Drug Treatment on Demand - Not

Drug treatment on demand, appropriate and affordable drug treatment for injection drug users who are "ready" to enter a program, is a humane approach to drug treatment services and an important mechanism to halt the spread of HIV. However, drug treatment on demand is not a reality in the United States. In fact, due to funding cuts at federal, state, and local levels, entry into drug treatment programs has become increasingly more difficult over the past decade. In a NIDA-funded ethnographic study of methadone maintenance, IV drug use and AIDS, 70 heroin addicts who were out of treatment and actively seeking methadone maintenance were interviewed. In life-history interviews, the drug users described barriers to treatment, waiting-list experiences, and the impact of these experiences on their drug use, drug-using behavior, and emotional well-being. Respondents used many mechanisms to cope with the lack of availability of drug treatment slots, some of which have increased their risk of exposure to and spread of HIV. These findings indicate the need for an increase in the availability of subsidized methadone maintenance treatment slots "on demand" if individuals are to decrease their drug use and their high-risk behaviors. Drug treatment on demand is more than politically correct rhetoric. It is a necessary ingredient in reducing the harm caused by the use of illegal drugs.

Injection drug use and specifically sharing injection equipment continues to be the second largest category of behavior associated with the risk of HIV transmission in the United States. It serves as a potential bridge of infection to other groups, including non-drug-using sexual partners and children (Centers for Disease Control 1991a, 1991b; Des Jarlais &; Friedman 1988). In order to halt the spread of HIV among this population, alternatives to injection drug use must be available.

Methadone maintenance is one such alternative to using and sharing needles, and has played an important role in halting the spread of HIV among those heroin addicts enrolled in methadone maintenance treatment (Ball et al. 1988). According to Chaisson and colleagues (1989), clients in methadone treatment are less likely to be HIV positive than those who are not yet enrolled in treatment. Additionally, increased length of time in treatment has been associated with lower rates of needle sharing as well as seropositivity (Schoenbaum et al. 1989; Abdul-Quader et al. 1987). Furthermore, methadone maintenance programs give injection drug users (IDUs) access to AIDS education prevention programs and HIV testing, and provide contacts with health care systems to those clients already infected with HIV (Ward, Mattick & Hall 1992). The inclusion of AIDS education programs within methadone treatment protocols has been associated with clients' increased knowledge of AIDS risks as well as decreased drug-using and sexual behaviors that put individuals at risk for HIV infection (Magura et al. 1991; Casadonte et al. 1990). There is also documentation of a significantly lower probability of disease progression in HIV-positive methadone clients (Weber et al.1990).

Timing is crucial for successful drug treatment When IDUs feel they are ready to enroll in treatment, the opportunity for change is most pressing. Thus, providing appropriate and affordable drug treatment on demand seems a necessary, humane, and logical approach to the provision of services. Australia and The Netherlands, taking a pragmatic perspective, provide access to drug treatment on demand. In 1985, the Australian government adopted drug policies based on the minimization of harm associated with injection drug use. They accepted the inevitability of injection drug use, but attempted to reduce the amount of damage it caused by instituting programs to educate IDUs about safer injection practices and syringe exchange programs. One result of these campaigns is low rates of HIV infection. The Australians expanded methadone maintenance programs, tripling their number between 1985 and 1989. They also introduced new kinds of programs more accessible and attractive to IDUs. Such programs are "low threshold programs," with relaxed criteria for entry so applicants can bypass extensive screening before admission to treatment. They make few demands on clients and do not react in a punitive fashion to illicit drug use (Ward et al. 1992).

Similar low-threshold and low-intervention programs were developed in The Netherlands. One such innovative program, which gives IDUs greater access to methadone treatment, is the "methadone by bus" project in Amsterdam. Clinics are located in mobile vans and methadone is dispensed on street corners along with clean needles and condoms. When clients refrain from the use of illicit drugs, they can "graduate" to other methadone programs with a higher threshold(1) (Buning, Van Brussel &; Van Stanton 1990).

During the 1980s, while funding and accessibility to drug treatment expanded in Europe and Australia, public funding for drug treatment in the United States decreased. The Reagan administration switched from direct federal funding to state block grants in the early 1980s. This increased state and local power regarding social service budget allocations and resulted in a reduction in federal monies devoted to drug treatment (McAuliffe 1990). Many states have reduced or eliminated public funding for methadone maintenance programs and allowed private fee-for-service programs to replace them (Britton & Rosenbaum In Press; Anglin et al. 1989). Those states with publicly funded treatment slots have lengthy waiting lists, prohibitive private fees, and cumbersome processes for entry into treatment (National Commission on AIDS 1991: Record 1991; Yancovitz et al. 1991).

Drug treatment on demand has been the desire of AIDS activists, drug treatment evaluators, providers, policymakers, the American Medical Association, and drug users themselves (Clark 1993; McAuliffe et al. 1991; American Medical Association 1989; Brickner et al. 1989; Des Jarlais and Friedman 1987). As early as 1988, numerous recommendations were made similar to the following one by the Presidential Commission on the Human Immunodeficiency Virus (1988:95): "The Commission believes it is imperative to curb drug abuse, especially intravenous drug abuse, by means of treatment in order to slow the HIV epidemic Because a clear federal, state, and local government policy is needed, the Commission recommends a national policy of providing 'treatment on demand' for intravenous drug abusers."

