Defunding the Poor: The Impact of Lost Access to Subsidized Methadone Maintenance Treatment on Women Injection Drug Users

Abstract

Qualitative data from women defunded from a subsidized methadone maintenance treatment (MMT) program were analyzed to determine the impact of defunding on the women and their dependents. Women attested to the efficacy of MMT in creating a stable environment in which their illicit drug use was eliminated or controlled; they were able to decrease their participation in illicit activities and pursue further employment and educational goals. "en defunding occurred women employed a variety of strategies including family borrowing, welfare funds, and illicit activities to remain on private MMT programs. The result of these payment strategies was often a premature detoxification from MMT due to unpaid clinic bills. Many women returned to heroin use to alleviate withdrawal symptoms from methadone detoxification. This return to heroin use was also accompanied by increased illicit activities. Defunded women reported severe emotional and financial destabilization as a result of lost access to subsidized methadone maintenance treatment.

"If a doctor is not allowed to raise his price in the middle of surgery, why should the clinic be allowed to raise your fee in the middle of your recovery?" (25-year-old Latina study participant, 228)

The chaotic lifestyle of heroin dependency has been associated with participation in illicit activities (Ball et al. 1983, Collins et al. 1984, 1985, Flaherty et al. 1984; Hammersley et al. 1990; Inciardi 1979, 1981 ; Johnson et al. 1985; Kozel et al 1972; Nurco et al. 1981), often resulting in eventual arrest and incarceration, the inability to maintain or pursue conventional employment (Bates 1968; Flaherty et al. 1984; Nurco et al. 1981); the inability to parent and fulfill family responsibilities (Rosenbaum 1981), and sharing injection equipment which places injection drug users (IDUs) at risk for contracting HIV (Chaisson et al. 1987,1989 McCoy and Khoury 1990, Newmayer 1988, Nwanyanwu et al. 1993, Steel and Haverkos 1992- Turner et al. 1989). While caught "in the life" many heroin-dependent persons find themselves at on-going risk for financial instability, incarceration, and HIV infection.

Women IDUs have been found to be at disparate risk for the harms associated with heroin dependency (Wayment et al. 1993). Heroin-dependent women, like many poor non-heroin using women in the United States, have less access to vocational and educational training opportunities and conventional employment (Ettorre 1992). Women take on the majority of the responsibility for the daily care, feeding, and emotional-developmental support of their dependents, which further restricts conventional employment participation, and contributes to a double work day if employed. Lengthy involvement with the criminal justice system, which can lead to jail or prison records, creates an additional barrier to conventional employment for IDUs. As an often marginalized group within the overall IDU world, heroin-dependent women can face an up-hill battle when attempting to secure basic necessities, such as food and shelter.

Methadone maintenance treatment (MMT) is well documented as a drug treatment modality affording harm reduction to heroin-dependent persons and their families (Abdul-Quader et al. 1987; Anglin et al. 1989- Ball et al. 1988; Ball and Ross 1991, Hubbard et al. 1989, Senay 1985, Rosenbaum et al. 1987, 1988), For women who face financial instability as a result of their heroin dependency (and often other factors as well), affordable and accessible MMT can provide a means to control or eliminate heroin use, thereby stabilizing other aspects of their lives. While in treatment, the pursuit of further training and conventional employment replaces the daily hustle for drugs. The women's ability to stop engaging in illicit activities lowers their risk for arrest, incarceration, and loss of child custody. Women are often able to re-focus on personal and familial responsibilities once an appropriate dosage of methadone is administered at MMT clinics (Rosenbaum 1982, Rosenbaum and Murphy 1988). On MMT, clients also have access to ancillary services, such as counseling, housing and employment referrals, and HIV/AIDS education and testing at many MNIT clinics.

Despite rhetoric to the contrary, because of shrinking state, federal, and local budgets, treatment on demand has become less a reality than ever. Over the past decade, federal funds for MMT have decreased by more than one third (Gerstein and Harwood 1990). As the number of low-cost public slots available nationwide has decreased, the cost to clients seeking private methadone slots has increased. Some clinics are entirely private, supported exclusively by client fees. The trend over the past 10 years has been that private clinics have replaced publicly owned and operated methadone programs and the cost of treatment paid out-of-pocket by IDUs has risen dramatically (Wenger and Rosenbaum 1994; Gerstein and Harwood 1990). Some clinics have remained mixed, with subsidized slots and private slots. The reason for this shift is simple; having little to do with therapeutic benefits and much to do with (lack of) money. There is no evidence that requiring clients with little income to pay for their methadone treatment is beneficial or that exclusively private clinics are necessarily superior. Although clinics with more resources may have amenities, they are still subject to extensive state and federal regulations.

