Methadone Treatment in Narcotic Addiction: Chapter 11

Introduction

The inability of short-term detoxification to achieve permanent abstinence is well established. At the same time, however, most workers in the field of addiction also believe that any treatment modality which does not aim for total "cure" is irrelevant to the management of addicts. Accordingly, virtually all reports in the literature evaluate detoxification services by the same criteria which are applied to long-term chemotherapeutic and drug-free approaches (lxix); the conclusions based on the degree to which abstinence and behavioral change are maintained after withdrawal are, inevitably, quite dismal. In published studies it is rare for even 10% of patients beginning withdrawal to remain free of drug usage following discharge, regardless of the setting in which treatment is provided or the duration of time over which detoxification is carried out (179-187).

With the focus of evaluation on long-term "success," most reports have dismissed detoxification as a futile effort: "Results of detoxification have been uniformly disappointing across the country.... Most addicts return to narcotic abuse very soon after treatment" (188). "Review of the empirical data presently available fails to demonstrate that detoxification, per se, regardless of technique, is in any way substantially related to achievable social, psychological or vocational goals, or to sustained abstinence" (189). "Methadone withdrawal by itself can not be considered definitive treatment, because experience has shown that most addicts require a great deal of social and psychological support to remain drug-free after detoxification" (190).

Although ambulatory detoxification is rarely accepted as a meaningful treatment in its own right, it is frequently afforded a role as a preliminary component of long-term treatment modalities, to eliminate a prospective client's physical dependence on narcotics prior to admission. The assumption that "...withdrawal is only the first and the least important step in the treatment of narcotic addiction" (191) would be true if one takes the narrow view that "success" can only be defined as lasting abstinence. Such a premise, however, ignores the frustrating reality that, to date, the problem of drug addiction has proven notoriously resistant to the myriad therapeutic approaches which have been applied.

The Perspective of the New York City
Ambulatory Detoxification Program

In February, 1971, the Health Services Administrator sent to the Mayor's Narcotic Control Council a draft proposal for a multifaceted detoxification program, to include both in-patient and out-patient withdrawal services, and a "crisis intervention" component which would provide medication on a one-time basis to alleviate acute symptoms of narcotic abstinence. At that time the New York City Methadone Maintenance Treatment Program was just getting under way, and the City Administration planned to increase the capacity of both methadone and drug-free programs by more than 400% to a total of 50,000 patients (lxx). With an estimated 150,000 addicts in New York City, it was readily apparent that even this extraordinary expansion would still leave the majority of heroin-dependent individuals with no care whatever; these comprised the target population for the detoxification program which was contemplated.

From the outset, the major emphasis in the H.S.A. proposal was on ambulatory detoxification, which had a cost-benefit ratio considerably greater than that of either of the other two components (lxxi). Basing its analysis on the conservative assumption that less than 1% of patients would remain drug-free for an extended period of time after withdrawal, and that for the remainder recidivism would occur within 2 weeks, the H.S.A. nevertheless concluded that the extremely large number of addicts who would want detoxification, and who could be accommodated at relatively low cost in outpatient clinics, justified implementation of a City- operated program (193).

The objectives of detoxification were initially summarized as follows: "Relief of addict suffering and reduction of the danger of overdosing, reduction of addict-caused crime in New York City, and provision of referral services to other treatment programs" (194). It was postulated that a safe, legal alternative to even one day's self-administration of street heroin, if provided to tens of thousands of addicts yearly, would inevitably benefit the general community as well as the patients themselves; that a positive treatment experience in a short-term detoxification program would influence at least some patients to seek long-term care; and that the anticipated demand for detoxification would confirm that addicts themselves perceived the program as beneficial (lxxii).

