Methadone Treatment in Narcotic Addiction. Chapter 4

Introduction

"Maximum feasible participation" of the community in the planning and delivery of services is usually a requirement for government-sponsored health projects. Such an approach, however, is not possible in the case of addiction treatment. Addicts themselves are hardly in a position to serve in an advisory capacity to program planners. They can only "vote with their feet," by accepting or rejecting services once they are made available. As for the nonaddict community, it is unrealistic to believe that it can identify with, and represent the interests of, the addict population. The all-encompassing involvement with the pursuit of drugs results in the isolation and disfranchisement of most addicts. Local support for individuals and agencies purporting to speak for "the community" is unlikely to come from that specific segment of the population which an addiction treatment program is designed to attract.

Politically, however, a narcotic addiction treatment program must seek to benefit the nonaddict, tax-paying public as well as the patients who are being treated. In the case of the New York City Methadone Maintenance Treatment Program (NYC MMTP), the City's Board of Estimate must approve all proposed leases and contracts, and their renewal on an annual basis. Such approval generally can not be obtained in the face of opposition from local organizations (xix). Consequently, the relationship with the community has been of critical importance to the expansion and ongoing operation, of the NYC MMTP.

Community Opposition to the Opening of NYC MMPT Clinics

Initially, I assumed that any community opposition to the establishment of NYC MMTP treatment units would focus on issues related to the use of methadone. The approach which I thought would overcome anticipated resistance was to explain the rationale for methadone maintenance treatment, and point out the positive results to date in enabling the majority of patients to give up heroin abuse and lead socially productive lives. I believed that such a presentation would make it clear that the community shares in the benefits when methadone maintenance is provided to former heroin addicts.

The experience of the NYC MMTP demonstrated that this simplistic analysis of community opposition to addiction programs was wrong. Criticism of the treatment modality itself was surprisingly rare. To the extent that opponents of proposed clinic sites believed such myths as methadone "gets in the bones," leads to senility and sterility, and is a covert plot to commit genocide, these issues did not seem to concern them. Whether the community was primarily Black, Hispanic, Italian, Jewish, or any other demographic group, there was an almost total disinterest in what methadone maintenance does, as long as it does it on some other street.

In retrospect, the resistance encountered by the NYC MMTP was essentially the same as that which met efforts to establish addiction treatment facilities, employing widely disparate therapeutic approaches, for more than 50 years. The following account is typical.

On August 5, 1919, the New York Times reported: "About 500 residents of The Bronx in the vicinity of Pelham Bay Park held a mass meeting... last night and protested against the proposal of the New York City Department of Health to have the City use the buildings of the Pelham Bay Naval Training Station as a hospital for drug addicts.... Resolutions were adopted condemning the proposal. A petition containing about l,000 signatures will be presented at today's meeting of the Board of Estimate asking City officials not to vote for the project" (34).

The effectiveness of the community opposition was headlined the following day: "No Addict Hospital in Pelham Bay Park - Patients Will Be Housed at Tuberculosis Institution on Staten Island." According to the news release, the Mayor's decision to choose an alternate site "...met with the unmistakable approval of a large delegation of residents of The Bronx, who had appeared to protest against the establishment of a drug addict hospital in their borough" (35).

The Mayor quickly discovered that his constituents in Staten Island were no more willing to accept addict-patients than were those in the Bronx. On August 10, the New York Times continued the story: "Drug Addicts Undesired - Staten Island Residents against Housing Them in Sea View. Staten Island commenced yesterday to organize for an aggressive campaign to prevent Health Commissioner Dr. Royal E. Copeland from bringing drug addicts to the Sea View Hospital now used for tuberculosis patients.... A vigilance committee of 150 members has been formed who threaten to picket the ferries in the effort to prevent drug addicts from being brought to Sea View. A former Assemblyman, who led the successful fight to prevent the City from locating a garbage disposal plant on Staten Island, has volunteered to lead the fight" (36). Once again, the community prevailed and the City was forced to abandon its plan (37). [Almost 50 years later, the City tried again to utilize the Sea View Hospital for the treatment of addicts; as in 1919, community opposition defeated the plan (38).]