In 1984, officials in Alameda County, California, concerned about a shortage of methadone slots and long waiting lists, instituted a new methadone service provision policy. After 2 years in a county-funded slot, clients would be given the choice of switching to a private slot and paying full fees for their methadone (then $200 a month) or detoxifying from their programs. Previous research studied half (n=1 50) the clients affected by the new policy and found that over 80% of those opting to leave MMT had resumed intravenous (IV) use of heroin and that over half of those remaining in treatment resorted to criminal activities in order to pay clinic fees (Rosenbaum et al. 1987). We were alarmed by these findings because IDUs had become the second largest and fastest growing population to be infected with HIV; we believed increased rather than decreased access to maintenance would reduce the spread of HIV. We tried but failed to convince Alameda County officials that their policy was counterproductive. By the time we began the study containing the findings reported on in this paper, some 5 years later, Alameda County was in the process of eliminating county-funded methadone maintenance slots completely.

The shift in numbers from publicly to privately funded slots has resulted in two related problems for those who are attempting to access MMT. First, heroindependent persons, who often have limited financial resources, experience difficulty entering and maintaining enrollment in affordable MMT programs. Second, many of those clients who manage to obtain treatment but cannot absorb increases in fees must detoxify prematurely from methadone (Anglin et al. 1989, Ben-Yehuda 1982; Farley et al. 1992; Johnson et al. 1991; Rosenbaum and Murphy 1988; Rosenbaum et al. 1987, 1988). Numerous studies have found that ending treatment prematurely increases the likelihood that clients will return to drug use and illicit activities (Anglin and McGlothlin 1985; Murphy and Rosenbaum 1987; Rosenbaum et al. 1987, 1988). Research on methadone treatment has indicated that treatment outcomes, including drug use, criminality, and morbidity, are directly related to length of stay in treatment (Ball et al. 1988-1 Condelli and Dunteman 1993 ; DeLeon et al. 1979; Simpson 1979; Simpson et al. 1979; Stimmel et al. 1978).

Study Methodology

In this paper we analyze a subset of data (n=27) from a longitudinal study of 233 IDUs in and out of MMT programs in the San Francisco Bay Area. Out-of-treatment study participants were recruited from needle exchange sites in San Francisco and MMT clinic waiting lists', in-treatment study participants were recruited from five MMT clinics in three San Francisco Bay Area counties (San Francisco, Alameda, and Marin) We used an open-ended, life history format to conduct initial interviews addressing the following areas: family, educational, and drug use history; illicit activities and involvement with the criminal justice system, drug treatment; motivations for seeking MMT; ; barriers to MMT program participation, current experiences on MMT ; injection and sexual practices (past and current). HIV/AIDS knowledge- employment and financial support- and experiences with voluntary and involuntary methadone detoxification. Interviews ranged from I to 3 hours and included a close-ended quantitative component. We conducted a total of four follow-up waves, using shorter versions of the initial qualitative and quantitative instruments. The grounded theory method (Glaser and Strauss 1967, Glaser 1978, Strauss 1987, Strauss and Corbin 1994) was used to analyze the qualitative data.

Presentation of the Study Data

At the beginning of the study (1990), one county in which our research took place was in the process of defunding MMT clients who occupied subsidized MMT slots. These subsidized programs were funded through the county, Medi-Cal (California's version of Medicaid), or a combination of those funding sources. When defunding occurred, study participants were given the option of detoxifying from their MMT programs or paying privately for MMT clinic fees that ranged from $200 to 375 per month. Subsidized MMT clinic fees ranged from $0 to 100 prior to defunding. For this paper we analyzed data from 27 women who had been defunded. That is, they had lost their subsidized slots and had to leave the program or be paying for a private slot. Issues specifically addressed include: women's experiences on MMT prior to defunding, payment strategies that women used in response to premature methadone detoxification, the financial and emotional consequences of those payment strategies on women and their families, and the risks women faced in returning to heroin use and illicit activities after being defunded. Demographic information for the study population (n=27) is listed in table 1.

