Money for Methadone II: Unintended Consequences of Limited-Duration Methadone Maintenance

Introduction

Economic growth in the United States following World War II allowed for taxing and spending policies that afforded national financing of a wide array of services for problem populations. In this context, drug abuse treatment proliferated. However, in the 1970's, when this historic cycle of growth came to an end, what O'Connor (1973) has called "the fiscal crisis of the state" became a palpable reality. Simply put, the fiscal crisis was the growing excess of the demand for services over the fiscal capacity for financing them. In such a context, policymakers across the U.S. were faced with a declining share of resources, resulting in the need to make difficult decisions concerning funding of human service programs. By the early 1980's, Alameda County (the fifth most populous county In California) was faced with significant budget cuts in the area of health care services, including drug abuse treatment. As a result of these cuts, treatment programs had long waiting lists. Among these were methadone maintenance programs, some of which had been accommodating clients indefinitely. In 1984, because expansion of the number of treatment slots was no longer fiscally feasible, the county tried to insure client turnover, and thus fairness in the distribution of publicly funded methadone maintenance, by instituting a two-year limit. The "two-year rule" specified that after two years on a county-funded slot, clients could either pay for their methadone (approximately $200 a month) or they could get off the program.

This was an attempt by locally elected officials to adapt to changing national political-economic conditions over which they had little if any control, but which impinged sharply on their communities. Although it was the county's intention to save money, several unanticipated, undesirable, and expensive consequences resulted from these cuts: Faced with expulsion from these programs, methadone clients developed strategies that circumvented the policy, subverted the goals of methadone program, and apparently incurred many additional costs to the county.

This article describes some of the additional, unintended consequences of the two- year rule. It begins with a discussion of the research study itself, the basis for the preliminary findings. Within this section, the methodology of the study and the study population are described. Next, a discussion is presented of the discretionary applications of the policy and the unintended consequences of the policy, which include client resentment of the clinic and counselors, and the discretionary application of the policy. This is followed by a look at client adaptations to the policy: inpatient psychiatric care; the manipulation of take-home doses; slow or nonpayment of fees; and back-to-back methadone detoxifications. Finally, the very serious implications of the policy are considered.

Investigation of the Impact of Alameda County's Methadone Maintenance Policy

In 1985, NIDA awarded the authors of the present article a four-year research grant to conduct a longitudinal study of 150 methadone maintenance clients who had occupied county-funded slots for two or more years. The purpose of the study is to understand the effect of the policy change by interviewing individuals over an extended period of time.

I. a. Methods

Each respondent was interviewed initially and then reinterviewed every six months for two-and-a-half years. The data collection combined two types of interviews: (1) an in-depth qualitative interview in which the respondent's life history is recorded, with an emphasis on his/her drug career, and (2) an extensive close- ended questionnaire in which quantitative data is collected, including demographics, overall drug use history, methadone maintenance history, treatment history and experiences, criminal history, current drug use patterns, recent employment status, criminal activities, and financial and health status.

In addition, interviews were conducted with program directors and counselors from the three methadone clinics affected by the policy. Counselors were asked to give their renditions of the background of the policy, their opinions concerning possible effects, and an account of how their clients were responding to the "pay or detox" ultimatum.

I. b. Demographics

The original goal of the project was to interview 150 clients, including 50 from each of the clinics with county funded slots. According to methadone clinicians in Alameda County, this figure would represent half of all clients initially affected by the policy. Ultimately, with study dropouts, a sample of 143 was obtained.

The sample consists of 58 males (41 %) and 85 females (59%), of whom 53 percent are White (n=76),27 percent are Black (n=39), and 19 percent are Latino (n=27). One respondent is a Native American. The median age is 35, the youngest being 21 at the time of the initial interview and the oldest being 58. The median time for length of heroin dependence is 8.5 years. In terms of education, 40 percent have less than a high school education (n=57), 35 percent graduated from high school (n=50), 21 percent had attended college (n=30), and two went on to graduate school.

Regarding criminal activity, 41 percent had never been convicted of a felony (n=59), 52 percent had been convicted of between one and six felonies (n=74), and seven percent had been convicted of eight or more (n= 10). Only 24 percent had never been convicted of a misdemeanor (n=34), while 37 percent were convicted of one or two (n=53), 15 percent having been convicted of four to eight (n=22), and 24 percent of eight or more (n=34).

With regard to work, only 29 percent of the respondents had a full or part-time job at the time of the initial interview; 42 percent were receiving public assistance (n=60). The remainder relied on unemployment compensation, disability payments or family help for income.

