Treatment as Harm Reduction, Defunding as Harm Maximization: The Case of Methadone Maintenance

Abstract

Despite numerous research studies demonstrating the efficacy of methadone maintenance treatment (MMT) in general and the value of retention in particular, the increasing defunding of this modal ity has compromised its potential. From 1990 to 1995 the lead author conducted a longitudinal research project to determine the impact of the cost of treatment on 233 San Francisco Bay Area study participants seeking, enrolled in, or defunded from MMT. This paper reports on selected findings from that study. Using variables of drug use, crime, gender and HIV risk, qualitative and quantitative results comparing those seeking treatment with those enrolled in treatment indicated that MMT functioned as a harm-reduction tool. When clients were defunded, however, drug use, crime and HIV risk increased and harm was maximized.

The success of methadone maintenance treatment (MMT) in the areas of drug use, crime reduction and HIV risk reduction, has been amply demonstrated by a number of research studies. Nonetheless, MMT is underutilized and has in fact experienced a decline in the 1990s. Although the efficacy of MMT has been established, significant barriers to treatment continue to reduce the potential benefits of this modality. Numerous researchers have found that only a small fraction of heroin addicts nationwide enter treatment, and that about two-thirds of these leave before completing their first year of treatment (Hahn & Onorato 1989; Ball et al. 1988; Hubbard et al. 1988; Simpson 1979.)

Arguably one of the most important barriers to entrance to and retention in MMT, and certainly one of the most overlooked in the literature, is the reduction in public funding of treatment. In addition to evolving doubts about the soundness of long-term methadone treatment, the re-prioritizing of public monies away from MMT has had an impact on access to and length of stay in methadone maintenance for the majority of clients. Over the past decade a shift in the ownership and funding base for methadone maintenance in the United States has decreased the number of low-cost public slots available nationwide and resulted in increased cost for clients seeking private methadone slots. Private clinics have replaced publicly owned and operated methadone programs, and the cost of treatment paid out-of-pocket by injection drug users (IDUs) has risen sharply (Gerstein & Harwood 1990).

The current preponderance of privately funded methadone maintenance clinics represents a movement away from the publicly supported programs of the 1960s. MMT was originally conceived as a medical treatment with the goal of reversing a number of antisocial behaviors including drug use, crime and unemployment, and was funded wholly by federal, state, and local governments. However, during the 1980s public monies for MMT decreased dramatically (Gerstein & Harwood 1990). Changing fiscal priorities mandated that different treatment modalities compete for scarce federal and local funds. The United States entered a period of fiscal conservatism in which less money was allotted to the states for social services. The political climate shifted away from maintaining addicts on "just another drug" and veered toward an abstinence approach. This period was dominated by the "Just Say No" dogma espoused by Ronald and Nancy Reagan (Rosenbaum 1995). A number of public misconceptions about methadone maintenance also facilitated this shift, including the beliefs that methadone maintenance clients are "substituting one drug for another" and that methadone "keeps you high 24 hours a day" (Zweben & Sorensen 1988). Due to the combination of funding cuts, political criticism, and clinical skepticism, MMT lost much of its public funding base.

Private, fee-for-service programs have replaced publicly funded clinics in many states and localities with sizable addict populations. Indeed, over the past ten years federal monies for methadone have decreased by more than one-third (Gerstein & Harwood 1990). At the same time, the fees paid out of pocket by NEWT clients themselves have increased by 80% nationally. In California, by 1990, 90% of the state's 202 methadone clinics were privately owned and the major source of revenue for methadone was, and remains, client fees (California Department of Alcohol and Drugs 1991; Anglin & McGlothlin 1985).

The shift from publicly to privately funded clinics has resulted in two related problems. It is difficult for heroin addicts, most of whom have limited financial resources, to obtain treatment. They continue to use heroin, commit crimes, and engage in high-risk behaviors. Those clients who manage to obtain treatment but cannot absorb increases in fees must detoxify prematurely (Farley et al. 1992; Johnson, Record & Young 1991; Rosenbaum et al. 1990; Anglin et al. 1989; Murphy & Rosenbaum 1988; Rosenbaum, Murphy & Beck 1987; Ben-Yehuda 1982). Numerous studies have found that ending treatment too soon increases the likelihood that clients will return to drug use, and that treatment outcomes, including drug use, criminality and morbidity, are directly related to length of stay in treatment. Therefore, the effect of limited duration methadone (both as the result of an abstinence orientation by individual clinics, counties and states, and the defunding of this treatment modality) has important implications for both addiction and AIDS. Simpson and Sells (1990) found that "71% of patients relapse within the first six weeks of treatment discharge." Kang and De Leon (1993) found that shorter stays in treatment were the strongest predictor of high-risk behaviors (e.g., needle sharing, high number of needle sharing partners). Rosenbaum, Irwin and Murphy (1988) warned that limiting public funding leads to the destablization of MMT clients, which can lead to increased drug use and needle sharing.