Slogans aside, what happens to IDUs who would like to be in treatment but are denied access? In this article, the selected findings from a National Institute on Drug Abusefunded longitudinal study of intravenous drug use, methadone maintenance, and AIDS are reported in which 234 injection drug users in the San Francisco Bay Area were interviewed. Study subjects were located and recruited using snowball sampling techniques (Biernacki & Waldorf 1981). At the time of their initial interviews, in-treatment participants were recruited from five Bay Area methadone maintenance clinics. Those seeking treatment at the time of their initial interviews were recruited from San Francisco neighborhoods known to have high rates of drug use. Study subjects were administered a combination qualitative and quantitative interview every six months for three years. The initial qualitative interviews were face-to-face in-depth interviews one to three hours in length that were audio taped for transcription. During these interviews an open-ended interview guide was employed, organized around topics such as the study subjects personal life history, initiation to and on-going drug-using patterns, experiences in drug treatment, current treatment needs, barriers to treatment, HIV knowledge, attitudes, and risk behaviors. The quantitative instrument was a closed-ended questionnaire designed to collect basic demographic information and quantifiable data, such as drug use, criminal activity, and HIV sexual and drug-using behaviors on all study subjects. Follow-up interviews were similar in format, but shorter in length and primarily conducted over the telephone.

The subsample discussed in this article is composed of 70 heroin addicts who were actively seeking but were not enrolled in treatment at the time of their initial interview (2): 67% were men and 33% were women, 61% were White, 21% were African-American, 11% were Latino, 1% were Native American, 1% were Asian, and 4% were Other (multiple ethnicities). The mean age of this subsample was 38 years (range 18-62 years). The median monthly per capita income was $666, with 41% depending on illicit activities, 27% using public assistance, 7% supported by a partner, and just 15% employed.

The purpose here is to describe the situation of addicts who are not able to enlist in drug treatment on demand. In detailing-their situation, study participants' motivations for getting into drug treatment are described as well as the barriers they encountered. Next, the waiting-list process, the emotional impact of this process on treatment seekers, and strategies they used to cope with their situation are analyzed. Finally, the effect of barriers to treatment on drug use and HIV-risk behaviors are discussed.

Most interviewees in this study population were long time heroin users, with an average of 10.01 years of heroin use. Most cited past treatment failures, fear of withdrawal, and "kicking cold turkey" as important reasons for entering treatment Methadone maintenance was viewed as a tool to assist them in the process of detoxification. A 44-year-old Native American described his need for treatment:

A: Well that's what I've been thinking about actually for the last couple of weeks. I don't know. It doesn't look good. I have to figure out how to deal with this heroin problem. It's come down to that. And I suppose if I have to, I'll cold turkey even though I get this weird feeling that it'll kill me if I do.

Q: What makes you think that?

A: Well, because I tried it. I can't go more than a day and a half without heroin.

Q: What kind of symptoms do you get? What happens to you?

A: Lack of motor function, temporary blindness, head spinning, short of breath, sweating, you know, the worst, the whole-everything. Stomach cramps, aching joints and the whole thing. I suppose technically it couldn't last more that 72 hours, but like I'm not ready to go that 72 hours, especially knowing in the back of my head that either there's heroin out there or else there's something else that would mitigate the pain.

One 31-year-old White woman detailed how past experience with kicking heroin had affected her current drug-using behaviors:

Now I use because I'm on a four-year run and I'm scared to kick. I kicked a two-year run I was doing. I was into counterfeiting. We were buying a quarter between two people, so I had a really bad habit. And I kicked in jail. And I never want to do that again. So it scares me. I tried kicking out on the street. I went to my mom's and there's no way on God's green earth I'm going to kick when I know I can get it. I mean I know and I didn't try to fool myself.

Interviewees recounted they were unable to take care of themselves, their families, and their day-to-day business while using heroin. Many participants were cut off from their families and were seeking treatment to allow them to facilitate reunification. A 40-year-old White man explained the ME- pact of long-term drug use. on his relationship with his family members:

I don't want to go around my family like this 'cause they know I had ten months clean and they don't know that I'm back on the shit. I don't want to let them know that I want to clean up and get on maintenance or do something. I gotta do something.

Heroin-using parents, like the 35-year-old White woman quoted below, lost custody of their children. She hoped that by enrolling in treatment, custody reinstatement would be facilitated:

Oh, if I can get clean, I hope to go back to work, get my kids back. That's what my goal is. That's why I'm trying to get on the program.

Some interviewees had been on maintenance prior to being interviewed, and described their treatment attempts as less than successful. Nonetheless, at the time of their initial interview, their lives were so chaotic they did not feel they had any other option but to get back on methadone maintenance. While discussing her plans to return to maintenance, this 31 -year-old White woman stated:

God, my life's a mess. You know, it's like I'm living with a man I don't really love. I mean I care for him. I look like hell. I mean I used to walk down the street and get whistled at. Now I-half the time, I don't even put on make-up. I walk out the door. If I'm sick, forget it, man. I'll go out in my pajamas. I mean I just don't care. I feel worthless so I look like I feel. And F. is----a good guy, but he makes me feel like nobody else would take me but him. Everyday he complains about what I did to him. What I used to do to him. And this and that. And I tell him finally, "Okay, now you made me feel worthless again. Are you satisfied?" And that's how I feel. I feel ugly. I feel skinny. I mean, you know, worthless.

Many of the study participants reported that at this point in their drug-using careers, they were more willing to try methadone because they were tired of the drug-using lifestyle. They believed if they were to enter treatment they could go back to school and/or get a conventional job, reenter mainstream society or in some cases enter for the first time (Rosenbaum & Murphy 1984). When this 44-year-old Native American reflected on his lifestyle, be said:

I mean, not that I don't mind avoiding police and avoiding the heat and cheating and lying and whatever, manipulating. I mean if that's what they want you to do, then that's what you have to do. But it becomes-if you step back and look at it, it's sort of a ridiculous expenditure of energy and time.

