Money for Methadone: Preliminary Findings from a Study of Alameda County's New Maintenance Policy

Introduction

Increasing pressure has been exerted on federal, state and local agencies over the past several years to cut back on or eliminate funding for formerly subsidized drug abuse treatment programs. The largest of the publicly supported programs is methadone maintenance, a treatment approach initially heralded as the ultimate cure for heroin addiction. The majority of methadone maintenance patients/clients have counted on public support to pay for their treatment for an indefinite time period. However, both public attitudes and budgets have changed regarding methadone policy. Public attitudes have become skeptical and budgets smaller, resulting in numerous proposals and actions that are altering the current system.

Two decades have passed since Dole and Nyswander (1967, 1965) published their initial findings extolling the virtues of methadone maintenance. They defined opiate addiction as a metabolic disorder and argued that at least some patients should be maintained for long periods and possibly for life, using the analogy of diabetics treated with insulin. Methadone was enthusiastically received by the Nixon Administration during a period of intense concern regarding the so-called heroin epidemic and consequent rise in drug-related crime. Maintenance was seen as the most economical and successful way to treat thousands of addicts, effectively reducing both heroin use and associated crime. Addicts were actively recruited into methadone programs and often were promised unlimited treatment at no cost. The numbers of patients grew, finally reaching over 75,000 by the mid - 1970's (Allison, Hubbard & Rachal 1985).

The initial enthusiasm about methadone maintenance soon gave way to criticism. Serious concern was expressed regarding issues of clients' use of other drugs in addition to methadone, unproductive lifestyles and diversion (Ausubel 1983, Epstein 1974). Although methadone was intended as a long-term therapy, perhaps most worrisome was the concern that once on methadone, a client had great difficulty getting off the drug and staying abstinent.

Despite many favorable evaluations of methadone maintenance that show it to be relatively inexpensive and cost-effective (Kaplan 1983; Senay 1983; Simpson & Sells 1982), the dream of an easy solution or a "magic fix" has soured (Kleinman, Lukoff & Kail 1977). Concurrent with this skepticism about methadone has come Reaganomics, the Gramm-Rudman legislation and increasing pressure on federal, state and local agencies to cut back on funding for formerly supported drug abuse treatment programs. As the most utilized of the drug abuse treatment modalities (41 percent of all clients) and as a program that has always been controversial to those individuals who view a drug-free lifestyle as the goal of treatment, methadone is particularly vulnerable to such budget cuts.

This situation has placed methadone maintenance at a critical juncture. Whereas maintenance was originally conceived by physicians as an indefinite -- possibly lifelong -- modality, the current political climate is changing this conception. A new reformist or rehabilitative posture has grown out of fiscal conservatism, namely that of short-term treatment. Regulations, both federal and state, governing the operation of methadone programs have followed suit, and clinics have had to conform. Whether or not specific methadone programs had originally defined successful treatment as retention or release, many clinics have been forced to choose the latter as their ultimate goal (Reed 1985; Rosenbaum 1985a; Meyer 1983; Langrod, Lowinson & Alksne 1977).

Despite the enormous difficulties encountered in detoxifying from methadone (Rosenbaum 1985b; Des Jarlais et al. 1983: Dole & Joseph 1978), policy is primarily moving in the direction of limited duration treatment. Anglin and McGlothlin (1982: 234) noted that these decisions are not necessarily based on any available scientific policy evaluations, but are for the most part a result of the general fiscal retrenchment at local, state and federal levels, as changing economic conditions and public attitudes mandate a re-evaluation of social service priorities. The regulations in California, for example, require that methadone clinics show just cause for retaining a client longer than two years (California Department of Alcohol and Drug Programs 1983).

As competing priorities and funding constraints intensify, attention is turning to the issue of how long public dollars should be used to support clients on methadone maintenance. Many California counties have instituted their own policy changes, often reflecting a skepticism concerning the ethics, efficacy and cost-effectiveness of long-term maintenance (Reed 1985). For example, Kern County closed its methadone maintenance program, while San Diego County eliminated all publicly funded slots (Anglin & McGlothlin 1982).