Positive Aspects of MMT for Women

Data from the lar er study population demonstrated that individuals able to remain in MMT derived several tangible benefits, as had the 27 women who experienced defunding from subsidized slots. Those benefits included: decreased drug use or abstinence, decreased illicit activity, ability to maintain or initiate conventional employment; and increased ability to respond to parenting and family obligations. Prior to MMT many defunded women's employment histories had been short and unstable due to heroin dependency, as one 36-year- old White woman explained:

[M]y first job at [department store chain] lasted like about 6 months and then I ended up as a waitress at [restaurant] and I stayed there for like 3 and a 1/2 years And, you know, I mean, I've had other jobs, I worked at [grocery store chain] and stuff and whatnot, but until I got on methadone and stuff it just-it was like, you know, the more money you made, the more you spent [on heroin] and the farther you got into it, the worse your performance was. [2531

Defunded women recounted that MMT had allowed them to distance themselves from the drug culture, thereby shifting their focus ftorn heroin acquisition to family responsibilities and economic stability. One 48-year-old White woman summarized these sentiments:

Well I think methadone programs definitely give people a chance to slowdown and get themselves together a little bit. You're not out there scuffling every day and-just-because pretty soon, I don't know if its the dope, the stuff, or what it is, but you're just moving so fast. And methadone gives you a chance to slow down, sort things out, get your lads back, get a place to live, get a job. It gives you a chance to live like a regular person. [203]

Once on MMT, several women had been able to attain conventional employment or pursue further education and training. One 37-year-old African- American woman explained the econorrical benefits of MMT program stabilization:

Well maintenance has been-has helped me continue to work. It's-with maintenance I've been able to pursue-go back to school and pursue a certification in court reporting to where if I had not been on maintenance, I know there's no way I would have been able to do that. There's no way. So I'm able to hold a full-time Job and I'm able to go to school full time. I work graveyard and then I go to school from I to 6, so it's worked out beautifully for me. [225]

The majority of women who lost their subsidized slots did not feel ready to detoxify from methadone. Although a small percentage (7%) did detoxify and remain opiate-free for the remainder of the study period, most women went through a process of severe destabilization as a result of defunding. In an attempt to counteract a return to the heroin use and illicit activities that had characterized their lives prior to MMT, defunded women responded in a variety of ways. Some women knew initially that paying private fees for MMT was a financial impossibility and detoxified from their MMT programs immediately. Others attempted to pay private fees through their conventional full- or part-time employment, or by borrowing money from parents, partners, lovers, and friends Still others were forced to use their Aid to Families With Dependent Children (AFDC) and other welfare funds to subsidize their treatment. Thirteen of the 19 (68.4%) women who paid privately for MMT at any point after defunding also resorted to illicit activities, over and above their work, welfare, and family resources, to finance their drug treatment.

Although women's options varied according to the resources they had available to them, most who tried to pay privately could not maintain that level of financial commitment. Many of the defunded women went through multiple processes throughout the course of the study: paying initially for treatment through family borrowing, then through AFDC funds, then through illicit activities; or, paying clinic fees through a combination of resources simultaneously. The result of the various coping strategies was often a fee detoxification (a detoxification process initiated in response to unpaid clinic bills) from MMT programs. Upon fee detoxification most (62.5%) of the defunded women returned to medium (90 to120 days of use per 6 month period) to high (160 to 180 days of use per 6 month period) heroin use and illicit activities to support that use.

Immediate Detoxification

Financial instability had initially qualified defunded women for subsidized treatment. Many continued to have financial difficulties on MMT and were, therefore, unable to consider paying privately for MMT clinic fees once defunding occurred. Their only choice was to detoxify from their MMT programs. One 28 year old White woman described the impossibility of paying private fees and her concern about the methadone detoxification process:

I couldn't ever, ever swing the $250 a month here [at the MMT clinic]. I was thinking about the one in San Jose because it's like way cheaper but the commute would just kill me ... I'll just, hopefully-it's gonna be a little trial trying to kick it [methadone]. Hopefully I'll Just live a normal life, you know? It's gonna take a little while for my bones to adjust because the methadone plays a--does something with the bones. [244]