This paper summarizes selected findings from a five year longitudinal study of San Francisco Bay Area heroin addicts seeking MMT, in MMT, and threatened with the loss of their publicly funded treatment slots. The goals were explicit from the outset: to provide a forum for methadone clients' unheard voices--a way for them to tell their own stories and in so doing illuminate their experiences-and to provide a context in which their actions could be understood. It was also hoped that the research would help to make policy more rather than less favorable to addicts who were struggling to utilize drug treatment; to contribute to. turning the tide of intolerance; and to facilitate positive change for these individuals, whose chances for success in MMT had been victimized by political maneuvering and fiscal shortsightedness.

A structured longitudinal study combined qualitative and quantitative methods, recruiting 240 subjects from various methadone maintenance clinics in the San Francisco Bay Area. Each person was interviewed initially, using a life-history/depth interview as well as a closed-ended survey instrument. The depth interview would provide thick description and enable interviewees to articulate their experience, opinions, and suggestions as consumers of MMT. Each individual was contacted every six months and re-interviewed, using a shorter closed-ended instrument with a short qualitative component. The six-month follow up interviews were conducted for three years. Seven individuals were dropped from the study almost immediately due to attrition and death, so at the initial interview the study population numbered 233.(1)

The concept of harm reduction was used as a theoretical framework. Offered as an alternative to the "zero tolerance" approach that is a cornerstone of the War on Drugs, the harm-reduction framework accepts the inevitability of drug use and emphasizes minimizing the risks associated with such use. Public debates regarding harm reduction have been phrased in terms of "self-protection" and "managing risks." At a policy level, such efforts might include the provision of clean needles to injection drug users, or the shift in funding from criminal justice measures to prevention and treatment programs (Nadelmann et al. 1994).

The research findings contained both good and bad news. MMT functioned as a harm-reduction tool for the vast majority of the study participants. Although program goals of abstinence from illicit drugs and total elimination of criminal activity were not always met completely, using the variables of drug use and crime, and to a lesser extent HIV-risk and gender, individuals utilizing MMT simply fared better than those who could not access treatment. That is the good news. The bad news is that access to MMT has become increasingly restricted, and treatment is cut short for many clients due to limited funding. This policy consistently maximizes harm in the same areas that MMT otherwise proves beneficial: drug use and crime, and to a lesser extent HIV-risk and gender. Methadone's harm-reduction potential is detailed below, followed by an examination of the harm maximization effects of defunding.

In comparing the participants in the present study who were seeking treatment with those already in methadone maintenance, striking differences were found in the areas of drug use and crime. MMT also proved a less dramatic, though impressive harm-reduction tool for IUV-risk and women.

Drug Use

This study population included individuals seeking MMT. At the beginning of the study they numbered 70, but over the course of the three-year data collection period some were able to get on methadone. Some participants got on and then got off again. Half (n=35) of those originally seeking treatment were never able to access MMT.

The study participants seeking MMT, whether ultimately successful at getting it or not, used a great deal of heroin. In the 180 days prior to the first inter-view, the median days of heroin use for those seeking treatment was 180. This is the reason, of course, they wanted to enlist in treatment. Although their heroin use was constant, these individuals attempted to manage their drug use in order to minimize damage to their health and general lifestyle. They were not completely self-destructive, and tried to maintain control, periodically abstaining and limiting their intake in order to avoid becoming addicted. Individuals seeking treatment tried a potpourri of alternatives, including and especially 21-day methadone detoxification. While the study participants' heroin use was consistent and frequent, it was not characterized by the ingestion of large quantities of the drug. The study participants seeking treatment, for the most part, were using enough heroin to stave off withdrawal symptoms and stay "well" until they could get into MMT.

Those individuals seeking treatment experienced numerous barriers. They had to consider the rules and regulations that characterized MMT, including conforming to nonnegotiable dosing hours that might conflict with their work or family schedules, mandatory urine testing, and counseling. Those holding conventional jobs had to consider the implications of drug testing, which would reveal their (often concealed) methadone status, at their workplace. They had to decide whether they wanted to be inextricably tied to a clinic, on a daily basis, to receive their medicine. Most did, and proceeded to enlist themselves in the "hoop jumping" that was needed to enroll in a program.

After making the difficult decision to enlist themselves in MMT, most could not get in a program immediately. Either there were no openings or they could not afford to pay the fees. Nonetheless, most continued to try, and over half (51.4%) of the study participants got on a waiting list. Being on a waiting list required a high level of persistence and the ability to live with frustration. Most individuals had no telephone, therefore they had the responsibility for continually calling the program. Many had busy "hustling" routines, and otherwise rather chaotic lives, rendering follow-through very difficult. In fact, of the 36 individuals on waiting lists at the beginning of the study, only 14 eventually got in a program.