At the time of the initial interview, 34 percent were in a program and paying for their methadone (n=48),48 percent were in a program detoxifying (n=69), and 16 percent were not in a program at all (n=23). Two percent had special exemptions (n=3).

It is important to note that the findings that will be presented are preliminary, and that the present article has been written from the clients' perspective. Interviews with clinic staff were included in the analysis, but the major emphasis throughout is client perceptions of, attitudes toward, and responses to the two-year rule.

Discretionary Applications of the Policy

Although the two-year rule was spelled out clearly, its actual application was not so simple. Clinics were given certain discretionary powers with regard to the implementation of the policy. All clinics were given a 10 percent exemption, and one clinic was given a reprieve and then total discretionary powers. The following paragraphs describe these applications of the policy.

II. a. The 10 Percent Exemption

When the pay-or-detox two-year rule was instituted, each clinic was given 10 percent of its census as discretionary treatment slots to be used as clinicians saw fit. The clinic staff could exempt certain clients from having to detoxify or extend the period of detoxification for hardship cases. The clinicians' use of these discretionary slots has had the unexpected result of alienating clinic-client relations.

Clinicians reported that staff used the 10 percent exemption to continue to medicate those clients with severe mental health problems who, in their estimation, would have represented a danger to the community had they been detoxified from methadone. The use of methadone maintenance as an adjunct therapy for certain mental illnesses has been reported elsewhere (Ayres 1987). One counselor described twin brothers in his caseload, who immediately following dose reduction began to exhibit psychotic behavior. Clinic staff were able to raise their doses immediately, and the twins were returned to their previous levels of functioning. The medically indigent with degenerative or chronic physical conditions were also exempted.

Clinics are also using the discretionary slots as a way to extend some clients' detoxification time. If, in the clinician's judgment, it would be beneficial to give an individual more time on a funded slot, the clinic has the power to implement such an extension. A clinic director described the clinic's use of the 1O percent exemption:

Q: It seems-let me see if I understand-with [X Clinic], what you are doing with the 10 percent is you're helping people that are detoxing, but, say, haven't gotten quite all the way off [the maintenance program]. A: ... we are tending to use it to elongate people's detox who are having problems, but we don't tell them that we have that possibility. If somebody comes to us and says they're having it rough, we would rather use it and try to make the detox work better than to just give it all to one person. So we're trying to eke it out that way.

II. b. The West County Case

A major exemption that has had an impact on the implementation of the policy (as well as the course of the research) was the West County exemption. The clinic director, a physician, argued to the county that clients who had been on a program prior to the institution of the two-year rule should be exempt from the policy and that only those clients who had gotten on the program after the policy was implemented (i.e., October 1984) should have to get off or pay within two years. Subsequently, a client who was detoxing threatened to sue the clinic, claiming he was physically unable to detox. The county then granted the physician total discretion. Thus, in the West County program, it is the director, rather than the county and its policy, who determines the time at which detoxification occurs.

II. c. Client Resentment of Discretionary Applications

The discretionary powers given clinics have resulted, in many cases, in client resentment. Whereas some clients who are having difficulty are afforded extra time to detoxify, this leeway is not applied in a uniform manner. When client requests for a reprieve are rejected, or in cases where clients with no apparent medical conditions or mental disabilities receive more time, other clients claim that unfair application of the guidelines of the policy is occurring. Some clients--often not being privy to complete information about other individual patients' circumstances--see other clients receiving extensions and exemptions, and formulate strongly held opinions about why some clients are forced to comply with the policy and others are not. As one client put it succinctly, "...We [the clinic] like you, you can stay. We don't like you, county detox." Most clients agreed that people who were troublemakers or who were just not liked by counselors suffered more stringent application of the two-year rule.

Whether or not clinicians are following sound therapeutic judgments or in fact are showing favoritism to particular clients cannot be determined within the scope of the present research. But clients' beliefs that they are being dealt with unfairly exist, and can affect the therapeutic relationship negatively (Working Party for the American Friends Service Committee 1971). The clinicians' use of these discretionary slots has resulted in the unexpected alienation of clinic-client relations.

Client Resentment of the Clinic/Councilors

It is axiomatic among professional therapists that patients' payment of professional fees-for-service has the therapeutic value of providing a concrete commitment to therapy, a so-called investment in the therapeutic process. This idea may be valid when the patient is from a middle-class background with a middle-class income. Members of the underclass (the majority of the present sample) view the notion of fees as symbolic of their own commitment with cynicism at best. They simply cannot afford to pay for their methadone treatment and those who attempt to pay do so at the expense of food, clothing, and shelter allowances for themselves and often for their children (Rosenbaum, Murphy & Beck 1987).