All of the women who attempted to detoxify from MMT programs, rather than paying private fees, had the goal of remaining opiate-free. However, this goal proved impossible for the majority. One 35-year-old White woman described the difficulty of remaining heroin-free while experiencing a methadone detoxification:

It makes me angry and it makes me mad at myself. It makes me-I don't know. It just-I feel like I got cheated a little bit by getting cut off so fast at 8 mgs [milligrams] a week. God damn! Come on. That's a little bit too much. Shit! It was too fast. I tried to stay clean. I did stay clean while I was detoxing off for a little bit. I went to see the doctor. I tried to get some medication. I got enough to last me a few days 'cause I managed to give one clean urine [at the MMT clinic]. And then I just-I don't know. I couldn't sleep. Shit, nothing was-hell I was taking hot baths. I was trying. And I said "Fuck it." And then I-to get some relief I started using to kick the methadone. I felt better. And then I just got strung out, had to go out there and hustle every day to get the money. [261 ]

Of those women who immediately fee-detoxified from their MMT programs because they were unable to pay private fees (n=1 1), two were eventually able to remain opiate-free; another two returned to very controlled (5 days of use per 6-month period) heroin use; and the remaining seven women slowly returned to medium to high level heroin use.

By the fifth wave of the study, three of the nine women who returned to heroin use had re-sought MMT, paying private fees. One 35-year-old White woman expressed her frustration at having to spend half of her welfare funds to pay private MMT clinic fees:

About I month ago I got on [maintenance] ... I couldn't find a Medi-Cal slot anywhere in the Bay Area. The ones that did take Medi-Cal had long waiting lists. So I said screw it and paid (private fees) ... I don't know when the slots are going to be opened up ... I'm on a waiting list up there and I'm like number 100 ... I check it once in a while. It's so expensive. It's ridiculous to spend half of my SSI [welfare] check for the clinic bill [261 ].

Of the six women who did not re-seek treatment after fee-detoxification, all remained daily heroin users and resumed participation in illicit activities in order to finance their renewed drug habits. The relationship between the return to heroin use and the return to illicit activities after defunding from treatment was described succinctly by one 48-year-old Aftican- American woman- ,rm using [heroin and crack] more because now I'm dealing [drugs] " [208]

Paying Privately

Some of the defunded women initially chose to pay privately for MMT, rather than immediately detoxifying from treatment. Sources of money for clinic fees vaned from part or full-time employment, borrowing from family and friends, illicit activities, or a combination of those strategies. In spite of the financial difficulty presented by paying private fees, these women felt it was a better alternative than risking a relapse of heroin use. One 40-year-old White woman described her options'.

And I don't want to pay $345--that's like paying rent somewhere! It's ridiculous, it's too much money ... At first I was going to start detoxing and then I said, you know, I'm not going to do that. Like I said, if worse comes to worse I Might have to pay for a half a month here. But anything's better than being thrown back to the wolves, than to be off methadone and back on heroin. [240]

Paying privately for MMT clinic fees with limited financial resources also contributed to strained family relationships. Defunded women described feelings of emotional stress and guilt about using family resources for their drug treatment costs. One 32-year-old Latina explained

It's hard coming up with the money. I used to have to do illegal stuff to pay for the clinic. I was stealing and robbing to pay my fees. Now I have a job but I still struggle to come up with the money. It takes away from my family and I feel guilty taking money from my family every month. It's a necessary part of the household bills. But, it's really steep. The government should help. People who are on the clinic are doing illegal things to stay on. I think it would be helpful and bring the crime down. There would be less people using and less criminal activity. More clinics are desperately needed for people like me. Now I struggle, but I have to do it. My family suffers-I go to thrift stores to buy clothes for my baby. I go to canned goods stores to make ends meet ... I get stressed every month when the [clinic] bill comes up. I'm more uptight. I have less patience and my husband and I have terrible arguments about the clinic. [2591

Several of the women who had maintained conventional employment lost their jobs as a result of the defunding policy, because premature detoxification from methadone led to immobilizing withdrawal symptoms. Some women found they could not maintain employment under these physical conditions. Further, these women could not discuss their difficult methadone detoxification processes with their employers due to the perception of employment discrimination that exists against MMT clients (Murphy and Irwin 1992). With defunding these women risked termination if they revealed their MMT status (consequently revealing their former heroin dependency) or if they were absent from work too often (due to methadone Withdrawal). The conventional benefits of MMT participation were essentially reversed for those women who lost their employment as a result of defunding.

