Methadone Treatment in Narcotic Addiction. Chapter 2

The Initiative of the Health Services Administration

Almost immediately after his appointment as Health Services Administrator in January, 1970, Gordon Chase began to plan for a City-operated methadone maintenance treatment program. He considered issues such as dosage, duration of treatment, and the optimal "mix" of supportive services to be of secondary importance while there remained thousands of heroin addicts who wanted treatment but had to wait many months for admission to existing facilities. In March, 1970, I was recruited by Chase to oversee the preparation of a substantive proposal for a methadone program which would admit between 20,000 and 50,000 patients within one year (viii).

Initially, Chase's unrealistic program projections created considerable anxiety. There was a widespread fear that quality of care would be sacrificed to achieve the short-term political objectives of the "numbers game." Realizing that methadone maintenance treatment, already under severe attack and close scrutiny, could be irreparably damaged by a large-scale fiasco and the attendant publicity which would be associated with a program operated by the City of New York, proponents of methadone treatment offered the most insistent arguments against expanding too rapidly. Chase, however, considered "maximum effort" and "realistic goals" to be inherently contradictory concepts, subsequently acknowledging: "When I wrote that memo [indicating a target of 20,000 admissions within one year], everybody got a lot of laughs. 'Wow! Look at that nut.' But the point I wanted to get across was that that was the magnitude of what had to be done. it was important that we recognize it as that kind of magnitude and start going in that direction, even if it took longer than a year" (25).

By the middle of April, 1970, a proposal was drafted by the Health Services Administration (H.S.A.) and submitted to the Mayor's Narcotic Control Council, an advisory group established earlier that year to formulate policy and coordinate the Administration's efforts in the area of drug abuse (ix). Criticism of the proposal came, not unexpectedly, from the Addiction Services Agency (A.S.A.), and reflected the basic conflicts between the chemotherapeutic and drug-free philosophies. Thus, the A.S.A. voiced concern that there was insufficient emphasis in the protocol on psychiatric services, and urged that more stringent admission criteria be employed to ensure that methadone maintenance be limited to those addicts who had previously failed in other forms of treatment. The A.S.A. also urged that the program be experimental in orientation, that special attention be given to the utilization of low dosages of methadone and, above all, that eventual withdrawal be the ultimate therapeutic goal. In response, the H.S.A. noted that the proposed program was patterned closely on the Dole-Nyswander model, which had successfully demonstrated an ability to attract and retain large numbers of heroin addicts, and to assist in their rehabilitation.

No significant modifications in the proposal were made, and it was submitted to the State Narcotic Addiction Control Commission in June, 1970.

Operational Responsibility: H.S.A. versus A.S.A.

At its inception in 1967 under the leadership of Dr. Ramirez, the New York City Addiction Services Agency was firmly and outspokenly committed to an approach which was "...generally anti-drug, anti-methadone, anti- intellectual, and pro-drug-free treatment on the Synanon model" (26). The appointment of Larry Alan Bear to succeed Ramirez in 1969 did not change the Agency's orientation. Nevertheless, once the concept of a large-scale methadone program was accepted by the Mayor and the Narcotic Control Council, Bear insisted that ultimate operational authority rest with the A.S.A. On the surface, it seemed reasonable that a program designed to provide the largest addiction treatment capability in the City should be under the control of the agency which had the mandate to coordinate, monitor, and direct the City's efforts in the field of drug abuse. On the other hand, there were substantive arguments in favor of giving the responsibility for operating the new program to the Health Services Administration (x).

H.S.A. emphasized its organizational and contractual ties to municipal and voluntary hospitals and District Health Centers, which could provide space as well as backup medical services for the program clinics. Additionally, there was an obvious need to coordinate with the other methadone programs in the City; the polarization which had developed between the A.S.A. and those programs did not portend a good working relationship.

The undisguised ideological hostility of the A.S.A. toward chemotherapy in general, and methadone maintenance treatment in particular, would inevitably have an impact on the implementation of the program and the nature of the services provided. In rationalizing its insistence for control over a treatment modality which it emphatically rejected, the A.S.A. argued that its skepticism would ensure a diversified, experimental approach to methadone treatment, and pointed to the many unanswered questions relating to optimal staffing patterns, dosage levels and ultimate detoxification. The H.S.A. did not refute the need for additional clinical research into these and other aspects of methadone treatment, but maintained that a major research design within the framework of the overall operation of the program would not be practical (xi).