The greatest barrier to treatment was the cost of methadone. In the course of each of the five interviews, individuals seeking treatment were asked to name the main reason they had not accessed MMT. Of all the reasons they gave, inability to pay fees was most consistently mentioned, with nearly half the participants noting this as the primary obstacle. Although many were able to sporadically support an expensive heroin habit, most could not rationalize "hustling" to pay for treatment. The reason for enlisting in treatment, after all, was to get out of "the life." Ultimately, as a result of rejection and frustration with the process, half the individuals who were seeking treatment at the beginning of the study gave up. The result was continuing heroin use and concomitant activities, including crime and the use of syringes, which put them at risk for HIV.

When individuals finally did gain access, they gradually began to derive benefits from MMT. It did not happen overnight. The majority of the study participants had been heroin addicts for several years prior to getting on methadone, and it took time for them to reorient their thinking and lifestyle completely. While two-thirds continued to use heroin occasionally (one to three days per week), methadone was a tool used to control the use of heroin, and only 9% used heavily (six to seven days per week). These data indicated a clear reduction, a process of decreasing heroin use involving an adjustment period.

Those study participants in MMT who continued to use heroin could take it or leave it. Some used because they continued to be members of social worlds that were characterized by heroin use. Women who had been sex workers, for example, continued in that occupation because they needed the money. Drug dealers continued in that line of work for financial reasons, and 90% of them used heroin. Others had partners who were out of treatment and active heroin addicts. After years in "the life," many symbolic aspects of heroin use endured. As alcohol is used in society in general for celebratory enhancement, heroin continued to be defined as a substance to be used to reward oneself. It was also used for therapeutic reasons: to relieve pain, stress, depression, or boredom. Some individuals found treatment a difficult transition, and were slow in assuming new nonaddict identities. If, in the context of treatment, they were subjected to inadequate dose levels or blind dosing, the adjustment could take even longer. Nonetheless, being on methadone enabled these individuals to reduce their use of heroin, and to begin to change their priorities in the direction of conventional employment, school, and family. Money was redefined and no longer seen simply as a commodity to be exchanged for heroin. Heroin use had decreased from out-of-control to controlled, from daily to occasionally, when there was extra money, such as on paydays or to celebrate. At the time of the initial interview, individuals were asked to report how many days of the previous 180 (six months) they had used heroin. Those who were still seeking treatment reported the most days (mean= 154), compared with those who had been on methadone less than two years (mean=43 days). Having put in more time, those who had been on MMT for more than two years reported a mean of 19 out of 180 days. Clearly, "success" in terms of drug use must be seen as a process of harm reduction, of using less (albeit some), becoming stabilized, and maintaining contact with social services and health care through MMT.

Crime and Employment

Study participants who were seeking treatment had limited experience with and resources for conventional employment. Most (65%) noted some form of public support as their main lifetime source of income. All had committed crimes as a main or supplemental means to support their heroin habits as well as basic needs, and three in four (76%) had been apprehended and involved in the criminal justice system. The overwhelming motivation study participants noted for MMT was to lessen their risk for incarceration. In addition, women who were sex workers wanted to extricate themselves, but there was a Catch-22: study participants seeking treatment could not afford to pay program fees up front. In the interim between deciding to get on methadone and actually enrolling in a program, they had to continue committing crimes in order to earn enough money to stay well and earn enough money to pay fees. Only an immediately accessible subsidized slot could extricate them from hustling. As a consequence, many of those who were denied access to MMT continued to commit crimes. Three in five (58.6%) were arrested for a variety of crimes during the course of the study, with over half going to jail or prison.

Study participants in MMT fared better in terms of crime and employment, after a time. At the initial interview, nearly two-thirds (65.8%) of those seeking treatment reported criminal activity, compared with only 22.3% of those in MMT. As with the use of heroin, moving away from criminal activity toward licit ways of earning a living was a process: a process of harm reduction. "Marginal" clients were closest to the street, with a medium to high degree of heroin and other drug use. Four in five continued to be involved in criminal activity, and only one-third held even a part-time conventional job. Although financial instability characterized this group, most could not procure a subsidized slot because they were on General Assistance and not the requisite Supplemental Security Income. As a result many moved in and out of the treatment they needed so badly. "Stabilized" clients were "on their way" to a heroin-free lifestyle, and MMT had enabled them to seek and maintain employment, if only part time. "Model" clients, having been in MMT the longest (an average of five years) were the closest to achieving financial stability. Their lifestyles had shifted from desperate and chaotic to stable and routinized, with nearly half (43%) working full time for at least part of the study and few committing crimes. Again, the process of harm reduction is emphasized. For example, by the end of the study, 27% of clients who had been in MMT less than two years had been involved in the criminal activity of boosting (stealing). Only 5% of those individuals who had been in MMT for more than two years had committed similar crimes. Using a more directly drugrelated crime as an example, 22% of those who had been in MMT less than two years sold drugs, compared with 7% of those who had been in MMT more than two years.