Many women who used parental and family resources to pay their clinic fees also found that this strategy was difficult to maintain overtime. They often had to supplement their income with illicit activities. One 48-year-old White woman described her fight budget and how "scoring" drugs for others (procuring drugs for others and taking a portion of money for procurement) would be necessary to meet all of her financial demands:

Aid to Families With Dependent Children (AFDC)

Slightly more than a quarter (29.6%) of defunded women used AFDC monies, money meant for their family's basic survival needs, to pay for MMT after being defunded from subsidized programs. For most of these women, paying for clinic fees with AFDC money was a temporary emergency measure taken to prevent total destabilization. The majority were eventually granted subsidized slots (by the fifth wave of the study) opened for pregnant and parenting women as a special exception to the cuts in subsidized methadone maintenance treatment. These perinatal subsidized slots, however, did not become available until approximately 6 months to 2 years after the defunding policy initially went into effect.

When mothers used AFDC monies to pay for MMT their families suffered direct harm in the form of inadequate food, clothing, and shelter. A 29-year-old White woman explained her situation,

But it was like $230 and I'd have to give half my [AFDC] check [to the clinic] ... And my son's getting bigger now. My son's 9 now. He was like 7 or 8. You know, his clothes cost a lot of money. There was Just a lot more things. And it was hard. [247]

Faced with this economic strain, defunded women had the choice of detoxifying from methadone, thereby risking a return to heroin addiction, or paying clinic fees and attempting survival without basic necessities. Some women chose to put off clinic payment so their families would not feel the financial strain from the loss of subsidized treatment, particularly around holidays and children's birthdays. Many clinics have a policy of lowering clients' methadone dose as punishment for non-payment of fees. Such a policy added the burden of methadone withdrawal to the financial instability defunded women experienced. The woman quoted above described this situation:

[A]nd Christmas Is coming I'm supposed to pay [the clinic fees]--okay, the first I couldn't do it. My son's birthday is November 17th. I had the baby October 20th. So I have two kids. You know, I had to buy things for the baby. Whatever-my son's birthday, this and that. Okay, so I didn't pay on the first. I was going to pay everything on the 15th. The 15th came I got to buy Christmas-the other day-I got to buy Christmas presents. I haven't paid it [clinic bill] now. I'm going to be practically--I'm going to be like on what, 27 [mgs, a low dose]-oh, I don't even know what [dose level] I'm going to be on by the time I pay. I won't be able to pay until... January. And then I'll have to pay my whole check, my whole first [AFDC] check's going to have to go to them and then my whole second check will have to go to them to catch up. [247]

For most women relying on meager AFDC funds of about $400 to 600 per month to pay expensive MMT clinic bills of $200 to 375 per month was financially unfeasible. Additional funds were procured through continued borrowing from other sources, if those sources of support existed. One 38-year-old White woman's resources were completely exhausted as a result of defunding:

Hustling Not to Use

Many women resumed illicit activities (hustling) in order to pay clinic fees. These women found themselves hustling to stay on methadone and avoid heroin use. Ironically, a desire to leave a life of illicit activity had initially led many women to MMT. The futility of these women's positions was summarized by one 29-year-old White woman:

I thought the idea [of MMT] was to help people stop their criminal activities and start feeling good about themselves but I know a lot of people who are committing crimes to stay on the program. [247]

Those who returned to illicit activities to pay clinic bills (n=13) faced the constant threat of arrest and incarceration. Ten of the 13 women reported one or more arrests, 6 were jailed or imprisoned for a time during the study. For the defunded women, 59% of whom were taking care of dependents, potential arrest and incarceration also placed their families at risk, and could result in the loss of child custody. One 28-year-old White women described her fear that stealing food for her baby would lead to the loss of custody. She said

I still do steal but I steal stuff that I need. Like medicine for the baby or food, I don't take nothing that I don't need. Diapers, 'cause like last week as a matter of fact we-I ran out of diapers and I had no money so I had to go into the store and-you know ... I said, "Man, if these people-I don't care if I go to jail. My baby's hungry, that's just the price that has to be paid.' So that's my justification for it. If I do something like that for the food, if the people can't understand, you know... Like I said, if I'm in there and if I get busted for taking diapers or something, the only thing that scares me is having the baby with me, you know what I mean? 'Cause they'll take him. [244]