A 28-year-old Asian woman described a lifestyle that became increasingly difficult to maintain:

Because it's very hard being addicted to something and having it just drain everything out of you.... And that's like the ultimate goal is survival, right. And you know you're not going to survive like this 'cause it's not getting any better and it won't. See, I mean, it's not like you want to be hooked on this or anything. It's just that, yeah, if you don't have like some kind of miracle happening, it just gets harder and harder to do it. And then it gets more and more expensive. It takes more and more of your time and you get sicker and sicker and more people get busted. Your drugs get harder to get and its harder to keep well. You have less and less options.

Interviewees detailed increasing entrenchment in drug using lifestyles over time and simultaneous disillusionment with drug-using scenes. The following passage from a 40-year-old African-American woman's interview characterizes this concurrent escalation of involvement and disenchantment:

Well, I'm tired of pounding the streets. I don't want to go back to prison. I don't want to pick up a gun again 'cause if my money's funny, I'll do a robbery. I just don't want to go back to prison and I'm trying to make it. I want to get on methadone and start working. I got to get some kind of structure, some kind of foundation. I've been going to meetings too, NA meetings, even though I'm using. I'm just trying to----I don't want to use no more. I'm tired.

Over time, interviewees' criminal convictions accumulated and they expected to receive increasingly severe penalties. This 40-year-old White man's motivation for entering treatment reflects other addicts' experiences:

I want to clean up and get on maintenance or something or do something, man. I gotta do something. They're gonna give me a habitual criminal act pretty soon. One more felony, I'm gone, man. They'll give me the career criminal act.

Many addicts characterized themselves as "at the end of their ropes." They were frustrated by the lack of availability of treatment slots and they did not see any other available options. Some even discussed suicide as an alternative to continued drug use. Most wondered how much longer they could survive continued drug involvement.

Some interviewees had been on methadone maintenance before and found it beneficial. This 37-year-old Latino's account illustrates the perspective of many returning patients:

I know I'll clean up and what it'll do for me is just make me feel better as far as not having to wake up every morning looking for a fix and feeling sick. Okay? And it'll help out in a lot of ways-stop my drinking. 'Cause when I was on the detox, I didn't drink, which is a hard thing. I was drinking maybe five bottles of beer a day. I had to stop drinking 'cause I didn't want that to affect my methadone. But also it makes my mother feel like I'm doing something for myself besides sitting in my van and fixing dope.

The 40-year-old White man quoted above predicted that:

If I was on maintenance, I could go to work every day 'cause that means I ain't gotta go out and cop dope all hours of the day and night and go out and steal and do all this extracurricular bullshit to make money to get drugs. If I was on maintenance, I could go to the hall every day until I got a steady job, which usually comes right away. But I can't get down there often enough now because I'm using, man. And it's kind of hard to-especially when you're using drugs every day, you're on the job. If you are working, you got to split al lunchtime to go cop, to get a shot of dope or whatever.

Participants repeatedly recounted that methadone maintenance gave them the option of discontinuing drug use and criminal behaviors while attempting to reenter the work force. The same man went on to say what life would be like for him if he was on maintenance:

So with methadone, you don't have to go out and use any other drugs. You have a choice. You don't have to go out and steal. And you can go to work and you can live almost a pretty normal life....

Methadone allowed heroin addicts to find order in chaos and to try to find work. It was also an alternative to continued criminal activities and incarceration. A 43-year-old African-American woman summed it up succinctly:

[To] keep me from going back to doing what I used to do, like going in stores and stealing. And help me start being productive again. go back to work, or maybe go back to school. You know, going back to doing the things I used to do, things that I like doing instead of going to jail. I'd like a little car and new furniture, and the only way I'm going to get that is to go to work. And by being on methadone, I can save money to do these things instead of shooting it all up in drugs.

For IDUs, financial issues, particularly the lack of available subsidized treatment slots, were the primary enrollment barriers to getting on methadone maintenance programs. Secondary issues included fear of withdrawal from methadone and its consequences, and difficulty setting aside enough time to get on a program.

Many study participants were living on public assistance and supplementing their incomes with illicit activities. Often their minimal needs for shelter and food went unmet in order to obtain enough heroin to support their habits. For these individuals, payment of private fees for methadone maintenance was out of the question. A 28-year-old Asian woman remarked:

If you're poor and you're a junkie forget it. I mean, if you don't have the means of putting out cash and having all the luxury of time, you don't have nothing. You can't stay on the program practically. Al least not the way I'm living. If I have to go to a job every day, if I don't have money, you can't. You don't have the luxury of getting well.

Although interviewees spent an average of $80 on heroin daily, most were unable to pay private fees for methadone. Providers often argue that this amount of money would more than cover treatment costs, but they are missing the point: addicts engage in illicit activities for the express purpose of maintaining their heroin habits. While in drug treatment, they were not only attempting to abstain from illicit drug use but to discontinue their involvement in criminal activities. A 38-year-old White woman delineated the ways in which motivational processes changed regarding money:

I mean before, years ago, it wasn't that much to get money and shit. Now they say, "Well, you were doing it out there on the street to get your dope." But when you maintain with your dose (methadone] every day, you lose that motivation to want to go out there and hustle because you're kicked back and you're okay. Like if I go and get my dose [of methadone], I ain't going to be sick. They want you to come out with a couple hundred bucks in a couple weeks or something. That amount is just too much.

Nearly one-third of the study participants subsisted on fixed incomes (General Assistance, Aid for Families with Dependent Children, or Supplemental Security Income). They knew that even if they did get a private (fee) treatment slot, they would no longer be able to finance their basic needs. According to this 30-year-old White man on General Assistance:

They only give you $170 and $50 bimonthly. The clinic wants $179 a month to be on maintenance. So that means for two weeks out of a month, you have to live on the streets in order to be able to pay for your maintenance and there's no common ground in between.