HIV Risk

One item of good news from the study is that many IDUs have been educated about the risk of HIV and AIDS and seem to be heeding harm-reduction messages. The vast majority of the study participants had been tested for HIV 94% of those seeking treatment at the initial interview; 85% of those in treatment; and 93% of those whose slots had been defunded. Both in- and out-of-treatment participants knew about their risk for IUV through needle-sharing, and to some extent through sexual contact. During the course of the study, the proportion of study participants reporting needle-sharing dropped from 62% to just 9%. Even among the out-of-treatment population, syringe-sharing dropped from 39% at the time of the initial interview to 13% at the last interview, nearly three years later. The availability of syringe-exchange programs, of course, was a factor in the reduction of needle-sharing among study participants, and most of them had been recruited from such programs. Also important was their knowledge of and experience with injection-related problems prior to the AIDS epidemic, such as hepatitis, abscesses, and sexually transmitted diseases. Based on reports from study participants, it seemed that the street outreach, AIDS education, harm-reduction messages and programs begun in the late 1980s had been successful to a large degree. These programs simultaneously educated IDUs and facilitated their own harm-reduction attempts.

Methadone maintenance itself, while not the significant harm-reduction variable seen in heroin use and crime, provided clients with a way to stabilize their lives, reduce their heroin use, and as a result cease or reduce syringesharing. As noted in the discussion about drug use, methadone removed the daily heroin-seeking desperation from clients' lives. If it occurred at all, drug use was occasional, controlled, and certainly reduced. In turn, because heroin use was transformed from mandatory (to stave off withdrawal symptoms) to optional, injection practices were controlled. Clients did not have to share needles if clean syringes were not available because they had methadone as a buffer, and could opt not to use heroin in the first place. Methadone, in essence, gave clients the choice not to use heroin and the option not to share syringes out of desperation.

In addition to providing a safety net, MMT programs offered concrete resources. AIDS education programs within the clinics ranged from mandatory to optional, and extensive to minimal. With few exceptions, clients applauded such programs as useful and beneficial. Clinic staff provided information about AIDS and HIV-risk, professional counseling, an open forum for discussion, and occasionally even risk-reducing materials such as condoms and bleach. Most clinics offered free HIV testing, which often provided clients their first opportunity to discover their serostatus. Of those few individuals who had not been tested at the initial interview, nearly half (44%) changed their minds and were tested at a later point in the study. Of those who were tested later, 70% were in MMT.

Gender

Women in the study population experienced unique difficulties as heroin addicts. If they became pregnant they had to confront potential damage to their unborn baby that might be caused both by injecting heroin and the chaotic heroin lifestyle. Women who had been pregnant also had cause to fear loss of custody if their baby tested positive for illegal drugs. The threat of loss of custody also applied to women in the study population who were not pregnant but were mothers of minor children.

When women injected drugs and out of desperation shared needles, they often did so "behind" their shooting partners, putting them at higher risk for contracting HIV. Finally, women in the study population often resorted to sex work to earn enough money to support a habit and basic needs. This occupation required them to use heroin as an emotional buffer, and put them at higher risk for sexual transmission of HIV.

Methadone maintenance offered women stabilization and the option to exit the chaos and risk of the heroin life. They were able to create a more routinized lifestyle for their children and avoid custody challenges. Study participants indicated an improvement in their ability to be effective parents after accessing MMT. Quite simply, their lives were more predictable and conducive to raising children. A facilitating clinic structure, in which women were able to juggle program requirements with childcare, proved most beneficial, if not the norm. MMT enabled women to reduce their risk for IUV by, as discussed above, providing a safety net that rendered needle use optional. Finally, methadone provided study participants who had been sex workers the opportunity to earn money in less dangerous (albeit less lucrative) ways. They no longer needed the money to buy heroin, and because they were no longer turning tricks, they no longer needed heroin to deal with the emotional distress attached to that occupation.

Quantitative data indicated few statistically significant differences between men and women on the major variables of drug use, crime, and HIV risk. Women as well as men experienced harm-reducing effects from MMT. However, with regard to issues specific to women--pregnancy, parenting, needle-sharing practices, and sex work-qualitative data indicated a marked improvement on accessing methadone.

As a legal narcotic, the distribution of methadone in the United States involves a complex bureaucracy. There are innumerable state and federal regulations that dictate almost every aspect of the daily routine at most clinics. There are also local policies that add to the plethora of "regs" with which both clinic staff and clients must contend. Many of these rules actually compromise the harm-reducing potential of methadone, and from the view of consumers, hinder their progress.