A major unintended consequence of limited publicly funded methadone maintenance is the erosion of, rather than commitment to, the therapeutic relationship between clients and clinic staff. Counselors on the front lines inform clients of their get-off-or-pay dates and then become the recipients of client fear, anger, and anxiety. Clients begin to see counselors as ruthless bill collectors "just in it for the money." Anyone familiar with the pay scale of the average methadone counselor is cognizant of the injustice of this accusation. Nonetheless, the notion that methadone counselors somehow share in the profits made from the collection of clinic fees is a pervasive one among clients and has had detrimental effects on the client- counselor relationship.

Clients are also upset about the steady increase in clinic fees since the inception of the policy. Since the present study began, monthly fees for methadone maintenance have risen from $160 to $200 per month. Clients do not understand the reasons for these increases because there have been no visible changes in services provided. Clients are concerned that fees will continue to climb, further straining what for most are already meager budgets. Clinics can offer no guarantee that fees will not continue to increase.

For most clients, payment of fees is problematic. Counselors faced with clients who opt to pay rather than detoxify must push them, if verbally, into making major lifestyle changes. Many do not have jobs and otherwise lack the skills and other preparation necessary to support themselves and to afford the clinic fees. Nonetheless, counselors must encourage them in this new and seemingly impossible direction, with a time limit, and this often leads to conflict.

The institution of fee-for-service arrangements for methadone maintenance treatment has the unintended consequence of eroding the relationship between the helper and the consumer of these services. Clients begin to see counselors as merely collectors of fees and begin to question staff motives. For those clients who had held funded slots for several years prior to the implementation of the new policy, clinic betrayal took on a historical aspect. Clients often traced perceived changes in the level of caring and commitment on the part of clinic staff to pre- and postpolicy eras. One respondent aptly summarized the long- term client's evaluation of changes in counselor attitudes over time: "I hate to say this, but since they have been collecting money, X Clinic has changed. I have been on that clinic for five years and I used to get along with everyone there. They have changed. They have all changed. It's all about money now. They don't care about you any more."

Creative Adaptions to the Policy

The majority of clients, when confronted with the two-year rule, choose one of the two options, to get off or pay. However, in the desperate situation of needing their methadone and not having enough money to pay for it, some devise methods by which they can stay on methadone. Erosion of the already debilitated therapeutic relationship, combined with their natural creativity, prepares these clients psychologically to engage in imaginative adaptations to the policy. Client adaptations designed to dilute the impact of the two- year rule took the following courses: (1) late and/or nonpayment of fees; (2) manipulation of take-home privileges; (3) back-to-back 21-day detoxifications; and (4) the use of acute care mental health facilities.

IV. a. Late and/or Nonpayment of Fees

Clients are required to keep their fee payments current or they will be detoxified. However, clients who choose payment of clinic fees (as opposed to getting off the program) often find themselves in a constant state of arrears. These clients are habitually about to be put on a fee-detoxification regimen (i.e., some percentage of their maintenance dose is reduced daily until they bring their account up to date) or are in the process of having their doses raised or lowered. Once they can make a satisfactory payment, if possible, they try to get their doses raised to the limit, anticipating the next fee detoxification (e.g., a client starting on 40 mg is reduced to 20 mg and then has the dose raised to 60 mg). "Roller-coaster dosing" through slow or nonpayment of fees is a common, if not planned, adaptation to the policy.

These same clients are at risk of supplementing their lower methadone doses with street drugs. When they are able to pay and are brought back up to their usual maintenance dose, they are often no longer stabilized at that dose and may suffer some of the side effects more common to new patients on programs (e.g., intoxication, spontaneous sleepiness, and/ or excessive sweating).(1) Conversely, when clients are having their doses reduced, they are also able to feel heroin more effectively, as methadone's opioid-blocking mechanism is weakened, thus making heroin use even more tempting. Roller-coaster dosing places methadone clients at risk of returning to the activities that their programs have been trying to turn them away from, namely hustling (income-generating criminal activities) and illicit drug use.(2)

IV. b. Manipulating Take-Home Doses

This adaptation involves stretching take-home doses. Thus, it is restricted to those clients who qualify for take-home doses. It is usually used only by couples, since a permanent, trusting relationship would be necessary for it to work on any long-term basis. The following is an example of how this adaptation has worked.