The aims of the New York City Ambulatory Detoxification Program were stated consistently in many contexts subsequently. In a proposal to the Office of Economic Opportunity submitted in May, 1971, the need for ambulatory detoxification was explained as follows: "The existence of a large number of heroin addicts in New York City, most of whom do not voluntarily seek long- term treatment, suggests the value of a service which would allow an addict, even temporarily, to reduce his habit" (196). In the City's "Comprehensive Plan for the Control of Drug Abuse," released in November, 1971, the new Program was described as an effort to "...intervene in the lives of previously unreached addicts" (197). The clinical goals enumerated in the NYC ADP Policy and Procedures Manual (198) were:

• To provide during each day of treatment a safe, legal and effective alternative to the physical need to self-administer illicit narcotics.
• To eliminate the patient's present physical dependence on narcotics through the administration of decreasing doses of methadone until, after about seven days, a drug-free state is achieved.
• To motivate patients to seek long-term treatment for their narcotic addiction.
• To provide referral services to appropriate long-term treatment programs.
• To provide screening and follow-up as indicated for acute and chronic medical conditions, whether related to addiction or not.

Notable by its consistent omission from all references to Program objectives was the achievement of permanent abstinence. To prevent frustration among Program staff and disenchantment of funding sources and the general Public, it was essential to distinguish between realistic and unrealistic goals. With respect to funding sources, however, the Program's candor also produced disappointment. Skepticism regarding program objectives which failed to include permanent abstinence was the prevailing attitude of the National Institute of Mental Health when the NYC ADP sought support in the summer of 1971. Expressing concern that "serial detoxification of the same patient without intensive follow-up [would become] a substitute for treatment" (199), N.I.M.H. requested several revisions of the Program protocol with progressively greater emphasis on the mechanisms for patient referral to and from long-term treatment facilities. Although these changes were implemented in the initial clinics of the NYC ADP, the fundamental doubts of N.I.M.H. regarding the utility of out-patient narcotic withdrawal as a distinct treatment entity could not be overcome, and after more than a year of fruitless negotiation the City gave up the attempt.

The unwillingness of N.I.M.H. to support a program which, from its inception, attracted unprecedented numbers of addicts, (lxxiii) was especially frustrating given the existing situation in New York City in 1971-1972. Even the most ambitious plans to expand chemotherapeutic and drug-free programs would leave about 100,000 heroin addicts with no alternative to continued, daily, illicit drug use. The plight was most obvious in the case of more than 10,000 applicants for methadone maintenance who were on "waiting lists," and for whom no temporary relief from the physical dependence on narcotics was readily available.

Fortunately, other funding sources were available to the NYC ADP. The Program's primary objectives remained essentially unchanged, and it continued to operate as an independent entity rather than as a subsidiary unit of a comprehensive treatment agency. Eligibility for admission has never been made contingent upon a commitment by the applicant to pursue a goal of total rehabilitation (lxxiv); while orientation and referral of interested patients to long-term programs has consistently been a secondary therapeutic goal, it has never been permitted to take precedence over the narrower aim of detoxification per se.

Notes

lxix. One exception is found in the assessment of treatment modalities included in the Drug Abuse Council's Report to the Ford Foundation: "The most straightforward way to help a heroin addict is to detoxify him.... Detoxification has several clear benefits for both the addict and society. Even if the addict does not intend to stay off drugs, it reduces his habit and decreases its cost. This spares him the hassle and society the crime costs of his addiction for some period, even if only a few days, after the process is complete. For some addicts, it is also a step toward rehabilitation. After repeated failures to remain detoxified, they become ready for other modalities. It is valuable, especially for anyone who believes that addicts should be treated more humanly that they are at the present time and that bandaids can be valuable things" (178).

lxx. This ambitious goal was achieved within 2 years, during which the census of patients being treated in addiction programs in New York city increased from slightly more than 12,000 to almost 53,000 (192).

lxxi. In-patient detoxification and crisis intervention were almost immediately deleted from the H.S.A. proposal since it was not clear that there would be a significant demand for these services once a network of out-patient clinics had been established.

lxxii. It was known that in-patient detoxification at the Morris J. Bernstein Institute of Beth Israel Medical Center was in considerable demand: there were reported to be between 800 and 1200 addicts awaiting admission for narcotic withdrawal in late 1970 (195).

lxxiii. In the first 12 months of operation, beginning July, 1971, over 10,000 individuals were admitted to the NYC ADP.

lxxiv. By contrast, another, independently operated detoxification program in New York demands that applicants first attend at least four consecutive sessions at a neighboring drug-free Community Service Center as a prerequisite to enrollment (200).