At the same time, the primary source of income for 41 % of this subsample was illicit activities, including prostitution, petty theft, burglary, and drug sales. Study participants explained that the only way they could afford a private slot was to continue engaging in criminal activities. Thus, clients experienced a Catch-22. It is antithetical to treatment goals for clients to engage in illicit activities, yet in order to pay for their treatment, they often have no other alternative (Rosenbaum, Murphy & Beck 1987).

Some of the clinics in the Bay Area not only required payment for treatment, but a deposit to secure a treatment slot. Some interviewees indicated that these deposits were yet another obstacle keeping people from getting into treatment.

As illustrated by this 40-year-old White man's account, the consequences of having been previously detoxified off methadone for failure to pay fees discouraged many respondents from seeking treatment:

I didn't like it---the reason I didn't like it is because they want to charge you $180 a month and if you don't got the money, all of a sudden they're telling you, well they ain't gonna-they're gonna start dropping your dose if you don't pay them by tomorrow morning. If you're not working that means that you got to go out and do something wrong. And sometimes I had to go out and do something wrong because in two and a half years, I never missed a day of methadone. I was there every day 'cause it helped me stay clean. I mean, it helped me stay clean. I mean, it helped me not go out and shoot dope and have to go steal. But when they're telling you that they're gonna drop you if you don't pay them their money, they're gonna start dropping you and they'll drop you quick. I mean you'll be really sick man. Finally, I got busted.

Some interviewees were unable to enroll in treatment because subsidized methadone slots no longer existed. The only available free slots at many treatment programs were specifically earmarked for clients with HIV-related disease or other disabling conditions. According to this 35-year-old White woman:

Well, San Francisco General Hospital is almost closed down completely, their detox program. Their maintenance program is only for people that are sick. You have to have AIDS or cancer, something like that.

In spite of numerous barriers, many individuals sought methadone treatment. The first step was getting on a waiting list.

Treatment intake procedures are time-consuming, cumbersome, complicated, and at times demeaning to people who are in need of assistance. Interviewees described scenarios where they signed up on "waiting lists" and called the clinic on a daily basis to prove their motivation to get into treatment. Others recalled situations in which they called clinics to get on waiting lists and were told to call back in a month to see how they ranked on the list. Still others signed up on waiting lists and were told, "Don't call us. We'll call you." This entire process was made more complicated and difficult since many participants were without phones or permanent residences, and most spent their days hustling for money, drugs, food, and shelter. A 31-year-old White woman's experience represents the frustration of many other interviewees:

Last time I called I had to get on a waiting list. Wait a minute-get on a waiting list to get an appointment for the waiting list. Yeah. She said, "Call me back on Thursday and I'll give you your appointment." You're on a waiting list for them to get on a waiting list. The one in San Leandro is an 18-month wait. The one in Richmond's like an 18-month wait. The one in Oakland is like a 16-month wait.

Treatment seekers were often told they must put their names on a list and wait seven months to a year for a slot that was not guaranteed. A 34-year-old White woman related how capricious the waiting-list system seemed:

I call every couple of weeks. You know, at one point I was way up high on the list. And all of a sudden, I called them back two weeks later and they put me back on the bottom of the list. They had thrown that list out and started again. You know, it was really sad the way they handle themselves sometimes. I thought I would go-you know, within a month I'll be on. And then the next time I called, they didn't even have my name on the list anymore.

Despite differences in process and length of waiting lists from clinic to clinic, respondents for the most part shared the frustration echoed by this 62-year-old African American man:

Each one of these programs tell you the same bullshit, man. Waiting, waiting---well what they got-a year waiting list to get on methadone? That sounds ridiculous to me.

Many treatment seekers found the intake process demeaning as well as confusing. A 44-year-old Native American man refused to beg:

First of all, I'm not going to go and beg them. That's the other thing, I'm not going to beg them to get on their program....

After finishing a detox and being told to come back in two weeks to try to get on methadone maintenance, this same man recalled his confusion:

It was just so many different restrictions that I really couldn't even understand them, let alone understand why they were asking me to do that. I mean, you figure if somebody's asking to get on methadone maintenance, like the least you could do is help them do it rather than make it difficult.

Others reported they felt as if they were lost within the system. They were told they would be called when their name came up on the list and they never heard from the clinic. Or they called and discovered that they had been moved to the bottom of the waiting list for no apparent reason. Participants characterized clinic staff as rushed and disinterested. One 43-year-old African-American man reported the following:

They didn't have time and they didn't take an interest. They didn't have the time. At the time I called them, they said, "Why don't you do this? And why won't you do that?" You know what I'm saying? Call back later. You know? And at the time something about being all filled up and stuff.

Interviewees felt the staff were stringing them along by making them "jump through hoops." Most reported they would have preferred a direct answer concerning treatment slot availability. As reflected in this 44-year-old Native American man's statement, the intake process discouraged treatment seekers from continuing to try to get help:

Like it's hard to consider going through all the hassle of going through these programs and stuff. Because they don't make you feel welcome.

Even interviewees who were employed and had an income to pay for a private slot, such as this 28-year-old Asian woman, were kept out of treatment programs because of the cumbersome waiting-list process:

It's like, God, you'd have to be unemployed to go there every day, you have to take hours there out of your day to accommodate them. How do they expect you to live? I mean, that's a real problem. They punish you for you to get well.

It was not uncommon for study participants with money in their hands to be turned away because no slots were available. A 49-year-old White man recounted being turned away:

I had the $87.50 to start. I went down there and they put me off for two days. I said, "Well, $87 to a dope fiend for two days, you can't do that, forget it. You can't do that. I got the money now, start me on some program today. I go through today, I'll come back tomorrow morning and dose if that's what you want. But for two days, forget it." But $87, shit. I could buy a gram-for two days, that's it. So that finished that whole idea, right there.

