Methadone Treatment in New York by Michael Grenga and H. Spencer Nelson

When the first methadone programs were set up in this country, one of the
biggest factors in allowing these programs to exist, was the rationale that an
addict, once supported with a daily dose of methadone, would refrain from a lot
of criminal activity. Also, it was felt, the addict would start to take a
productive role in society and would pursue gainful employment and/or schooling.
While the programs and agencies involved were new to the needs of methadone
patients and probably made a lot of mistake s in the learning process, it was
never felt that this was a planned objective of treatment.

The programs stuck quite close to the basic needs and wants of the patient.
That is, that we needed to be encouraged and eased back into society. We needed
an affordable and adequate dosage of methadone on a daily basis, and clinic
hours that were reas onable and of a long enough time frame to enable every
patient to get their medication. These were the basic tenets of methadone
maintenance treatment. This philosophy predated methadone treatment in the
U.S.A. This was the philosophy in England for the t wo decades preceding the
experiments of Nyswander and Dole……”Lets give the addict enough drugs
to take away the need to commit crime to get these drugs.” However,
somewhere along the line, we — the patients — feel that these basic principles
have b een overlooked. Forgotten in the virtue of the moral entrepreneurs who
believe that there is only one “good” way to live — their way!

The majority of clinics in New York have tended to gild the lily with
expensive counseling and clinic costs that are usually way beyond the means of
the average methadone patient. Clinic hours are clearly designed to suit the
hours of the average hospi tal executive; they just aren’t flexible enough for a
person who works shifts. We know of several patients that have lost good jobs
because of this and the distance traveled to the program. This aside, the
majority of methadone patients improve their heal th and social status with
methadone maintenance while a large minority are clever enough to manage a
system of bureaucracy and regulations and to make methadone maintenance work for
them. So well that they have turned themselves around and came off of wel fare
and hospital charity. What happens? One would hope, indeed — expect that the
patient would feel good about this and go on with a happy and productive life.
Unfortunately, the reality is often times a lot different.

Having come off the protection of welfare and medicaid and medicare, the
patient is often faced with the daunting prospect of paying for services that
they cannot nearly hope to meet. Particularity the so-called working poor which
constitute a large nu mber of methadone patients who are struggling to make ends
meet. These people earn just enough to disqualify them from agency help, but not
enough to pay the bills. Faced with this prospect, a lot of recovering addicts
particularly single mothers and fath ers, go back on the welfare rolls. The
myopic eye of the press often picks this up as a deliberate character flaw of
the addict and as a conspiracy to defraud the federal government. In New York
the concept of rehabilitation has become low priority. Metha done programs
receive more money for patients on welfare receiving medicaid and some programs
even refuse to accept “a paying working patient.” Programs have
numerous social workers on staff, but no vocational counselors.

In the 1970s over 65% of the methadone patients in New York State were
working (55%), going to school (5%) or full time home makers (5%). Today that
has dropped to 28%! Why? Well, one could argue that HIV infection has an impact,
but most methadone p atients that are HIV+ are asymptomatic. They can and
probably should work at least part time, but no one encourages them. One could
also argue that many of the semiskilled industrial jobs that employed many
methadone patients have left the city and state. But successful addicts (and
most methadone patients were successful addicts or else they would not quality
for treatment) are clever and will find ways around the stigma and
discrimination to work. They did it in the past, so why not now. The answer is s
imple — they are not encouraged by their programs to work. Programs prefer that
they remain on welfare so that they receive top dollar for their treatment. The
proof is in the fact that very few clinics have hours conducive for working
patients and in Ne w York City, where about 28,000 patients reside the Late
Clinic for working patients was closed by Beth Israel Medical Center with no
alternative. Also, After Care slots have been and continue to be reduced
throughout the state.

What can be done about these concerns? Are we undoing the progress we have
make in the field of addiction by pricing it out of the average patients grasp?
In the last issue of The Ombudsman there was an article that mentioned the work
that was being done so that methadone could be obtained from physicians in their
office (p 12, In The News, New York City). This would make it a lot easier for
patients that need the drug to get it without resorting to the geographic
location of a few programs. Also, ma ny patients find that the restrictions of a
program eventually hinder their progress in society and some methadone patients
may respond to the more individualized treatment of a physician in their office.

Finally what about the terminally ill patient? Why should someone that is
critically ill be forced to run the daily gauntlet of a program when they could
be treated by the same physician who is treating them for their illness. For
many terminal condit ions and especially AIDS, stress is the killer, and I can’t
think of anything more stressful than a methadone program.

There is a great deal of need out there and certainly room for change to suit
the needs of a diverse population. Are we up to the challenge?