As discussed earlier, since 1980 the funding policy of MMT has changed. In the state of California, for example, there has been a reduction in publicly supported methadone treatment. This has necessitated the institution of a number of different policies designed to move treatment from subsidized to fee-for-service. The present study was designed to describe and analyze the impact of the policy of defunding of MMT. In this effort, those on methadone were compared with individuals who had occupied a subsidized MMT slot, but as a result of budget cuts, lost their funding. In short, the study indicated that in the areas of drug use, crime/work, HIV risk, and gender, a policy of defunding ultimately maximized harm and proved to be counterproductive.

Drug Use

The quantitative study data indicated statistically significant differences in heroin, tranquilizer, and crack cocaine use among participants who left MMT before the end of the study and those who remained in treatment. Those who had left MMT by the end of the study (Time 5) reported an average of 48 days of heroin use, compared with just 21 days for those who remained in treatment. Only 4% of the individuals who stayed in treatment reported heavy use of heroin, compared with over one-third (34.4%) of those who had lost their funding. The reverse also applied, and at the end of the study, nearly 68% of study participants who remained in treatment were using heroin only occasionally (twice a month or less), compared with just 28% of those who left MMT. Men and women differed little regarding heroin use. By the end of the study, men who stayed in treatment averaged 20 days of heroin use, compared with 52 days for those who left. Women in treatment averaged 22 days of heroin use, compared with 44 days for those who were defunded.

Knowing that increased heroin use was a real possibility, study participants who had been on methadone, but whose subsidized slots had been defunded, did not want to leave treatment. They appreciated the harm-reducing potential of MMT, and most initially tried to remain in their programs. Despite their good intentions, many individuals who wanted to remain on methadone after defunding found it fiscally impossible, and had to begin a detoxification. As a result of methadone withdrawal, many experienced mental health problems, such as depression and even suicidal feelings. Heroin consumption escalated, with median days of use at 24 before and 102 after detoxification. Mean days of use increased from 32.3 at the beginning of the study to 48.6 days at the end. The initial harm-reducing effects of MMT (as opposed to the harm maximization demonstrated by the defunding policy) were demonstrated by comparing those who initially left and then returned to treatment with those who left permanently. Those who temporarily left MMT reported a median of 12 days of heroin use (in the past six months) at the beginning of the study, which increased to 25 days by the end. By comparison, those who had been defunded reported heroin use a median of 20 days, which by the end of the study had increased to nearly 80 days.

Crime and Employment

Compared with clients who occupied private slots, study participants who occupied county-funded slots were in need of financial support for their methadone treatment. Whereas 62% of "private" clients were employed, only 37% of "funded" clients held conventional jobs. Alternatively, 47% of the funded clients used illegal means to earn money, compared with just 28% of "private" study participants. Nearly one-third (32%) of funded clients, compared with 20% of private clients, were immersed in the criminal justice system as repeat offenders. In short, study participants who occupied funded slots badly needed the financial assistance provided by the county. Of the 56 study participants who were defunded, nearly half (46%) were long-term addicts who had used heroin for more than ten years. They were limited educationally, with 45% having less than a high-school education. Over half (57%) had little conventional work experience, instead using illegal activities or public support for income. In sum, they simply were unable to assume, using conventional means, a clinic payment of nearly $300 per month.

Nonetheless, some attempted to stay in treatment and pay. This caused financial destabilization, with 2 1 % utilizing criminal activities to pay for treatment, and 59% arrested. The risk and chaos inherent in participation in criminal activities lead to a compromised treatment regimen. Many study participants could no longer conform to the many structural requirements of MMT Those who initially used illegal means to pay clinic fees could not sustain this behavior in the clinic setting and earn enough money for payment, and were "fee-detoxed" within a year. Participation in criminal activities had already pushed these individuals back into "the life," and a detoxification from methadone led to the escalation of heroin use. This, in turn, produced feelings of resignation and affirmation of the old once a junkie. . ." adage.

Study participants who left MMT immediately as a result of defunding also experienced an increase in their criminal activity, with nearly one-half (48.6%) charged with a crime during the course of the study (compared with 29.5% of in-treatment study participants). Of the six kinds of criminal activity examined (stealing/boosting, robbery, trafficking, sex work, copping drugs, and drug dealing), with the exception of robbery, those participants who were defunded reported higher activity than those in MMT. Not surprisingly, the most striking and significant (p<.001 and p<.004, respectively) differences appeared in the drugrelated crimes of copping drugs and dealing. The defunded group copped an average of 59 times in the six months prior to the final interview, compared with four times for the in-treatment group. Dealing was similar, with the mean number of sales for the defunded group at 162, compared with 22 for the in-treatment group.

HIV Risk

When heroin addicts are unable to access or remain in treatment because of long waiting lists or fees, they often continue to use drugs. Out-of-treatment heroin addicts use more heroin than those in treatment, and heroin use and addiction often lead to the need to share syringes. Policies that turn individuals away from MMT in essence encourage heroin use, automatically putting addicts at risk for HIV and maximizing drug-related harm.