One such Northern California county, Alameda, has attempted to remedy the problem in a unique manner. Confronted with appeals for more treatment slots by methadone maintenance programs with long waiting lists, the Alameda County Board of Supervisors endeavored to ensure client turnover -- and thus fairness in distribution of publicly funded treatment -- by limiting the length of time that a client could occupy a county-funded slot. As of October 1, 1984. Alameda County no longer would provide funding for individuals who had occupied county slots for a period of two years or longer. Such individuals would then have the option of transferring to a private slot (if available) and paying between $160-$200 per month or being detoxified. (Programs are allowed clinical discretion with 10 percent of their funded slots to extend treatment time as deemed necessary.)

Concomitant to Alameda County's institution of the two-year policy, the authors of the present article were working on a study examining the process of getting off methadone maintenance (Rosenbaum 1985b). This research team had observed the increasing movement away from government funding and toward private short-term treatment. However, clinic policy decisions and client decisions to get off methadone remained essentially voluntary (except when clinic rules were violated). Therefore, Alameda County was charting new territory by forcing clients to either get off methadone or pay after a set two-year period of time.

Without a systematic study assessing the impact of such a policy, its success or failure could never be fully ascertained. The publicly funded programs in Alameda County provided a perfect research laboratory. Here was an opportunity to observe individuals affected by the policy in order to answer some pressing questions: Would many clients get off methadone and go on to lead more productive lives?; Would they go back to street drug use and/or crime?; and Would they somehow find the money to pay for their treatment? If limited duration methadone maintenance was to be the wave of the future, it seemed imperative to know what would happen when such policies were instituted.

The authors of the present article obtained funding (NIDA Grant No. I-ROI-DA-03804-01) to conduct a longitudinal study examining the impact of Alameda County's new policy. The research plan is to interview 150 individuals who are directly affected by the policy: They have been on a county-funded slot for a period of at least two years and are now forced to either pay or get off. Each individual is interviewed initially, and then every six months for two and a half years. By following up individuals for this length of time, it will be possible to assess both the immediate and long-term effects of the policy.

The interviews consist of two parts. First, a qualitative, in-depth open-ended interview will be conducted with the respondent. Next, extensive quantitative data will be collected, including demographics, methadone maintenance history, information about criminality, drug use history and current patterns, treatment and employment histories, financial situation and health status. Currently, initial interviews have been completed with 118 respondents as well as the first wave of follow-up interviews with 50 of these individuals.

At this stage in the research it is important to stress the preliminary nature of the findings, particularly those based on quantitative data. Ideally, the initial interview of each client should have occurred six months before the date s/he would have to pay or detoxify with follow-ups conducted at six-month intervals after that, but this was not possible for a variety of reasons. For example, one of the three county-funded clinics in Alameda was given a year's reprieve. In addition, the 10 percent exemption was used in different ways by the three clinics. Moreover, there was much variation by each clinic in the implementation of the policy. Therefore, an initial interview with one client may have been conducted six months before the date s/he became a paying client or was detoxified, while another might have been done six months after that date. These considerations will become less important as the study progresses, because by the end of the study all of the clients will have been affected by the policy for at least two years. With these caveats aside, the ensuing discussion is a description of the study population, preliminary indications from the quantitative data, relevant case study, data from the qualitative interviews and an overall consideration of the policy change as well as its possible implications.

The population consisted of 40 percent men and 60 percent women. In terms of ethnicity/race, 50 percent are White, IS percent Hispanic and 32 percent Black. The majority (60%) were between 31 and 40 years of age, with 12 percent under 30 and 28 percent over 41. Most of the respondents (58%) had children under 18 living with them. Educational level was generally low (43 percent of the population had less than a high school education and 33 percent had graduated from high school or earned a General Education Diploma). In the category of occupation, 56 percent were unemployed at the time of the interview and 15 percent never held a job for more than six months.

During the Initial interviews, the respondents fell into three basic program categories: those who were now paying full fees for their methadone (N = 35); those within six months of their get off or pay date (N = 51), and those already off the program (N= 25). An additional seven respondents had either switched to an out-of-county subsidized slot or were, at the time of the interview, part of their program's 10 percent exemption.