In order to verify the experiences of the study participants, Community Substance Abuse Services (CSAS) of San Francisco was contacted as well as the five methadone clinics that receive public funding. According to the director of CSAS, the length of waiting list varies from clinic to clinic. He estimated this waiting period to be from four to six months (Curtis 1993). When the five methadone clinics in San Francisco were contacted, they reported that it was difficult to estimate the length of time a person would be on the waiting list. This time period could range from two months to one year to an indefinite period of time. One of the treatment staff corroborated the sentiments of the study participants. When asked how long the waiting list at her particular clinic was, she responded that "HIV-positive addicts are given priority for treatment slots and healthy addicts are the last choice for a slot-you may never get on."

When respondents were prepared to make drastic changes in their lifestyles by enrolling in methadone maintenance programs and were confronted with financial and waiting-list barriers, many were emotionally devastated. In the following passage, a 31-year-old White woman remembered her emotional turmoil:

It's crazy. I don't cat. I'm stressed out. I mean I'm down to---I can't sleep. I have to---I didn't sleep at all last night.... It's terrible. I'm constantly on the verge of---I feel like sometimes I'm going to have a nervous breakdown.

Many, like this 37-year-old Latino, were angry:

It makes you mad. So I'm trying to figure, I want to go through maintenance, but they make you mad---Wait, wait, wait!

Many interviewees made suggestions about how to change the system to better suit their needs. However, due to their disenfranchised status in society, they did not know where to focus their energies in order to facilitate appropriate changes.

Participants were frustrated because they did not know if and when they would ever get into treatment. Disillusionment with drug-using lifestyles and their treatment-seeking endeavors left many feeling hopeless. According to a 35-year-old White woman, the process of seeking treatment made her quite depressed:

I feel helpless. And hopeless. Sometimes I almost feel like giving up hope. I'll tell you one thing---the other day I was so depressed that I actually felt like I didn't even want to be. And if it wasn't for a friend of mine, I probably wouldn't be. And that's the way I feel.

Frustration, anger, helplessness, and hopelessness rendered many interviewees emotionally overwhelmed and depressed. Without the option of methadone maintenance, they were essentially left on their own to cope with their addiction.

Individuals who sought treatment but failed to get on methadone used a variety of coping mechanisms to deal with continued heroin use. Strategies included back-to-back 21 -day detoxifications; decreasing their heroin use by substituting other street drugs (e.g., Valium R, Klonopins, alcohol); taking private-fee methadone maintenance slots knowing they could not afford the fees but hoping a subsidized slot would open up; and continued daily heroin use.

Some interviewees manipulated the 21-day detoxification treatment system by signing up as often as possible. They enrolled in these programs to stave off withdrawal and reduce the amount of heroin used. A 43-year-old African-American woman was on a 21 -day detoxification program and explained her motivation for this type of treatment as follows:

I'm still trying to get on maintenance right now. They have me on the waiting list. That's why I'm on the 21-day, so maybe by the time I finish this, I'll be able to be put right on.

This alternative is expensive in several ways. Fees for short-term detoxification average $220 ($20 the first day and $ 10 for each day following) for 21 days of methadone. Each time a client enters a 21 -day detoxification program, they must have a full physical along with a series of lab tests, including drug screening urinalysis. Not only is this an expensive form of treatment, but research has indicated that short-term methadone treatment is not a very effective treatment modality when compared to methadone maintenance (Vanichseni et al. 1991; Segest & Mygind 1989). A 30-year-old White male who had utilized 21-day detoxification programs many times described his problems:

Three times already I've been on detox and gotten a job within the first week of feeling okay and then had to lose out because I came down off of 40 units of methadone too fast (within 21 days) and was sick again and couldn't give an employer what you're supposed to give an employer. Cheating him and cheating me, you know? I feel cheated too. Here I was stabilized, already in the first week of feeling better, three times and couldn't handle it, just couldn't handle it. So, my drug use went up little by little.

Respondents also tried to detoxify by reducing their daily intake of heroin. Most of the time, they succeeded for a few days until they felt so sick they had to increase their use again. They also supplemented their daily heroin with other drugs, such as Valium, Klonopinl, or alcohol. A 31-year-old White woman described how she decreased her heroin use by substituting Klonopin for heroin:

Q: What about other drugs? What other drugs have you been using lately besides cocaine and heroin?

A: Klonopins. As much as I can get them because they cut my habit down.... I don't go crazy with them. I just use (hem to cut my habit. But I took one-one Klonopin, and I could not wake up the next morning. I mean they make you forget. I mean forget. I totally forget. I mean I actually got up and talked to somebody on the telephone, told them I'd call them back and don't remember even talking to them. That scares me ... I do it to cut my habit down because if I take a Klonopin, I won't use dope.

Although they knew it would be a difficult task, some clients attempted to pay for a private methadone slot on a temporary basis, hoping a publicly funded slot would become available. They described scenarios in which they took money needed for daily survival, borrowed money from relatives, and/or continued to engage in illicit activities in order to pay these fees. Study subjects were often detoxified from programs because they could not continue to pay their private fees. A 47-year-old White man recounted his past experience trying to pay private fees for methadone maintenance:

And one month, I couldn't pay so he (counselor) said, "Well, ask for an extension to the next month." So the next month, I had to pay double and it was really hard for me to pay double the next mouth. And finally, I scraped together the double. And by that time, I had another month's due and I couldn't come up with the money and they go, "Well, we can't give you two extensions in a row so we're going to fee detox you." And then they brought me down in like ten, fifteen days I was off the program and right back into heroin. It was the worst detox I ever had. I mean they just brought me right down, 5 milligrams a day from 40 milligrams. And it was like a crash course.