Study participants who were in MMT for the duration of the study had a lower number of sexual partners and used heroin less than those who were out of treatment. Accompanying defunding and detoxification was the elimination of the constant risk reminders confronting clients in the clinic setting, increased heroin use, illegal activity, desperation, and risk. Fortunately, the availability of syringe-exchange programs helped reduce HIV risk, even for those study participants who were unable to access and stay in treatment.

Although the incidence of needle-sharing was consistently low for study participants both in and out of treatment, if did occur. Qualitative data indicated two major contexts of syringe-sharing. The first, and most common, involved "being sick." Study participants reported that although they attempted to avoid sharing, when they were experiencing heroin (or methadone) withdrawal and no bleach or clean needles were available, they would reluctantly share with another user. Several study participants reported that they shared syringes when they were too intoxicated to practice safety.

Study participants noted several barriers to consistent non-sharing, even when they were absolutely committed to risk-reduction. The major obstacle to safety was the lack of availability of clean syringes. Although this study took place in the San Francisco Bay Area where a few programs were underway, some participants noted that when they could not get clean syringes, they were forced to share. Others reported they were deterred from carrying clean syringes because it was illegal to do so, and they feared being arrested. For those who could not utilize the needle exchange program and had to buy syringes "on the street," lack of finances was an obstacle. The belief that it was safe to share with a "known" individual was another obstacle to consistent non-sharing.

Gender

Policies that made it impossible for women to access or remain in MMT put women in jeopardy and maximized harm to their children, if indirectly. Women who sought but could not get into a program, as well as women who were defunded, continued to use heroin. In support of their habits, over half (53%) of the out-of-treatment female study participants resorted to sex work. This was one of the most lucrative ways of making money open to them, since only 35% (compared with 56% of men) had been employed in conventional occupations during their lifetimes. Women's difficulties in earning money in conventional ways was illustrated by the fact that 40% of the women, compared with 6% of the men, had listed "illicit" occupations as their primary lifetime source of income.

The use of sex work to earn money for heroin (when women could not access MMT) or for treatment (when their slot was defunded) resulted in compounded, escalating risk factors. Participation in sex work necessitated heroin use in order to cope with the stress and degradation associated with it. In turn, heroin use often escalated to addiction and constant "dope sickness." The desperation to alleviate withdrawal symptoms caused these women to share injection equipment, putting them at risk for HIV transmission through contaminated syringes. Study participants reported becoming intoxicated regularly in order to cope with sex work, and as noted above, this proved a barrier to consistent non-sharing.

Sex workers were. also at risk for IUV transmission through unprotected sexual contact. Women reported inconsistent use of condoms because they needed money for drugs and basic needs. Out of desperation, some consented to unsafe sex with a trick who did not want to use a condom. Women also noted that intoxication compromised their own commitment to safe sex.

Perhaps the most painful and fearful aspect of heroin addiction for women is the perception, and occasionally the reality, that their children are being harmed. Many women lamented their inability, due to lack of funds, to access or remain on methadone, noting the stability provided by MMT as much more conducive to child rearing than the high-risk and chaotic life of heroin addiction. They (rightfully) worried about losing their children to Child, Protective Services (CPS) while they were using heroin,* earning money illicitly, and not in treatment. Getting on methadone, for many women, was inspired by their desire to retain custody and raise their children in an environment free of heroin and crime.

Women were so committed to remaining in treatment that some used a sizable portion of their meager ($400 to $500 a month) Aid to Families with Dependent Children (AFDC) to pay for MMT ($300 a month) when their slots were defunded. This effort, of course, could not be sustained, and many of these women ultimately detoxified from methadone and returned to sex work for financial support. They also returned to heroin use to alleviate withdrawal and cope with prostitution, putting them at risk for injection and sexual transmission of IUV.

Women who could not access or were defunded from MMT, as noted above, often did return to heroin addiction, and did lose custody of their children. This had the effect of spiraling them deeper into drug use and further from conventional life. Nonetheless, several of the study participants continued to pursue treatment in the hope that they could convince CPS of their ability to parent.

Data from the present study indicate clearly that methadone maintenance is a harm-reduction tool. MMT facilitates a process of gradual reduction in heroin use, reduction of syringe sliming and HIV risk, and reduction of criminal activities. It is cost-effective from a societal standpoint and removes the issue of drugs from the life of an addict Recently, however, it would seem that policymakers in the United States have lost sight of the modest benefits of methadone. Consequently, policies such as reduction in public support, resulting in defunding of slots for those in need, have been instituted in an effort to cut costs for social programs. The result, as indicated by the present study data, has been the maximization of harm: increased heroin use, increased crime, increased risk for HIV, and increased risk to families of heroin addicts. The harm-reduction potential of methadone maintenance must be realized. In that effort, treatment on request, an end to limited-duration treatment, and the treatment of clients as patients and consumers are the recommended policy changes.