Although most of the findings are rather pessimistic, the policy appears to have had positive effect on at least a small number of individuals. A few clients who had already intended to get off methadone regardless of the policy, were successfully detoxified and were not using heroin. These individuals were provided with a deadline to finalize their plans. Counselors agreed that for these few clients (each counselor knew of one or two), the policy served as a push to take action and begin the difficult transition. As the study progresses, the research team will have a better idea of the actual number of individuals who got off methadone and subsequently remained free of heroin addiction. In addition, a few individuals previously on county slots were now paying for their methadone with apparently minimal financial hardship. However, with the above exceptions, the policy has proven to present a seemingly intractable dilemma for the majority of clients: Failing to successfully detoxify from methadone, they are also unable to pay legally for their maintenance.

This population, as a group, was found to be financially disadvantaged. Only a little over a quarter (28%) reported a job as their primary source of income in the past six months, whereas over half (56%) were primarily dependent on some type of government assistance. The majority (64%) noted that the sum total of their assets (material goods and cash) totaled less than $1,000. These self-evaluations were largely substantiated by counselor assessments and interviewer observations (most interviews were conducted in clients' homes). It should also be noted that most clients possessed few job skills, had little education and had extensive criminal records, making their prospects for future employment rather dismal.

Many clients responded to the policy by initially deciding that they could not possibly afford to pay and thus attempted to detoxify. As their doses were lowered, they began to experience methadone withdrawal symptoms, with many turning to heroin for temporary relief. It was found that 83 percent of the individuals who had gotten off the program reported an increase in their heroin use. Realizing that they were becoming addicted to heroin again, a few of these individuals scrambled to find clinics in nearby counties that still subsidized treatment. However, a large number decided to get back into the Alameda County clinics by paying for their treatment.

For those clients (N=35) who opted to pay $160-$200 per month for methadone, extra money had to be found. Many clients claimed to have resorted to criminal acts in order to pay their clinic fees. Otherwise, money was taken from an already existing source -- often money that had been previously spent on children (58 percent had children living with them). For example, a married couple with four children was interviewed. Both had been on methadone in county-funded slots for nine years. During their years on methadone, they started a small janitorial business, and with the help of a relative managed to buy a home. When told that they would have to begin paying for their methadone or detoxify, they realized that nearly $400 a month between them was unmanageable, and both began to detoxify. Both had difficulty during the detoxification, felt defeated and believed that the situation was hopeless. In order to deal with their methadone withdrawal symptoms, they started using heroin, and soon they were both using heroin daily. They lost their home and their business, and at that point the initial interview was conducted with them. As the woman reported, "We were doing really well, and now it's falling apart." Six months after the first interview, follow-up interviews with the couple were completed. They had both gotten back on methadone and were paying for their treatment. They felt that they had to make this move, even though they are now paying nearly $400 per month. It is noteworthy that the couple got back on methadone in order to stabilize their lives (primarily for their children), yet the money to pay their clinic fees often comes from government assistance intended for their children's welfare.

Although in the six months prior to being interviewed, the majority of this population (73%) had not been booked on a criminal charge almost all had a previous history of extensive criminal involvement (85 percent had been convicted of at least one misdemeanor, 63 percent had one or more felony convictions and 81 percent had served jail and/or prison time). The majority of the respondents claimed that their criminal activity had lessened after getting on methadone. This finding is in agreement with counselor assessments and previous research that documents reduction in criminality as a result of methadone maintenance treatment (Simpson & Sells 1982: Edwards & Goldner 1975; Newman, Bashkow & Cates 1974). Those respondents who resumed heroin use,. when off the program or in the process of detoxifying, often reported beginning to commit drug procurement-related crimes again. One client described how he drifted back into criminal pursuits to buy heroin when he began to feel sick during his methadone detoxification: "I started back into it again slowly. Before I knew it. I was driving guys to go boosting [shoplifting], and then once in a while I would go boost myself. I could feel myself slipping back into that life and it scared me.

It should be noted that approximately half of those who were now paying for maintenance reported resorting to crime to pay their clinic fees. As one client described the situation: "The clinic has now become my dealer. I am now committing crimes to pay for an addictive drug [methadone]. It's really not much different than the street.