Perhaps the most persuasive argument in the eyes of City Hall was Chase's "track record for mounting new programs rapidly," while the Addiction Services Agency was generally viewed as "incompetent to mount and manage the proposed large-scale methadone maintenance treatment program" (32). The fact that Chase and his staff had taken the initiative and had a final proposal ready for immediate submission to the State for funding, while the A.S.A. had only lengthy memos criticizing the suggested "Beth Israel model, " further enhanced the credibility of the H.S.A (xii).

On June 10, 1970, Mayor Lindsay announced a "compromise" solution. The Addiction Services Agency would submit the proposal to the State and be the recipient of the anticipated funding; these funds would then be turned over to the Health Services Administration, which would have sole responsibility for operating the program. While this "fragmentation" of addiction treatment services has been conscientiously avoided in most localities, in retrospect it has had many advantages in New York City. Since the staffs of the chemotherapeutic and drug-free programs have been organizationally distinct, internal philosophical conflicts, and pressures for programmatic compromises, have been kept at a minimum. Equally important, the City Administration's commitment to expand rapidly methadone maintenance treatment capacity did not detract from the simultaneous effort of the Addiction Services Agency to expand and improve drug-free treatment and prevention programs; competition for personnel and other resources, which would have been inevitable had the City's programs all been under the aegis of a single agency, were avoided. At the same time, it was found that communication between the two agencies could be maintained, and a satisfactory working relationship developed.

"Fiscal Intermediary"

The consensus among the planners of the New York City Methadone Maintenance Treatment Program (NYC MMTP) was that a large-scale program could not be launched within the City bureaucracy, given the complex and time-consuming civil service and budgetary restrictions for hiring staff, purchasing supplies, renting equipment, and leasing and renovating facilities. Thus, a "fiscal intermediary" was sought with which the City would contract to operate the program. Under such an arrangement the City could retain complete control over the program's operation, but without the usual bureaucratic red tape (xiii). In June, 1970, the H.S.A. urged the City Budget Director to approve the operation of the program "entirely outside of the City line-item system by using a fiscal intermediary" (33). The following arguments were presented:

Salary levels under civil service would not be competitive. Physicians' pay scales were cited as an example: the Department of Health could pay a maximum of $16,800 for a full-time clinician, while all existing methadone programs in New York paid at least $30,000.

Acquisition and alteration of space through the Department of Real Estate routinely took at least 18 months. The H.S.A. goal of opening 20 clinics within 12 months would obviously be out of the question.

Many hospitals, which were counted on for backup medical services, would refuse to participate in a program forced to operate under the severe restrictions and delays inherent in the City's bureaucratic procedures.

In early 1970, however, the Lindsay Administration had come under strong public criticism for its allegedly lavish use of outside consultants to perform tasks which, it was claimed, could have been carried out by the City itself at considerably less cost. Consequently, City Hall was reluctant to use an approach clearly intended to circumvent the civil service system, especially with such a highly visible program, and refused to approve the use of a fiscal intermediary. Ultimately the Program was given the option of contracting with individual hospitals for the administration of the clinical units, but the Central Office staff, which would determine the direction and monitor the quality of the Program, would have to operate within the framework of the civil service system. Under this plan, I had serious misgivings that I would be able to exercise authority and maintain direct supervisory responsibility. In addition, contracting with hospitals would conflict with the practices of other large methadone programs, which also relied on hospitals for backup services, but hired all personnel on their own budget lines.

In retrospect, the anticipated difficulties were largely overcome by strong and consistent support from the Mayor's office. Throughout the Lindsay Administration the Program was given highest priority by all of the many City agencies upon which it had to rely, including the Purchase and Personnel Departments, the Department of Real Estate, the Budget Bureau, and even the Department of Marine and Aviation (which, for over a year, placed a ferry boat at the Program's disposal for use as a temporary clinical facility serving almost 1000 patients).