Virtually all of the 44 clinics established by the NYC MMTP were opened ,after a protracted, uphill struggle to overcome neighborhood opposition. Arguments which stressed the need for services, the voluntary nature of the Program, and the strongly positive conclusions regarding the outcome of methadone treatment reached by independent evaluators after several years of study, all fell on deaf ears. As a rule, community meetings began with the local residents emphatically declaring their support for methadone maintenance treatment; there was generally an impatience with attempts to describe the therapeutic regimen and its impact on the lives of patients. The response was the following: "We know all that, and agree that methadone maintenance is worthwhile; we hope you open dozens of clinics to treat all the addicts in the City. But not here!"

Efforts by the Program to select locations which would not be objectionable were futile, since the rationale for rejecting proposed sites could be adapted to any circumstance. It was based on the proximity of a site to a school, or a church, or a playground, or a bar, or an Off Track Betting Office. Where public transportation was not accessible within a block or two, inconvenience to the patients was the reason for insisting on an alternate location; where a subway or bus stop was directly adjacent, the argument was that patient flow in and out of the clinic would compound an existing problem of congestion. In one case the community rejected a building which was across the street from a police station, on the grounds that patients should not be obliged to risk surveillance as they came to the clinic; where there was no nearby police station, concern over security was the basis for disapproval. In residential areas, it was vehemently stated that a drug treatment program would destroy the neighborhood and lower property values; in commercial districts, business leaders argued that customers would be frightened away and their stores plagued by thefts. A common goal of communities was to have clinics located within hospitals, an alternative generally rejected by the physicians, union representatives, and administrators of the many hospitals contacted by the Program.

The fundamental obstacle to overcoming community resistance was the widely held view that addiction treatment facilities were a part of the addiction problem, rather than a response to this problem. This orientation was frequently expressed in terms such as the following: "We've got enough to deal with in this neighborhood. We're already overwhelmed with junkies, prostitutes, panhandlers, loiterers, and thieves. The last thing we need is to compound all these troubles by allowing a methadone maintenance clinic to open up." Even in areas with a particularly high prevalence of narcotic addiction, and where the residents were willing to admit to such prevalence, there was a fear that hordes of heroin addicts from all over the City would descend on the neighborhood to seek admission to the new clinic. The implication seemed to be that methadone patients from outside the local community were a greater potential threat than were the existing heroin addicts.

Another factor which played a role in the opposition to proposed clinics was the tangible target which a treatment center offered for the enormous frustration which pervaded many neighborhoods. The "plague of addiction," and innumerable related and unrelated urban ills, generated fear, anxiety, and resentment, but were too amorphous to be attacked directly. A request by a City agency for approval of a methadone maintenance facility permitted the community's frustration, borne of a long-standing sense of hopelessness and impotence, to be focused on a concrete, attainable objective. "Success" was defined as thwarting the bureaucracy's efforts to open a clinic, and was worth pursuing for its own sake, regardless of the ultimate consequences of denying treatment services to addicts.

That the communities approached by the NYC MMTP were responding to issues far removed from drug abuse per se was repeatedly made apparent. At one meeting, following my lengthy presentation concerning the Program, and the advantages to the neighborhood of providing methadone treatment to heroin addicts, a local resident demanded to know, "Why haven't you picked up my garbage in the last week?" My attempt to explain that the NYC MMTP had no connection with the Sanitation Department was greeted by cries of "buck passing!" The consensus was that since the City refused to provide adequate garbage pickup, the community should refuse to allow the establishment of a City-sponsored addiction treatment clinic. Other seemingly extraneous issues which were raised included school busing, excessive welfare payments to the indolent, inadequate and unsafe public transportation, and poor medical care for the elderly. Resentment of the hospitals with which the Program planned to contract for backup services was also directed at proposed clinics; in more than one case, approval was denied based on the allegation that the hospital was seeking to drive out its neighbors to facilitate institutional expansion.

In the initial stages of Program development, NYC MMTP staff attended three or four community meetings each week (xx). As many as ten possible clinic sites were located and presented to neighborhood groups before one was ultimately approved. In some areas, such as the west side of Manhattan (home of the notorious "Needle Park"), approval was never obtained. Meanwhile, the gap between demand for treatment and availability of services continued to widen, until at one point over 8000 applicants were on the Program's waiting list. It was not until the end of 1972, 2 years after the NYC MMTP began, that the City-wide methadone maintenance capacity was sufficient to accommodate all those who sought admission.