Finally, the principal coping mechanism used to deal with the lack of subsidized treatment was continued daily heroin use. In the following passage, a 31 -year-old White woman detailed her daily routine:

My day is, I come here (San Francisco) in the morning and I cop. I drop my old man off at work. Here's the money to cop. I go, pick him up, then we come back, we cop again and we go home. I mean, that's my day.

As noted earlier, in order to afford daily heroin most study participants engaged in illicit activities, including drug sales, burglary, robbery, and prostitution.

Anger and frustration resulting from the lack of subsidized drug treatment led many interviewees to continue if not increase their drug use. A major consequence of this continued drug use was their risk of HIV exposure through needle sharing. Another consequence is increased risk through unsafe sexual practices.

Increased Risk Through Sharing

Most interviewees were aware of the risk of sharing syringes. They attempted not to share needles as evidenced by the fact that more than half of this subsample attended an illegal syringe exchange program in order to procure sterile injection equipment. However, the need to inject heroin in order to prevent withdrawal sometimes placed individuals in situations in which they felt compelled to share injection equipment. A 44-year-old Native American man told of the frustration of failed help-seeking and how it led IDUs to put themselves at risk for HIV exposure:

That kind of frustration does increase somebody's tendency to be careless. And a lot of times you get involved in a situation where you absolutely have to share a needle. I mean, there is a certain immediacy to heroin-it's not like carrying a loaf of bread home or something. And so you're in a situation where there's no clean syringes and you have to use it. And at that point, you really do wish that you weren't using it, that you had a choice to make. So, yeah, I guess it has affected my behavior a little bit.

Methadone maintenance provided an even more protective role, as this 23-year-old White woman revealed:

A: And I thought I wouldn't share with anybody once I got a negative [HIV test], two or three negatives, but I still share.

Q: And do you think methadone would help that?

A: Yeah, 'cause then-I mean, how can you share when you don't shoot up methadone?

Interviewees were often very aware that not being in treatment led them to engage in HIV-risk behaviors. Many, like this 30-year-old White man, questioned policy changes that resulted in decreased funding for treatment slots.

I wonder sometimes, what do these people want me to do? Do they want me to hit myself with a needle that I know has HIV in it so I can get on maintenance because that seems to be the only criterion that they'll give you to get on maintenance. I mean, isn't that pretty sad, that a person had to think like that? God, do I hit myself with a needle that's got AIDS so I can finally get this madness over with and get on maintenance?

Interviewees knew methadone maintenance decreased injection drug use, needle sharing, and risk of HIV infection. They saw methadone maintenance as a tool to remain HIV negative. When asked directly if she thought being on methadone maintenance would help her stop sharing needles, a 40-year-old Asian woman discussed how methadone had decreased her injection drug use and her needle sharing in the past:

Yeah. I wasn't using-because that's the one thing that I like about being on the program was that you weren't sick and you didn't have to shoot up. And if you did, you wouldn't get high anyway. So right there, you-if I was smoking crack or doing any speed or snorting or smoking, I wasn't using any injectable needle and, therefore, I wasn't infecting myself. And for that reason, it was very good, you know? That was the one thing that I still think of as being a safety net for not getting AIDS.

Increased Risk Through Sexual Contact

IDUs, both in and out of treatment are also at risk for contracting and spreading HIV infection through sexual contacts. Enrollment in drug abuse treatment has been associated with a lower incidence of high-risk sexual behaviors (Watkins et al. 1992). Methadone maintenance in particular has the effect of routinizing the lives of addicts. Without having to support a heroin habit, they can give up criminal activities, such as prostitution. Clinics also offer tangibles (aside from a substitution drug), such as free condoms and HIV testing, in addition to a barrage of information about high-risk behaviors.

Study participants displayed a high level of knowledge regarding high-risk sexual behaviors. Some, like this 38-year-old White man, were protecting themselves by testing for HIV and using condoms:

I've had three tests and they've all been negative. So I don't want that. Hey, I could straighten up in six months and get married and I want to have some kids or something. I don't want to be a---" can't make love to you honey 'cause I'm infected and I don't want my baby to be born with AIDS." I don't want that.

However, it was more common for interviewees to be aware of the behaviors that put them at risk for HIV exposure, yet still engage in high-risk sexual behaviors. One 51 -year-old Latino explained this:

They told me, well, you know, its dangerous to have sex even though-'cause you're in a bad risk area. So you should use a condom 'cause you don't know what the other person's done in the last five years or whatever. I believe it. I should. I should but I don't. 'Cause, of course, I don't have sex that much. Maybe that's one of the reasons.

Others changed their behaviors, but not until they learned that someone close to them had contracted HIV. A 43-year-old African-American man, when asked if he used condoms, said:

A: Oh, yeah. Yeah. Definitely.

Q: That's really good. A lot of people aren't taking this seriously.

A: Yeah, it's serious, baby. I know that 'cause I lost a few friends behind that because they weren't cautious and they weren't taking heed. So, hey...

Q: How many friends have you lost at this point?

A: About three. And that's enough.

When asked if their sexual behaviors had changed since they learned about HIV, many answered affirmatively and described behavioral changes, including condom use, testing for HIV prior to getting sexually involved with a new partner, and only being involved in monogamous relationships. But there was a lot of confusion. Many study participants who were in "monogamous" relationships felt they were automatically having safe sex. They also told us that since they were sharing needles with their partner, there was no need to have safe sex. The risk was already there. One 23-year-old White woman said:

I used to share with my ex-boyfriend, but I mean we never used condoms or anything anyway so it didn't really matter.