The Alameda County methadone maintenance policy ostensibly offers clients who have been in treatment for two years a choice: pay or get off. But is this really a choice al all? In an effort to answer this important question. the authors of the present article will first look at those who chose the pay option and then look at those who have detoxified.

Alameda County's perception of methadone maintenance clients' ability to pay for their treatment appears to be unrealistic. Over half of this population receives government support and has to take the money for their clinic fees out of food, clothing and shelter allowances. Ultimately, clients' children suffer as their parents' income diminishes and there is less and less money left over. The data indicate that most of this population is in no way able to pay an additional $160-$200 a month for any service. The money to pay clinic fees does not come from the extras, but cuts into the vital essentials of people's lives. Those clients who are attempting to stay in the program do so at great financial hardship. Perhaps the most glaringly ironic outcome of this policy is that clients return to criminality. Now, however, their involvement is often for the purpose of paying for their methadone treatment rather than their heroin habit.

On the surface, having fee-for-service arrangements for methadone treatment appears to save county governments social service monies.(1) However, an increasing number of incarcerations and medical and psychiatric hospitalizations are beginning to be seen, all of which are costly sources of public expenditures. Providing the $2,000-$2400 per year required to maintain an addict on methadone has already been shown to be much more cost-effective than the negative results of fee-for-service arrangements (Anglin & McGlothlin 1982).

Unable or unwilling to pay for their methadone, most of the study population have attempted or are attempting to detoxify. Numerous studies have described the problems that often result from attempts to leave or detoxify from methadone maintenance. Follow-up studies amply document the great difficulty that ex-methadone clients encounter in remaining drug free (Des Jarlais et al. 1983, Cushman 1981. 1978: Simpson 1981: Dole & Joseph 1978: Stimmel et al. 1978). Even under the best of circumstances, studies have shown less than a 50 percent chance of remaining abstinent as long as three years after detoxification (Hargreaves 1983). Most often, individuals return to heroin and/or other addictive drugs, particularly alcohol. Many return to maintenance if it is still an option (Rosenbaum 1985a, 1985b). The return to heroin and/or other drugs brings with it a host of health, social and legal problems, including increased criminality (Anglin & McGlothlin 1982; McGlothlin & Anglin 1981 Stimmel et al. 1978: Chappel & Senay 1973).

The major follow-up studies are in fundamental agreement that clients who detoxify before they have achieved stable social functioning are extremely unlikely to remain abstinent. For example, Des Jarlais and colleagues (1983) found that over 90 percent returned to daily opiate use. McGlothlin and Anglin (1981), who compared addicts formerly treated in a closed clinic with a comparable population still in treatment, found that the out-of-treatment addicts had been arrested and become readdicted more often and were less often employed than their still-in-treatment counterparts. These pessimistic findings have led many prominent researchers to suggest that methadone maintenance be allowed to continue as long as the client feels it is necessary (Goldstein & Judson 1983: Senay 1983. Newman 1982. Dole & Nyswander 1976).

As with other studies, the preliminary findings of the present study strongly indicate that most clients who detoxify involuntarily are returning to heroin use (and frequently to concomitant crime as well). To reiterate, 83 percent of the population who had gotten off methadone had increased their heroin use. So far, the follow-up interviews suggest that this trend will continue to increase as the study progresses.

If all the known factors were applied to them, this population as a whole would not appear to be strong candidates for either paying for their methadone or detoxifying successfully. Regarding reentry into the conventional world, this group is at a distinct disadvantage: 59 percent had been addicted for more than 10 years, a variable that immerses many of them in the nonconventional (deviant) world. On known success variables, such as the possession of education and job skills, this population falls far short. Thus, instead of reentry, what is being suggested for many of these clients is actually first-time entry into the conventional world, at middle age and with few skills to make the transition.

This population also lacks support systems and coping mechanisms. Whereas most individuals who voluntarily detoxify have clinic support, these clients are often at loggerheads with their counselors and are furious with the clinic for complying with the policy, resulting in detoxification or payment for continued services. Many clients voiced the opinion that the clinics are instituting this policy for personal profit. As one counselor put it, "it feels like you're on the front line and you're having to deal with a group of people through all these policies and all the clamor. And you are the one they see as being responsible."