A common form of illicit money making for the women in our total study population was sex work, with one-fourth (25.9%) having been paid for sex. Of those who were defunded and engaged in Illicit activities (n=17) (either to pay for clinic fees or renewed drug heroin habits), eight reported engaging in commercial sex. Many of the women who were paid for sex, even if they hadn't intended it, also returned to heroin and other drug use in order to perform commercial sex. One 35-year-old White woman explained that while sex work was unnecessary while on MMT, once defunded her financial situation required a return to sex work. Drug use can accompany participation in sex work, as she explained:

But I was on the methadone. I didn't need to [have sex for money]. And now since I got off the County, since they detoxed me like 8 mgs a week off the County slot 6 months sooner than I'm supposed to get off, now I've been out there hustling ... And I know if I have to go out and hustle it, I'm not going to be able to stay clean. It's an automatic trigger for me-when I go out and hook, I have to get high. I have to do something. [261]

The relationship between the stability of MMT program participation and overall financial and emotional stability was very complex for defunded women. MMT had allowed many of them to move away from daily hustling for heroin and toward living conventional lives. Although certain aspects of women's economic and familial lives may have seemed stabilized prior to defunding, MMT was an essential component of that stability. Consequently, destabilization as a result of defunding occurred on many levels. One study participant, a 43-year-old White woman, provided an example. She initially tried to borrow money to stay on the program; the loss of her slot meant she would be too sick to continue her job training Participation in that job training secured her AFDC funding eligibility. For her, defunding meant not only a return to heroin use to combat methadone withdrawal, but a complete disruption in her future plans for economic stability and her current financial support. She described her process:

I borrowed money to get on [MMT] and I just now, the money that I borrowed to get on I was supposed to pay back on the first, night? And I can't pay it back and it's due again. Now-and I just came up with half the money, $125 and it's Just so hard to try and explain it. I'm going to this program tomorrow and because I couldn't go I was too sick to go to their work program and they cut my [AFDC] check in half Now I don't know what I'm gonna do because what's gonna happen is I'm gonna get kicked off the clinic and be sick [from methadone withdrawal] again and I can't go to school or work. That's what I can't get through to these people, they don't even give me a chance to get started. I can't use my Medi-Cal and then I want to do the right things but I can't financially pay to get on methadone to be able to go do-to live a normal life. [257]

Women who lost their funded MMT slots experienced feelings of demoralization. Many had been able to gain control over their drug use and stop illicit activities when they accessed subsidized MMT slots. When defunding occurred, financial destabilization often followed. This destabilization was antithetical to the treatment success these women had experienced on MMT, as one 25-year-old Latina explained:

I love the clinic. It's helped me a lot and it's got me away from money problems-it straightened out my money problem. But now it's all coming apart because of this budget thing. It's really-I mean $250 on top of my $535 rent, my food, my PG and E, my mother, I give her about $300 a month. I can't-my mother needs this money ... I was paying $40 a month for this clinic. They want $250 from me ... I've been seriously thinking about going to-I think that-I would seriously think about maybe instead of something I could go to, some kind of senator or somebody, and show them how clean my record is and telling them why are they making me pay $250. 1 feel very-maybe this is a ego trip or something, but I feel like I'm doing good. I feel like I shouldn't deserve this. I do not deserve this. I've been so broke, I have not committed a crime in 3 years. And the day I was broke, and I went and stole because I was broke, behind paying my [clinic] bills and trying to save up money. [228]

The demoralization felt by these women extended beyond themselves to their families who were suffering financially and emotionally as a result of defunding. One 35-year-old Latina explained the consequences of her return to sex work on the lives of her children

Their education was lacking and the love wasn't there. The motherly things that I was supposed to do wasn't happening. I was controlled by drugs. They didn't like it when the men was coming over. So I would get someone else to take them out of the house when I would bring home a trick. [242]

Women who lost their funding and had to get off methadone also lost MMT clinics' ancillary services, such as counseling about drug addiction, recovery, harm reduction, and family issues- AIDS education, HIV testing, and risk assessment (in most cases), health care advice and physical examinations, and referrals to welfare and housing services. The woman quoted above explained the benefits of MMT for herself and her family and the emotional consequences of the loss of those benefits.