Most of the women in this sample who were working as prostitutes in order to support their drug habits told interviewers they always used condoms when they were with customers. Even when offered extra money not to use condoms, these women told us they refused the date. Some women, though not formally prostitutes, found themselves exchanging sex for favors. A 38-year-old White woman described what she had to do to survive when her husband was incarcerated:

He's been off to prison several times, which left me without a pot to piss in or a window to throw it out of. And I'd end up so fucked up out there on the street and with my parents---and then they're gone and I end up shacking up with this one or that one. And it just-you know, just to get your drugs 'cause drugs was still a part of my life.

This woman, who also had a difficult time surviving on the street, described similar situations in which she was unable to protect herself from possible exposure to HIV:

A: When I was single, last year for a while, I was fighting that. Every single guy that I ended up having to sleep with for whatever reason---they would never use them. And I would give them a couple.

Q Like turning a trick you mean?

A. No, it would be more like having a place to stay, because I didn't have a place to stay and-they'd go--"Oh, we've got a hotel room, you know, and you can stay there. But you know we have to have sex," or something like that. They don't want to use condoms. They just won't. I mean, I'd say ten guys out of 20 won't use condoms. It's ridiculous.

A 30-year-old White male interviewee was in a monogamous relationship; however, he still felt at risk because his regular partner was a prostitute and they did not use condoms when having sex:

I've always been monogamous so promiscuity really wasn't a problem. I don't use condoms but---I'm monogamous so it really isn't a problem. I mean the only way my spouse could get it is if she was working turning a date and got it through an exposure through a broken condom. And then if she got it, then I could definitely get it. We'd both be fucked is what it would be.

Without the stability of methadone maintenance, the chaos surrounding a heroin-using lifestyle negatively impacts the ability of IDUs to avoid high-risk sexual behaviors.

When IDUs seeking treatment are denied access, there are serious implications. They do not simply suspend their drug habits until they can get on a program. Instead, they cope by continuing to use drugs. This continued use often leads to sharing injection equipment, putting themselves and others at risk for HIV infection. Methadone, which is taken orally, can put an end to needle use altogether or at least substantially reduce needle sharing.

In order to purchase illegal drugs, addicts most often resort to criminal activity. One of methadone's most obvious benefits, according to users, is that when it is inexpensive or free, involvement in criminal activity is no longer necessary.

Finally, methadone maintenance reduces the chaos inherent in the heroin lifestyle. It imposes a routine on clients, forcing them to come to the clinic at a designated time each day. Maintenance treatment can be seen as a package providing structure, alleviating the need to use and share syringes and engage in high-risk sexual behavior as well as the criminal activities needed to pay for illegal drugs.

But it is not enough to offer methadone maintenance as a fee-for-service modality. In this population of individuals on waiting lists for methadone programs, the vast majority lived well below the poverty line, and simply could not afford to pay clinic fees. While some might argue these same individuals were able to produce an average of $80 per day to support a drug habit, they miss the point. A major impetus for getting on a methadone program is to enable the addict not only to stop using drugs, but to stop participating in criminal activities. In fact, often the major reason for wanting to get on a program is to stop "hustling." Therefore, after getting on methadone, most plan to quit illegal moneymaking schemes.

Drug treatment on demand is more than politically correct rhetoric. It is a necessary ingredient in reducing the harm caused by the use of illegal drugs. When drug treatment is not offered on demand and stipulations such as high cost are attached, the consequences are dire. Adopting drug policies that include the expansion of drug treatment services and adapting innovative and successful treatment models found outside of the United States are necessary to curb the AIDS epidemic. Treatment on demand must be available to all drug users in search of a way out of drug-using lifestyles.

1. Once a client graduates to a higher threshold program, they have access to services, such as counseling and job training. They are also able to earn take-home doses based on their progress in treatment (Rengelink 1993).

2. Findings reported in this article are based on qualitative data collected at the time of the study subjects' initial interview. These interviews were phenomenological, loosely structured, and designed to elicit study participants' views rather than to quantify responses to specific questions. Hence, when such findings are reported, an estimate of responses is being offered, with data presented in the form of quotations rather than hard percentages.

* Research Analyst, Institute for Scientific Analysis, San Francisco, California.

** Director, Center for Drug Studies, Institute for Scientific Analysis, San Francisco, California.

<>This paper was presented at the American Public Health Association 121st Annual Meeting and Exhibition, October 24-28, 1993, San Francisco. Research was supported by a grant from the National Institute on Drug Abuse (Grant # 1RO1 DA05377); Marsha Rosenbaum, Principal Investigator; Brandy Britton, Project Director; Bennett Fletcher, NIDA Project Officer.

Abdul-Quader, A.S.; Friedman, S.R.; Des Jarlais, D.; Marmor, M.M.; Maslansky, R. & Bartelme, S. 1987. Methadone maintenance and behavior by intravenous drug users that can transmit AIDS. Contemporary Drug Problems 14 (3): 425-34.

American Medical Association Council on Scientific Affairs. 1989. Reducing transmission of human immunodeficiency virus (HIV) among and through intravenous drug users. AIDS and Public Policy Journal 4 (3):142-51.

Anglin, M.D.; Speckart, G.R.; Booth, M.W. & Ryan, T.M. 1989. Consequence and costs of shutting off methadone. Addictive Behaviors 14:307-26.

Ball, J.C.; Lange, W.R.; Myers, C.P. & Friedman, S.R. 1988. Reducing the risk of AIDS through methadone maintenance treatment. Journal of Health and Social Behavior 29 (3): 214-26.

Biernacki, P. & Waldorf, D. 1981. Snowball sampling: Problems, techniques and chain-referral sampling. Sociological Methods and Research 10 (2): 141-63.

