A Glimmer of Light?

"It is clear from the figures that more addicts can be salvaged by methadone than by any other method."--Dr. Vincent Dole, Rockefeller University

"Methadone is increasing the addiction rate among young people. I predict that in five years there will be millions of people on methadone and no reduction in crime. Methadone will turn out to be a tremendous national embarrassment."--Dr. Mitchell Rosenthal, Phoenix House

These statements, both by experts deeply concerned about epidemic drug abuse, typify the growing controversy over methadone as a substitute for heroin. Last week, in a book that may help to resolve the controversy, Consumers Union came out strongly on the Dole side of the argument. Licit and Illicit Drugs, a five-year study by Medical Writer Edward Brecher and the editors of Consumer Reports (Little, Brown; $12.50), advocates legalizing marijuana, supplying heroin, opium and morphine to some addicts on an experimental basis, and providing methadone maintenance--legal administration of methadone to heroin users--for every drug abuser who asks for it.

The C.U. recommendations are not based on any new scientific research but on a detailed review of available scientific evidence and on interviews with experts and addicts. "The ideal solution," conclude the authors, "would be a cure for opiate addiction. But no such cure exists, nor is there one on the horizon--and there exist no clues as to where such a miracle cure might be found. Methadone maintenance is not a panacea. But it frees addicts from the heroin incubus" and can turn "a majority of heroin addicts into law-abiding citizens."

In 1964 Metabolic Specialist Vincent Dole and his wife, Psychiatrist Marie Nyswander, conducted the first pioneering experiments in methadone maintenance. Their success helped make maintenance a preferred U.S. method of rehabilitation. Already some 60,000 of the country's 600,000 addicts are being treated at 460 public and private clinics in 40 states; another 30,000 are on waiting lists. As use widens, problems mushroom, and critics have begun to remind advocates that heroin itself, when it was discovered in 1898, was touted as a desirable alternative to morphine.

Transformed Lives. Methadone prevents withdrawal symptoms when the addict stops using heroin. Swallowed in individually regulated doses, it keeps him on an even keel without producing either euphoria or lassitude. It also helps suppress his craving for drugs--and keeps the addict from getting high on heroin if he tries going back to it. Most important, stabilizing an addict on methadone often brings his previously buried emotional problems to the surface where they can be treated.

The best clinics offer a balanced program of medication and rehabilitation. As a result, many methadone-maintained addicts hold jobs. In Boston, 70% of patients have jobs. In Washington, D.C., only 30% of patients are employed at the time they go on methadone, but 65% have jobs when they have stayed on it six months or longer. Thousands of addicts rehabilitated with methadone abandon crime as a way of life. The view of addicts who have managed to resume a near-normal existence is summed up by Pam Smith, 46, a Manhattanite who once supported her heroin habit with prostitution: "I'm a human being again."

But methadone is powerful stuff and carries its own dangers. To Psychiatrist Mitchell Rosenthal of Phoenix House and Psychiatrist Leon Epstein and Sociologist Henry Lennard of the University of California at San Francisco, methadone "permits the illusion of a solution" while actually doing more harm than good. In a much-discussed article in Science last spring, they argued that methadone maintenance "reinforces the popular illusion that a drug can be a fast, cheap and magical answer to complex human and social problems." Because methadone is addictive, opponents also find maintenance morally abhorrent and believe that moving an addict from heroin to methadone is like shifting an alcoholic from bourbon to Scotch.

Bearing out this contention is the fact that there is a growing black market for methadone. In many cities, it is being sold by pushers to "virgin" drug abusers seeking the orgasmic reaction, almost as intense as the heroin "rush," that methadone produces when injected into a vein rather than taken orally. Besides, though complicated to manufacture, methadone is cheaper than heroin (perhaps $20 instead of $50 a day) partly because big crime has not--as yet --moved in.

Mouthwash. Worst of all, black-market methadone is said to have caused hundreds of deaths last year. Figures can be misleading; they often include deaths resulting from heroin or other causes when a trace of methadone is found in the victim's body. Nevertheless, the death totals are rising.

Ideally, methadone is mixed with fruit juice (to make injection difficult if the drug is stolen) and administered under the eyes of doctors or nurses. In practice, carelessness or corruption permits a few patients to hold the juice in their mouths until they can spit it into plastic bags and sell it as "mouthwash methadone." Some unethical doctors are selling the drug to nonaddicts or prescribing unneeded amounts to real heroin users; many addicts are getting extra supplies by enrolling at more than one treatment center. In clinics where vigilance is slack or rehabilitation services inadequate, take-home privileges may be too quickly granted and too often abused: given enough methadone to tide them over a weekend or longer, addicts may reduce their need by tapering and sell the rest.

The best-run programs have built-in safeguards. In many cities, doctors have reduced dosages to the smallest effective amounts. Since instituting a computer system that prevents registration at more than one clinic, Georgia has had no overdose deaths or other indications of drug diversion. Regulations issued earlier this year by the Food and Drug Administration should help. The new rules make it easier to crack down on private dispensers and require clinic dispensers to be registered after screening. The rules also require at least one urinalysis a week for every patient to make sure that he has not gone back to heroin and that he is swallowing rather than selling his prescribed dose.

No such simple measures can satisfy those who believe, with Lennard, that the only legitimate treatment goal for most addicts is abstinence. Some clinics are beginning to favor the "maintenance to abstinence" approach, with methadone only a way station. But "rehabilitation of any significant number of addicts in a drug-free condition is a completely unrealistic goal," according to the director of Georgia's drug program, Psychiatrist Peter Bourne. Psychiatrist Edward Senay, director of the Illinois program, reports that an addict who is back in the community after getting the heroin out of his system has "a 95% probability of returning to drug abuse."

The Alternatives. What about the so-called therapeutic communities like Phoenix House, Synanon and Daytop that shun all drugs, including methadone, and require patients to live together in treatment residences for a year or more? Harvard Psychiatrist Vernon Patch agrees with most methadone specialists that while an addict stabilized on methadone has "two chances out of three to make substantial changes in his life," a heroin user who tries a drug-free center has only "one, two or three chances out of a hundred."

Both C.U. and a new study by the American Psychiatric Association document this pessimistic view. The A.P.A. finds that "no therapeutic community has yet managed to graduate more than a tiny fraction of those who enter," and C.U. reports that only a "minuscule cadre of ex-addicts continue to live drug-free in the open community after graduation." Yet most communities claim cure rates of 50% and higher. They do so, say C.U. and A.P.A., by not counting dropouts as failures: of those who enter, 75% cannot tolerate the abstinence or the discipline and leave within a month or so. Even Synanon Founder Charles Dederich says of his "graduates": "I know damn well if they go out of Synanon they are dead. A person with this fatal disease will have to live here all his life." So the handful of cured addicts tend to stay on as counselors or as showpieces. To C.U., the communities, "without a single known exception, represent a major disaster, for they have helped persuade the public that heroin addiction is curable."

Yet methadone is no real solution. Says Billy Schwartz, counselor in a Manhattan methadone clinic and one of those rare ex-addicts who has made it from maintenance to abstinence: "Methadone is just a glimmer of light; it doesn't go to the heart of the problem." But it is a glimmer--provided efforts at rehabilitation accompany the medication. As Director Sidney Jenkins of the Detroit Drug Treatment Center puts it, methadone is "just an intermediate step so the addict can get his mind off finding a fix and get his head together."

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