Treatment on Request

Methadone maintenance is a treatment of last resort. It is a major commitment and not one taken lightly by heroin addicts. When an individual decides to enlist in MMT, he or she is using (often too much) heroin, injecting, frequently committing crimes to pay for drugs, and generally not taking care of business. The individual is desperate, at the end of the line, and usually depleting the community of thousands of dollars in health care and criminal justice costs.

When heroin addicts are turned away from treatment because of a lack of treatment slots, they most often continue to use heroin, inject, and commit crimes. Each day that MMT is delayed is another day in which societal as well as human costs are incurred. It is another day in which HIV may be spread from the desperate, communal use of contaminated syringes. It is another day of stealing in order to pay for drugs. It is another day that children are neglected because their father or mother is consumed with procuring and using drugs.

There is no excuse for turning a willing addict away from MMT. If an individual seeking treatment cannot afford to pay for it. local, state and federal funds must be granted to absorb the fees. The ultimate cost to the community, in terms of dollars, of providing affordable treatment consistently computes to far less than that of the price of continuing heroin addiction and concomitant crime.

An End to Limited-Duration Treatment

Once heroin addicts have enlisted in MMT, there should be no limit to how long they can remain in a program. Study after study, including the present one, has concluded that the longer a client remains in treatment, the better the results in terms of drug use, crime, and employment. Additionally, ending treatment too soon has deleterious consequences for drug use, crime, employment, and IUV risk. MMT should be redefined as a medical treatment in which the duration depends completely on the individual patient. Treatment may take several months, several years, or a lifetime. To abruptly end treatment before the client is ready by his or her own definition is an ill-conceived, inhumane policy having no basis in sound medical practice.

Policies that provide payment for treatment for a short period, with the assumption that at the end of that period the client will pay, are as ill-conceived as those that terminate treatment for other arbitrary reasons. Individuals in need of methadone treatment should not only be able to access it when they need it, they should be able to count on services until they are ready to detoxify, and no sooner. For the client, the loss of funded treatment, as well as the anticipation of that loss, produces destabilization that drastically compromises the treatment routine.

The societal and human costs of imposing fees that either financially destabilize or force clients off MMT are as great as those resulting from denied access. Again, a simple cost-benefit analysis should be made to determine the effectiveness of providing sustained MMT versus time-limited funded treatment. The costs of health care as a result of the damaging effects of heroin use, syringe use and sharing needles, and of criminal justice costs and incarceration as a result of using illegal activities to finance a heroin habit far outweigh the $4,000 a year to maintain a client on methadone. If MMT policy were restructured to include the option for "successful" clients to procure methadone through prescription, the cost of clinic administration and bureaucracy could be deducted, making its cost 10% that. of clinic treatment, the equivalent of other pharmaceutical drugs. To reiterate, whether MMT's cost is $4,000 or $400 per year, it is but a fraction of the estimated $40,000 Californians pay for incarceration and the estimated $120,000 paid in health care costs for AIDS patients (Volberding 1995).

The Treatment of Clients as Patients and Consumers

Methadone clients are human beings in need of medical treatment. They should be treated as other consumers of medical services, not as deviant, criminal, or inherently different from others seeking treatment. In the current system, potential clients are often put off by "hoop-jumping" requirements, seemingly arbitrary mechanisms of control and punishment, and disrespectful clinic staff. Consequently, clients respond in kind, perpetuating a combative tone that ultimately does not serve the commonly agreed on therapeutic goals of drug abuse treatment. Too often potential clients do not enroll in MMT at all.

Clients should be treated as consumers of services, with their needs paramount and their input seriously considered. They ought to be given the opportunity to participate in structuring their own treatment and certainly to have major input in decisions that so intimately affect their lives. Those who purport to deliver services to this population will find (perhaps to their surprise), that if treated with respect and dignity, methadone clients will behave in a respectful and dignified manner. The treatment process will begin to resemble closely that of its original intent, an ongoing interaction between patient and physician with the mutual goal of improving the health of the client.

1. The population reflected methadone maintenance clientele in terms of demographics, breaking down almost evenly in terms of gender; being overwhelmingly heterosexual; and primarily in their late thirties and early forties. Ethnicity was mixed: approximately 60% were White, 20% were African-American, and 12% were Latino. Consistent with popular notions about the relationship between drug use and crime, over three-quarters had been convicted of at least a misdemeanor offense. Nearly four in five had spent some time in jail, but only one-quarter had done prison time. African-Americans and Latinos were disproportionately convicted and incarcerated. Considering all the illicit activity reported by the study population, the relatively little time served in prison indicates their numerous crimes were primarily petty, not violent or dangerous.