Degree of Centralized Responsibility for Program Operations

The one organizational option which neither Chase nor I ever considered was that the H.S.A. serve as a funding agency, providing grants to hospitals and other institutions to run separate, autonomous programs, with accountability to the City limited primarily to fiscal matters. From a strictly political perspective, it would have sufficed to obtain funds and make them available through subcontracts to outside agencies, which would be responsible for meeting whatever program objectives were specified. The demands on the H.S.A. for staff and other resources would be minimal, since its role would be limited to carrying out periodic audits and determining, at the end of each contract year, whether funding should be renewed (this is the primary mode of operation of the Addiction Services Agency). In addition to being the easiest and least expensive way in which to establish a wide network of facilities addressing a particular problem, this approach would also have ensured the greatest flexibility and individuality among the various facilities, and might have been expected to increase the speed with which the program could be launched and expanded. Finding satisfactory space in the neighborhood, gaining the support of the local community (xiv), hiring staff and developing procedural guidelines could, theoretically, be accomplished more expeditiously by numerous individual contract agencies than by a central Bureau operating within the New York City Department of Health (xv). However, the price associated with these potential advantages - loss of control over the development and operation of the Program - was totally unacceptable both to Chase and me, for somewhat different reasons.

Chase refused to relinquish direct control over the speed and the scale of program implementation. Obtaining maximum effort from his own staff was clearly easier than dealing with several dozen hospital administrators over whom his only hold would be contract termination. With a centralized operation, directly responsible to him, Chase could constantly monitor the Program's status and apply immediate pressure to achieve greater results.

I had a different concern. My personal commitment lay in providing a specific form of treatment to all those who wanted and needed it. Simply overseeing the disbursement of funds to contract agencies would make it impossible to determine Program policy, and to ensure Compliance on a day-to-day basis with procedures which would be established and the philosophy upon which they would be based. As it was, there was considerable skepticism that programmatic control could be maintained by City employees over clinic staff working for the contract hospitals.

Notes

viii. At the time, I was the Director of the National Nutrition Survey in New York City, and had no prior experience in the field of addiction treatment.

ix. At my insistence, the projected number of admissions during the first program year had been reduced to 3500. Even this goal represented an increase of more than 100% in the methadone maintenance capacity of all the existing programs combined. Although the state ultimately approved a first year budget based on a capacity of 2000 patients, supplemental City funds were available, and in its first twelve months of operation the Program admitted 3715 patients.

x. It is interesting to note that Chase sought responsibility for this large and extremely controversial undertaking. His appointment as the first nonphysician Health Services Administrator had been severely criticized by the medical establishment (27) and by numerous community minority leaders (28). He had his hands full even without venturing into the area of addiction treatment, which logically could have been left to the A.S.A. As head of the H.S.A., he was ultimately responsible for the Department of Health, the Office of the Chief Medical Examiner, the Department of Mental Health and Mental Retardation, and all health care provided in the City's schools and correctional facilities. The combined annual budget of these agencies amounted to almost one billion dollars. In addition, he had the simultaneous role of Chairman of the Board of the new Health and Hospitals Corporation, which within six months of his appointment was scheduled to assume responsibility for operating the 18 municipal hospitals. In retrospect, Chase explained his desire to operate the methadone program by pointing out that he considered addiction the major health problem facing the City, and the need to expand methadone treatment capacity the top priority of the administration. He was convinced that the H.S.A. could implement a large-scale program more quickly and effectively than any other agency, and consequently felt an obligation and a challenge to do so (29).

xi. Others have reached the same conclusion: "Programs focused primarily on experimentation and research such as dosage level manipulation, random termination, use of placebo substitution and the like might best do this on a small pilot basis rather than in the context of a broad treatment program in the community" (30). This position was subsequently adopted by the A.S.A. as well, which in its 1972 Comprehensive Plan for the Control of Drug Abuse and Addiction stated: "In the interest of both treatment and research we recognize that these functions must be kept distinct. Our approach is to foster and help develop small and carefully controlled research programs while simultaneously continuing to expand the large treatment-oriented programs which must meet the existing demand... (31).

xii. Even before the organizational dispute had been resolved, the H.S.A. had tentatively identified space and backup facilities for the first 12 clinics, worked out arrangements for urine toxicology to be performed by the Bureau of Public Health Laboratories, and obtained commitments from other programs to assist in the recruitment and training of staff.

xiii. This mechanism had been used previously to operate other projects carried out by the Department of Health and other City agencies.

xiv. The Board of Estimate, which must approve all contracts entered into by the City, insisted that each proposed clinic have the written endorsement of the local Community Planning Board.

xv. The experience of the Addiction Services Agency in establishing its Methadone-to-Abstinence Program in 1972-1973 demonstrated that this advantage is more imaginary than real. The A.S.A. left implementation to the hospitals with which it contracted, and almost 18 months elapsed before the first clinic was opened.