves do not always seem supportive of patients who want to work. Consider the matter of hours. “Clinics give out medication only at certain hours,” says Benne Lovett, a 45-year-old patient. And that, he adds, often interferes with work schedules. A gentle man with a deliberate speaking manner, Benne himself works at the Angel Street Thrift Shop on West 17th Street, a project of the Lower Eastside Service Center. Staffed mainly by methadone clients, the shop was set up expressly to provide them with jobs. And the eagerness with which they fill them shows how effective such enterprises can be. Yet few methadone programs make arrangements for employment.

Many providers, in fact, feel more comfortable with their clients on welfare, because as long as they remain on it, they get Medicaid, and Medicaid pays a generous $107 a week, on the average, for each client in treatment. If a client gets a job, he might exceed the income cap and lose his Medicaid, and the program will then have to collect a fee directly from him (or from his health insurance). Since most clients end up in low-paying jobs, they can normally pay only a fraction of what Medicaid would. (Medicaid does not reimburse for vocational training.) For providers, then, it’s both easier and more profitable to have clients remain on welfare. And most do – for years at a time. In short, the city’s methadone programs have themselves become dependent on welfare – a reality that troubles even some providers.

It certainly troubles Rudolph Giuliani. Getting people off welfare has been one of his top priorities, and the city’s drug-abusing population has been a major obstacle. One study of the city’s welfare recipients found that 30,000 of them – nearly 10 percent of the total – were excused from working because of a drug or alcohol problem.

HRA wanted all treatment clients on public assistance – like other welfare recipients – to enroll in workfare programs. To help bring this about, HRA officials in late 1997 began meeting with New York treatment providers, methadone administrators included. While most of the treatment officials were cooperative, the methadone providers posed many questions. They agreed that their clients should work, but they worried that the city was rushing them along. One participant, Ira Marion, who runs nine clinics operated by the Albert Einstein College of Medicine in the Bronx, summed up the methadone position: “For many patients, this is a way of life. They have been on public assistance and in methadone maintenance for years. Some are working off the books. Some are dysfunctional and aren’t doing very well. Yet the city wanted all these people instantly to say, ‘I’ll give up this entire lifestyle and go seek meaningful employment.’ “

To HRA, this sounded like so much special pleading, and the meetings got quite heated. Irv Finkelstein, a deputy director of Greenwich House, which runs two downtown methadone clinics, approached the meetings as he would “a contract negotiation,” as he put it. Finkelstein clashed frequently with Rose Manchel, the HRA official in charge, and relations between them at times grew tense.

Worried about a possible rupture, a state official asked Mark Parrino, the president of the American Methadone Treatment Association, to intervene. A polished, articulate man who for years ran a methadone clinic in Manhattan, Parrino is something of a paradox. As head of the AMTA, he is the national spokesman for methadone, yet he is more willing than many to admit its shortcomings. Many programs, he believes, have become too rigid and wed to the status quo. Troubled by the reports he was getting about the HRA meetings, Parrino agreed to attend one in May, and at it he attempted to clarify the methadone field’s position on work: “I said, ‘Methadone is supposed to help people return to a state of normalcy. If a patient is not using heroin and not getting arrested, why can’t he be expected to work?’ We couldn’t take a position against that.”

The HRA officials listened attentively, but Parrino came away from the meeting with the distinct impression that HRA had already decided to go ahead and require that all methadone clients participate in workfare.

On July 20, Mayor Giuliani gave a major address on welfare to officials at the Republic National Bank. He originally planned to announce his intention of ending welfare in the city by the year 2000. One section was to address the city’s efforts to get more people in drug treatment to work. As drafted, the speech made only a passing reference to methadone, but Giuliani – clearly frustrated by the reports he was getting from HRA – veered from his prepared text to lob a grenade. “Over a period of time, hopefully within the next two, three, or four years, we will phase out and do away with methadone-maintenance programs in the city of New York,” Giuliani said, giving a self-righteous, ideological tone to what in fact had been a serious effort to address some of the shortcomings in how methadone was being delivered in the city.

As the press hastened to point out, the mayor does not have the authority to phase out methadone maintenance in the city. Giuliani does hope, however, that HHC’s new abstinence-based model will set an example. “If things go well, and I think they will, we will be sending out a message,” Luis Marcos observed. Marcos sees the city’s new approach as part of a grand trial in which one model “will drive out the other.” On August 12, in a first step toward implementing the new policy, Marcos told me, the city’s clinics began accepting only those patients who express an interest in eventually becoming abstinent.

To help minimize the risk of relapse and other attendant dangers of detox, Marcos said, HHC is hiring more counselors and plans to offer job training and other services; to finance this, the city is providing $5 million in new funds.

Given HHC’s extremely optimistic judgment that three quarters of the methadone population could make a rapid transition to abstinence, what will become of clients who resist? “We will work with them,” Marcos says. “We will not decrease the methadone of a patient who refuses to take less. This has to be done together with the patient.”

In fact, since the new policy went into effect, the city’s methadone clinics are showing far more flexibility than official pronouncements would suggest. I discovered this on a recent visit to Bellevue Hospital, site of one of the city’s five clinics.

A 39-year-old Brooklyn woman showed up expressing an interest in getting on methadone. She had a bloated face and distended stomach – the effects, she said, of the heavy doses of steroids she was taking to combat an asthma condition. She admitted to sniffing four bags of heroin a day and to using cocaine on the side. Had she ever before been in a methadone program? the staff wanted to know. Yes, the woman said, she had been on meth in the early eighties and had done quite well. Convinced she would benefit from Bellevue’s program, the staff decided to admit her. Once she was stabilized, she would be informed of the city’s new interest in abstinence, but her immediate needs took precedence.

“The city’s clinics are not going to compromise the medically based needs of patients,” says Dr. Marc Galanter, a professor of psychiatry at New York University who directs substance-abuse services at Bellevue. “We’re not going to terminate patients’ methadone to see if they can survive.” Instead, he says, patients will be fully informed of the range of options open to them, including abstinence. In the end, Galanter says, “the course of treatment will be tailored to the individual’s needs.”

At the city’s private programs, too, administrators are discussing new ways to serve their clients better. “The mayor’s remarks have served as a springboard for the field to discuss the services we provide and the ways in which we can continue to improve patient care,” says Eileen Pencer, the president of the Lower Eastside Service Center.

So, nearly six months after Rudolph Giuliani promised to phase out methadone in the city, there seems little chance of this actually happening. On the contrary, the mayor’s comments have helped spark a major reassessment of how methadone is delivered in New York – a process that, in the end, can only benefit the city’s clients.

The mayor would no doubt like to claim credit for this. And had he articulated his concerns about methadone in a reasonable fashion, he might deserve it. By instead turning the issue into a moral crusade, he frightened the city’s methadone clients, got into a spat with the nation’s drug czar, and handed the city’s methadone community a major PR victory. In the past few months, New York’s methadone providers have received more favorable publicity than they had in the previous 25 years. And they have Rudy Giuliani to thank for it.

The Real Methadone Problem