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 activit y. 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?

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