Brickner, P.W.; Torres, R.A.; Barnes, M.; Newman, R.G.; Des Jarlais, D.C.; Whalen, D.P. & Rogers, D.E. 1989. Recommendations for control and prevention of human immunodeficiency virus (HIV) infection in intravenous drug users. Annals of Internal Medicine 110 (10): 833-37.

Britton, B. & Rosenbaum, M. In Press. The privatization of methadone maintenance: Changes in risk behavior associated with cost-related detoxification. Addiction Research.

Buning, E.C.; Van Brussel, G.H.A. A Van Stantan, G.V. 1990. 'Me "Methadone by Bus" Project in Amsterdam. British Journal of Addiction 85 (10): 1247-50.

Casadonte, P.P.; Des Jarlais, D.C.; Friedman, S.F. & Rotrosen, J.P. 1990. Psychological and behavioral impact among intravenous drug users of learning HIV test results. International Journal of the Addictions 25 (4): 409-26.

Centers for Disease Control. 1991a. AIDS/HIV Surveillance. National Commission on AIDS Report, July.

Centers for Disease Control. 1991 b. The HIV/AIDS epidemic: Ile first 10 years. Morbidity and Mortality Weekly Report 40 (22): 357ff. June 7.

Chaisson, R.E.; Bacchetti, P.; Osmond, D.; Brodie, B.; Sande, M.A. & Moss, A.R. 1989. Cocaine use and HIV infection in intravenous drug users in San Francisco. Journal of the American Medical Association 261 (4): 561-65.

Clark, G. 1993. Personal communication, Project Director, Prevention Point Needle Exchange Program, San Francisco, March.

Curtis, J. 1993. Personal communication, Associate Director Community Substance Abuse Services, San Francisco, March.

Des Jarlais, D.C. & Friedman, S. 1988. The psychology of preventing AIDS among intravenous drug users: A social learning conceptualization. American Psychology 43 (11): 865-70.

Des Jarlais, D.C. & Friedman, S. 1987. HIV infection among intravenous drug users: Epidemiology and risk reduction. AIDS 1 (2): 67-76.

Magura, S.; Siddiqi, Q.; Shapiro, J.; Grossman, J. & Lipton 199 1. Out comes of an AIDS prevention program for methadone patients, International Journal of the Addictions 26 (6): 629-55.

McAuliffe, WE. 1990. Health care policy issues in the drug abuser treatment field. Journal of Health Politics, Policy, and Law 15 (2); 357-85.

McAuliffe, W.E.; Breer, P.; Ahmadifar, N.W. & Spino, C. 1991. Assessment of drug abuser treatment needs in Rhode Island. American Journal of Public Health 81 (3): 365-7 1.

National Commission on AIDS. 1991. The Twin Epidemics of Substance Use and HIV. (July). Washington, D.C.: National Commission on AIDS.

Presidential Commission on the Human Immunodeficiency Virus Epidemic. 1988. Report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic. Washington, D.C.: U.S. GPO.

Record, N. 1991. Increasing the capability of methadone maintenance programs. Network 2 (3): 10-12.

Rengelink, H. 1993. Methadone treatment and public health. Paper presented at the American Public Health Association 121st Annual Meeting and Exhibition, San Francisco, October 24-28.

Rosenbaum, M. & Murphy, S. 1984. Always a junkie?: 'Me arduous task of getting off methadone. Journal of Drug Issues 16 (4): 527-52.

Rosenbaum, M.; Murphy, S. & Beck, J. 1987. Money for methadone: Preliminary findings of a study of Alameda County's new maintenance policy. Journal of Psychoactive Drugs 19 (1): 13-19.

Schoenbaum, E.E.; Hartel, D.; Selwyn, P.A.; Klien, R.S.; Davenny, K.; Rogers, M.; Feiner, C. & Friedland, G. 1989. Risk factors for human immunodeficiency virus infection in intravenous drug users. New England Journal of Medicine 321 (13): 874-79.

Segest, E. & Mygind, 0. 1989. The allocation of drug addicts to different types of treatment. An evaluation and a two-year follow-up. American Journal of Drug and Alcohol Abuse 15 (1): 41-53.

Vanichseni, S.; Wongsuwan, B.; The Staff of Narcotics Clinic No. 6; Choopanya, K. & Wonpanich, K. 199 1. A controlled trial of methadone maintenance in a population of intravenous drug users in Bangkok: Implications for prevention of HIV. International Journal of the Addictions 26 (12): 1313-20.

Ward, J.; Darke, S., Hall, W. & Mattick, R. 1992. Methadone maintenance and the human immunodeficiency virus: Current issues in treatment and research. British Journal of Addiction 87:447-53.

Ward, J.; Mattick, R. & Hal I, W. 1992. Key Issues in Methadone Maintenance Treatment. National Drug and Alcohol Research Centre, Kensington, Australia: University of New South Wales Press.

Watkins, K.E.; Metzger, D.; Woody, G. & McLellan, A.T. 1992. Highrisk sexual behaviors of intravenous drug users in and out-of-treatment: Implications for the spread of HIV infection. American Journal of Drug and Alcohol Abuse 18 (4): 389-98.

Weber, R.; Ledergerber, B.; Opravil, M.; Siegenthaler, W. & Ruedi, L. 1990. Progression of HIV Infection in misusers of injected drugs who stop injecting or follow a programme of maintenance treatment with methadone. British Medical Journal 301 (6765): 1362-65.

Yancovitz, S.R.; Des Jarlais, D.C.; Peyser, N.P.; Drew, E.; Friedmann, P.;Trigg, H.L. & Robinson, W. 1991. A randomized trial of interim methadone maintenance clinics. American Journal of Public Health 81 (9): 1185-90.