July 22, 1998

Methadone Works, Usually

Mayor Rudolph Giuliani alarmed drug policy experts on Monday when he said he wanted to abolish all methadone programs for heroin addicts in New York City. Methadone, he said, merely replaces one dependency with another. In fact, he is both right and wrong to take this position.

I say this because I work in a methadone clinic and know the drug's considerable benefits and shortcomings.

First, the benefits. I have treated many addicts who function perfectly well as long as they take methadone daily. They are at our clinic at 6:30 A.M. so they can get to work by 8 A.M. This is not the way heroin addicts act; it's the way people who need a life-saving, if habit-forming, medicine behave.

Now, the downside. Methadone may quell a person's craving for heroin, but it doesn't prevent the desire to get high when he or she is feeling bored, depressed or anxious. Of the patients on methadone, a third or more will also use cocaine or street sedatives, like Xanax. Indeed, sometimes the money they save by not buying heroin is used to buy cocaine.

In this way, methadone can actually promote drug abuse. And many clinics are too tolerant of methadone patients who use other drugs. Not only does this make a mockery of the individual patient's treatment, it also hurts the credibility of the clinic in the eyes of other patients, who see that the staff cannot control the problem.

So, here are some suggestions for the Mayor.

First, don't alter the treatment of anyone on methadone who is doing well -- working, caring for children, obeying the law. I'd even make it available in pharmacies for specially approved patients. (This is already taking place in some cities.)

Second, create more intensive residential treatment slots for hard-core addicts. If there were more residential programs, like Phoenix House, then maybe methadone treatment wouldn't be so crucial. The catch? Methadone programs cost $3,000 a year; residential programs cost upward of $20,000.

Moreover, Medicaid doesn't pay for residential programs, but it does pay for methadone, even when patients don't give up their other drugs.

Third, we clinicians need help. My methadone patients clean up their acts when they understand there are real consequences for using drugs. For instance, a mother who lost her welfare check when her youngest child turned 18 had to get a job -- and she stopped using cocaine. Another addict started testing negative for drugs when his employer started drug screening. Addicts who continue to use drugs need to know that their habit might take away their workfare check, for example, or kick them out of public housing.

But neither workfare nor better residential treatment can rid us of the need for methadone treatment altogether. Those who find that using methadone is the only way they can lead a responsible and satisfying life should not be prevented from taking it.

Sally L. Satel is a psychiatrist who works in a methadone clinic in Washington.

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