Community Response to Operating Clinics
of the NYC MMTP

Resistance to the establishment of new clinics is only half the story of the Program's relations with the community. Once a clinic was opened, local opposition generally was minimal, regardless of the site which had been chosen: some clinics were in residential areas, others in commercial districts; one treatment unit was established on an unused floor of a hospital nurses' dormitory; another in a Wall Street office building; one clinic shared a City-owned building with a parochial elementary school, which had been displaced from its original location by fire. While there were a number of complaints from local residents regarding loitering, drug trafficking and crime which were allegedly associated with some of the clinics, community pressure was not so great as to seriously threaten the operation of any treatment unit of the NYC MMTP (xxi).

By far the most common complaints received by the Program have been with regard to loitering in the vicinity of treatment unit. The Program has developed several responses to this problem. Whenever possible, scheduling is arranged to minimize patient flow; for example, instead of having all patients who come to the clinic 3 days a week report on Monday, Wednesday, and Friday, some are scheduled for Tuesday, Thursday, and Saturday. In addition, many clinics reserve special hours for working patients. When complaints of loitering persist, staff members walk through the areas involved and ask patients to disperse. Of course, none of these measures has an impact on loitering by nonpatients. Rather than simply disclaim responsibility in such cases, the Program has frequently requested New York City Police Department support; increased police visibility has generally been effective, both in terms of discouraging loitering and in reassuring local residents.

The fear that an increase in crime would be associated with the establishment of a methadone maintenance clinic was almost always expressed in the community meetings which preceded clinic openings. In order to confirm the Program's impression that such fears were not warranted, a questionnaire was distributed in the summer of 1972 to each police precinct in which a NYC MMTP clinic had been established. Commanding officers were asked to compare arrest rates, in the immediate vicinity of the clinic and in the precinct at large, during the 6 months after the clinic opened with the corresponding 6 months of the previous year. All 22 precincts responded, and with only one exception, the arrest rate was reported to have remained the same or decreased after services were initiated.

In those instances where an increase in crime was attributed by the community to a Program clinic, however, Police Department data were rarely persuasive. The most widely publicized example involved Greenwich Village residents who in August, 1972, protested the temporary use of a ferry boat, moored at a Hudson River pier adjacent to the Village, as a NYC MMTP clinic: "Greenwich Village merchants, block associations, political and special interest groups say the center, which has been used to treat drug addicts from throughout the City, has been responsible for large increases in both major and minor crimes throughout the West Village area.... [Merchants] complained that panhandling, muggings, shoplifting, and apartment break-ins had multiplied since the arrival of the ferry." The newspaper account of the protest included a direct reference to the before-and-after arrest study described above: "The Commanding Officer of the Charles Street Precinct ... quoted a study comparing the first six months of this year with the same period last year [before the boat-clinic was established]. According to the study, serious crimes in the 6th precinct, which covers the West Village, decreased by 25.9% during this period" (40).

It is significant that the protest march to close the ferry boat operation occurred after community leaders had been informed that a permanent facility outside the Village had been obtained, and that relocation was imminent. One reporter rhetorically asked: "if the boat is moving, why was a march needed demanding its move?" He went on to provide the answer: "...the march gave many Villagers the opportunity to make their rage over what has happened to the neighborhood known. For Villagers are not fed up just with the boat. They are sick of the hustlers, derelicts, winos, and junkies who have taken over 8th Street, Sheridan Square, Washington Square Park, and Christopher Street.... There was also some politicking going on.... Some residents associated with the Community Planning Board feel the march was organized so that a handful of people could take credit for the boat moving. So when it sets sail the Village will be left with two problems - the crime not caused by the clinic's patients and the neighborhood's never-ending power plays" (41).

Conclusion

The difficulties encountered by the NYC MMTP in gaining community acceptance have been experienced by all treatment modalities, and are essentially the same today as those experienced more than a half-century ago. The basic problem is that since "treatment" is viewed with great skepticism, communities generally perceive the same threat from patients enrolled in treatment programs as they do from street addicts. As far as most neighborhood residents are concerned, the only acceptable approach is first to get rid of the addicts and then, in another locale, to provide them with therapeutic services. Since each community has precisely the same sentiment, however, this is hardly a practical solution.

While there have been enormous difficulties in establishing addiction treatment facilities in the past, the prospect for the immediate future appears to be even worse. Cynicism toward treatment efforts, which has always been widespread, has been greatly heightened in the last decade by the exaggerated promises of politicians and advocates of specific modalities, by premature and unwarranted claims of "success," and by the endless public attacks of one program upon another. In New York City, where the untreated addict population is estimated to be twice as great as the total capacity of all treatment programs, the future looks grim indeed.