One or both of the partners are told they must detoxify or pay by a given date. The individual with the most "take homes" and/or the highest dose remains on the program and the other officially detoxifies. The client continuing on the program has his/her dose raised as high as possible (on low or blind-dose programs this is not as feasible an option) and then shares the take-home doses with his/her partner. This keeps them both on a somewhat lower weekly dose than the clinic has prescribed, but allows the individual household to pay for only one person's treatment.

There are problems that arise from the use of this adaptation. First, neither patient nor partner is being adequately maintained by sharing one prescribed methadone dose, thus increasing the risk of both persons titrating the methadone dose with a variety of other drugs, most often heroin. Second, the person who is not officially on the program receives none of the ancillary services and medical monitoring that is afforded a registered maintenance client. Finally, both people run a serious risk of eschewing treatment altogether and returning to full-time street drug use. Often, clients are unable to support even one family member's clinic fees due to the expense of increased street drug use. The end result is that both clients return to heroin use and continue using heroin until they run out of money, are arrested, or one or the other is able to get another treatment slot.

IV. c. Back-to-Back Methadone Detoxifications

Another adaptation for those who choose not to pay, but who want to stay on methadone, is to manipulate the 21-day detoxification treatment system to structure a quasi-maintenance regimen by signing up for 21-day detoxifications as often as possible. Sometimes it is faster to get on a 21- day detoxification program than to get on another maintenance program. Maintenance programs usually have waiting lists of between several weeks and several months. In these instances, 21-day detoxifications serve as holding patterns between heroin use and methadone maintenance.

Alameda County requires that a 30-day waiting period occurs between each individual attempt at detoxification, but some addicts are able to get around this rule by going to surrounding counties for their treatment.(3) Medi-Cal (state funded health insurance) restrictions make this adaptation unworkable for many, because individuals have limited numbers of detoxifications that can be paid for through Medi-Cal. Addicts circumvent that problem by relying on the lag time before Medi-Cal discovers that they have used their quota of funded treatments. Some also borrow Medi-Cal stickers from their associates.

Designed to assist clients in detoxifying from heroin, 21-day detoxification programs were not designed as short-term or part-time maintenance programs. In a sense, this adaptation relates to roller-coaster dosing produced by fee detoxifications. Often clients in this pattern continue using street drugs and risk overdose or detrimental drug interactions with such use patterns.

IV. d. Inpatient Psychiatric Care

One creative adaptation to the two-year rule is the use of inpatient psychiatric facilities for short periods of time. Complaining of psychological trauma, clients present themselves to acute-care psychiatric facilities for treatment and while in the facility, are maintained on methadone at no charge. This adaptation was not easily used by a majority of clients, inasmuch as most do not have histories of mental illness. But for a few it worked rather well. One couple in particular became well known in the methadone client community for their use of this tactic. Both were in a private maintenance clinic, having been detoxified from their public slots. Neither was employed or able to work due to continued drug use and mental health problems. The clinic fee was $190 a month each, and only the wife was receiving a steady monthly income from Social Security Insurance. The husband's family helped him with his methadone bill. Continued drug use, eviction from various apartments, and other such exigencies typical of an addict lifestyle would often render them unable to pay their clinic fees. When this would occur, they would take would take turns entering an inpatient psychiatric facility in the county for 30 days. Whoever remained on the street took care of their three-year-old child. The facility would continue to provide the patient with his/her regular methadone dose, at no cost to the couple, of course. This adaptation suited their purposes rather nicely, and it is an option the couple is still exercising. Ironically, the cost-conscious county has paid a great deal more for a month of inpatient psychiatric treatment than they would have paid to maintain both clients in publicly funded methadone slots for the same period of time.

In effect all four adaptations subvert the goals of methadone maintenance treatment modalities. However, clients who feel they are not ready or able to successfully detoxify from maintenance see these adaptations as their only alternatives. Clients are not maintained on steady doses of methadone, and as a consequence, dosage stabilization--a major goal of maintenance--is uncertain.

AIDS-Related Implications

One of the most disturbing implications of erosion of the therapeutic relationship and client adaptations to the two-year rule is the increased risk of AIDS (and other needle related conditions) associated with client return to street drug use. Increased needle sharing and high-risk sexual activity are two such AIDS-related implications.