Like my mom always thought, "You just come in here for the methadone," No, that's not true. Yeah, the methadone is a big point but any problem that goes wrong in your home or-you got your counselor and even the others, they're all willing to help you on things that-and like I was homeless, they tell you where to go-information you need. You know? There's always something different, you know, that you can get help from hoe that you just don't realize. That I could never get mad at this clinic because they've done so much for me and my children that it's just-they've been too good... I was off the clinic and I felt like my whole world caved in on me. ~ Being on the clinic the staff became a family-you could talk to them... When I got off I couldn't talk to anyone. I felt all alone. I just wanted to sleep. I wouldn't OD. I'd wake up and do it all over again. [242]

The majority of women whose treatment slots were defunded had reaped the benefits of MMT program participation, thereby focusing energy on positive and productive goals for themselves and their families. Some had secured conventional employment while on MMT; others were enrolled in vocational training or furthering their education in order to secure employment. When defunding occurred, most experienced financial destabilization and emotional demoralization as a result of struggling to pay private clinic fees, detoxification due to nonpayment of fees, and a return to heroin use and illicit activities.

Those women who attempted to pay private fees, either immediately or following an initial fee-detoxification, did so only by borrowing from family members, partners, lovers, and friends; exhausting employment resources, or exhausting AFDC and other welfare funds. Regardless of payment source, paying privately presented a difficult financial burden and necessitated participation in Illicit activities by many defunded women.

The majority of the women who immediately detoxified from their MMT program upon losing their funded slot returned to heroin use and illicit activities. Methadone withdrawal, the return to heroin use, and participation in illicit activities reintroduced these women to the lives they were attempting to leave behind by entering MMT programs. This placed many women at risk for arrest, incarceration, and health problems. The potential loss of custody of children produced fear in the minds of defunded women with dependents, as did the physical and economic damage that resulted from a lengthy arrest or incarceration.

We found that the defunding of MMT slots contributed to increased drug use and criminality among those women who had been stabilized and then forced to detoxify prematurely. Our qualitative study data indicate that premature and involuntary detoxification from MMT should be discouraged. We advocate the increased availability of publicly funded methadone maintenance treatment as a humane and appropriate public policy.

This research was supported by National Institute on Drug Abuse Grants RO1 DA05277 and RO1 DA08982, Marsha Rosenbaum, Ph.D., Principal Investigator, Bennett Fletcher, Ph.D., Program Officer. We are grateful to our study participants and the MMT clinic staff for their cooperation, as well as to administrative assistant Sue Eldredge.

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About the Authors

Kelly Ray Knight, M.Ed., is currently a Staff Research Associate in the Department of Obstetrics/Gyn ecology and Reproductive Sciences at the University of California-San Francisco conducting HIV/AIDS intervention and qualitative research. Ms. Knight was a Research Analyst at the Institute for Scientific Analysis when this research was conducted.

Marsha Rosenbaum, Ph.D., is a sociologist and director of the San Francisco office of Drug Policy Alliance, a drug-policy *institute. She has been the recipient of and principal investigator on 10 grants from the national Institute on Drug Abuse (NIDA), completing studies of women heroin addicts, methadone maintenance treatment and policy, MDMA (Ecstasy), cocaine, and drug use during pregnancy.

Margaret S. Kelley is a doctoral candidate in sociology at New York University. Her dissertation research looks at methadone maintenance treatment organizational styles and HIV/AIDS risk behaviors for injection drug users in the San Francisco Bay Area. She is a research analyst for the Institute for Scientific Analysis on an NIDA-funded grant investigating drug use, pregnancy, and violence.

Jeanette Irwin, M.A., has conducted research on methadone maintenance treatment, cocaine, women heroin addicts, and drug policy on several NIDA-funded grants. She was a research analyst at the Institute for Scientific Analysis when this research was completed.

Allyson Washburn, Ph.D., is a research psychologist who has collaborated on numerous studies of innovative treatments for heroin and cocaine dependence. She is currently working as an independent consultant in the San Francisco Bay Area.

Lynn Wenger, M.S.W., M.P.H., is a research coordinator for the Institute for Scientific Analysis in San Francisco. Her previous research has focused on drug treatment, HIV prevention, and needle exchange. She is currently coordinating a street-based study of drug users' health status and their access to and utilization of health care services.