In order to cope with detoxification, successful individuals are often busy and have jobs and avocations, leaving little time for anything related to drugs (Rosenbaum 1985b). However, the majority (75%) of the Alameda study population were unemployed and had few avocations that kept them busy. This group also appears to be in generally poor physical and mental health, with 74 percent describing themselves as depressed. They have a very negative attitude toward detoxifying and experience fear about getting off as soon as they are informed that their time on methadone is limited. Half doubt that they will ever successfully get off methadone. In short, the individuals in this population do not appear to be ready or able to get off methadone and have limited access to membership in the conventional world.

Methadone maintenance is essentially a clinical treatment of opiate addiction. Experience in the health care system has shown that good clinical practice is based on a relationship between the helper and the individual seeking help. Recovery requires an active participation in treatment by the person being helped. Successful management of other chronic conditions, such as diabetes, epilepsy and arthritis, is based on this principle. The preliminary findings of this study clearly indicate that clinical decisions made by external administrative authorities can have a destructive effect on the therapeutic relationship and interfere with long-term recovery.

The results of previous studies combined with preliminary findings from the present study suggest a pessimistic appraisal of Alameda County's two-year limit on publicy funded methadone maintenance. The vast majority of affected maintenance clients fall far short on almost every variable accounting for successful detoxification. In addition, very few of the clients appear to possess the financial resources to pay the $160-$200 a month for treatment. However, more and more clients are now beginning to pay for their methadone (often following unsuccessful detoxification attempts). Inasmuch as only a small number of these individuals have jobs, the money is most often coming from Aid to Families with Dependent Children (AFDC), Supplemental Security Income (SSI) and/or criminal activity. With the exception of a handful of individuals who appear to have successfully detoxified, those who have remained off the programs have most often returned to heroin addiction.

According to Kueffner (1986), it is easy to see how implementation of this policy was a well-intentioned effort to "effectively address the waiting list problems and ensure that services became available to more individuals in a time of diminishing resources." Unfortunately, the long-term clients affected by this policy do not simply disappear. In most cases, they appear to be exerting an even greater financial burden on society than they were before, as a result of increased criminality, incarcerations and hospitalizations.

It appears that policies that limit the length of time in treatment and require unrealistic payment seem particularly counterproductive in light of current economic, social and public health concerns.(2) The timing of this policy is consistent with the conservative fiscal movement, but is ultimately shortsighted. It is likely that publicly funded methadone maintenance will prove much more cost-effective in the long run.

Finally, the policy is perplexing in light of two current crises: the War on Drugs and the Acquired Immune Deficiency Syndrome (AIDS) epidemic. If the city of Oakland, the largest in Alameda County, is sincerely trying to combat its drug problem, one wonders why time-limited treatment would be simultaneously instituted. Furthermore, the threat of AIDS and the connection between intravenous drug use and the spread of HTLV-III infection seems to demand expansion of treatments that help deter intravenous drug use (Kaplan 1986). Given these problems, one ought to wonder why the most effective treatment for reducing heroin addiction and consequent needle use is becoming less available.

1. At this point, five of the respondents have switched to out-of-county subsidized slots. Many others were considering this option, thus shifting the financial burden to neighboring counties.

2. The logical solution would be to subsidize the number of maintenance slots necessary to meet the demand. Unfortunately, in this regard the county is in a somewhat analogous position to the client who is forced to pay or detoxify. With limited funds available, the county would be forced to syphon off funds from other needed services, just as many clients are now paying for methadone treatment with their AFDC and SSI allotments intended for food, clothing and shelter.

Supported by NIDA Grant No. I-ROI-DA-03804-01. "Methadone Treatment: A Study of a County Policy Change."

* Institute for Scientific Analysis, 2233 Lombard Street, San Francisco, California 94123.

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Acknowledgments

The authors gratefully acknowledge the assistance of Jeanette Irwin, Lynne Jackson, Bruce Linton and Dan Waldorf in the preparation of this article.