Poorer addicts are more likely to share needles than addicts with jobs or steady hustles (Murphy 1987; Newmeyer 1987). Needles are scarce and cost money. Addicts in California cannot obtain needles legally, so they must buy them from a gray market that is subject to all the exigencies of an illicit marketplace. Most of the clients affected by the two-year rule have been away from the drug-and-needle scene for, at the very least, two years when they face a dose reduction or complete detoxification. Therefore, they are less efficient discoverers of drugs and/or needles, making them more likely to share needles than active users with numerous contacts.

Methadone clients are also impaired in a more subtle way. Goldsmith and colleagues (1984) have found that such ex-methadone clients lose their "heart," or their capacity to hustle. Years on methadone, a somewhat conventional lifestyle, and the aging process rob them of the energy and nerve necessary to commit the criminal acts they performed with vigor when they were younger. With lessened zeal and barely enough money and contacts to secure drugs, needle sharing is more likely.

The symbolic sexual aspects of intravenous drug use have been alluded to by respondents and reported in the drug literature (Rosenbaum 1981; Howard & Borges 1970). Drug dependent individuals often have a lessened libido due to their use of drugs. As one client said, "You could bring your grandmother to a movie about my sex life." They sometimes substitute needle sharing for feelings of sexual intimacy (Murphy 1987): Instead of sharing sexually, the pleasure of injecting drugs is shared. As the male partner generally fixes the woman, the symbolism is obvious. Most couples do not even acknowledge that this behavior is risky, and when asked if they share needles respond as did this woman:

Q: Do you share needles?
A: No
Q: Ever? With anyone?
A: Just my husband.

This population is also at risk for actual sexual transmission of AIDS. Many reported using no form of birth control at all; few reported using condoms. Most respondents did not see sexual transmission of AIDS as an issue for them. Some of the men associated sexual transmission with homosexual activities and believed that only gay men could contract AIDS through sex. Finally, because respondents had sex infrequently, they did not see unprotected sexual intercourse as a potential risk.

The link between needle sharing and sexual intimacy places these respondents at risk to contract AIDS. As noted, there is some evidence that needle sharing replaces physical intimacy in drug dependent couples' relationships (Howard & Borges 1970). This, combined with the lessened libido associated with opioid use, serves to weaken the impact of safer-sex public health messages for this population, thus placing them at risk of contracting AIDS from both needle sharing and failure to use condoms.

Conclusion

Alameda County public officials seeking to alleviate the problems of long waiting lists and limited funds designed what has become known as the two-year rule. The implementation of this policy had some consequences its authors did not intend. (1) alienation and mistrust resulting from client- perceived unfairness in the discretionary applications of the policy; (2) erosion of the therapeutic relationship between clinician and client; (3) client adaptations that were often more costly than publicly funded maintenance; and (4) the increased risk of AIDS as clients return to needle use and sharing.

The structural conditions that faced these public officials, such as the high crime and drug use rates as well as long waiting lists for maintenance treatment, juxtaposed with limited funding, seemed to warrant this policy shift. On the one hand, it has some what alleviated the waiting list situation in a cost-effective fashion. On the other hand, the policy seems to have been designed as if the methadone clients were objects who would simply react and go where they are told rather than subjects who interpret, impose meaning, and act willfully, if necessary, to offset changes in their circumstances. The results have included client adaptations that are often far more costly than continued publicly subsidized methadone maintenance treatment.

These are tough times for policymakers. Budget cuts rather than increases are in political and economic vogue. Yet drug-related problems remain at least as prevalent as ever, and the menace of AIDS infuses the whole field with deadly urgency. Methadone maintenance in such a context is profoundly inexpensive when compared to the use of other publicly funded activities, the misuse of maintenance, the return to street drug use and needle sharing, and the spread of AIDS.

Notes

2. For a further discussion of side effects, see Rosenbaum and Murphy (1981).
3. It is important to note that not all programs allow such flexibility in dosing (Rosenbaum 1985). On any methadone program, those clients who persist in using street drugs and produce dirty urine specimens are detoxified from the program regardless of their payment status.
4. More clients were expected to go to other counties for both detoxification and maintenance treatment. Only five (4 %) went to a maintenance program in another county. The follow-ups have not been completed, but the numbers are to be considerably higher for 2l-day detoxification. It appears that permanent relocation and transportation costs may be prohibitive for many clients.

Acknowledgments

The authors gratefully acknowledge Lynne Jackson for her editorial skills and her patience in preparing the original manuscript. The authors also would like to thank their colleagues Jerome E. Beck, Jeanette Irwin, John Irwin, Sharon Michalske, and Craig Reinarman for their contributions. Special thanks to the respondents who continue to give of themselves so candidly during the lengthy course of the research study.

References

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