This research was suported by National Institute on Drug Abuse grants R01 DA 05277/08982, Marsha Rosenbaum, Ph.D., Principal Investigator, Bennett Fletcher, Ph.D., Program Officer.

* Director, Drug Policy Alliance, San Francisco, California.

** Research Associate, The Lindesmith Center, San Francisco, California.

The authors wish to thank the following persons for their contributions to this effort: Sue Eldredge, Andre DeLeon, Ernie Drucker, Bennett Fletcher, Geoffrey Hunt, John Irwin, Katherine Irwin, Doug McDonnell, Sheigla Murphy, Craig Reinarman, Reda Sobky, (the late) John Watters, and Lynn Wenger.

This article is dedicated to the 233 study participants who generously shared their life histories over such a long period, and to the five methadone maintenance clinics that welcomed the authors and facilitated the research.

Please address correspondence and reprint requests to Marsha Rosenbaum, Ph.D., Director, Drug Policy Alliance San Francisco, 2233 Lombard St., San Francisco, CA 94123.

Anglin, M.D. & McGlothlin, W.H. 1995. Methadone maintenance in California: A decade's experience. In: L. Brill & C. Winick (Eds.) The Yearbook of Substance Use and Abuse. Vol. 3. New York: Human Sciences Press.

Anglin, M.D.; Speckart, G.R.; Booth, M.W. & Ryan, T.M. 1989. Consequences and costs of shutting off methadone. Addictive Behaviors 14:307-26.

Ball, J.C.; Lange, W.R.; Morse, C.P. & Friedman, S.R. 1988. Reducing the risk of AIDS through methadone maintenance treatment. Journal of Health and Social Behavior 29:214-26.

Ben-Yehuda, N. 1982. Private practice, competition. and methadone maintenance. International Journal of the Addictions 17:329-4 1.

California Department of Alcohol and Drug Programs. 1991. Fact Sheet: Methadone Program Licensing in California. September.

Farley, TA.; Canter, M.L.; Wassell, J.T. & Hadler, J.L. 1992. Predictors of outcome in methadone programs: Effect of HIV counseling and testing. AIDS 6:115-21.

Hahn, R.A. & Onorato, I.M. 1989. Prevalence of HIV infection among intravenous drug users in the United States. Journal of the American Medical Association May 12:2677-685.

Hubbard, R.L.; Marsden, M.E.; Cavanaugh, E.R.; Rachal, J.V. & Ginzburg, H.M. 1988. Role of drug abuse treatment in limiting the spread of AIDS. Reviews of Infectious Diseases 10 (2): 377-84.

Gerstein, D.R. & Harwood, H.J. (Eds.) 1990. Treating Drug Problems. Vol. 1. Washington, D.C.: National Academy Press.

Johnson, J.; Record, N. & Young, P. 1991. Drug treatment programs conduct effective outreach and behavior change interventions. Network 2 (3): 105.

Kang, S.Y. & De Leon, G. 1993. Correlates of drug injection behaviors among methadone outpatients. American Journal of Drug and Alcohol Abuse 19 (1): 107-18.

Murphy, S.B. & Rosenbaum, M. 1988. Money for methadone II: Unintended consequences of limited duration methadone maintenance. Journal of Psychoactive Drugs 20 (4): 397-402.

Nadelmann, E.; Cohen, P.; Locher, U.; Stimson, G.-, Wodak, A. & Drucker, E. 1994. The harm reduction approach to drug control: International progress. Unpublished paper.

Rosenbaum, M. 1995. The demedicalization of methadone maintenance. Journal of Psychoactive Drugs 27 (2): 145-49.

Rosenbaum, M.; Irwin, J. & Murphy, S. 1988. Defacto destabilization as policy: The impact of short-term methadone maintenance. Contemporary Drug Problems 15 (4): 491-517.

Rosenbaum, M.; Murphy, S.B. & Beck, J. 1987. Money for methadone: Preliminary findings of a study of Alameda County's new maintenance policy. Journal of Psychoactive Drugs 19 (1): 13-19,

Rosenbaum, M.; Murphy, S.B.; Irwin, J.; McDonnell, D. & Watson, L. 1990. Money for Methadone: A Study of a County Policy Change. Final Report to the National Institute on Drug Abuse, Grant #1 R01 DA03804. Rockville, Maryland: National Institute on Drug Abuse.

Simpson, D.D- 1979. The relationship between time spent in drug abuse treatment to post-treatment outcome. American Journal of Psychiatry 136:1449-453.

Simpson, D.D. & Sells, S.B. (Eds.) 1990. Opioid Addiction and Treatment: A 12-Year Follow-up. Malabar, Florida: Robert E. Krieger Publishing.

Volberding, P. 1995. Personal communication.

Zweben,J.E. & Sorensen, J.L 1998. Misunderstandings about methadone. Journal of Psychoactive Drugs 20 (3): 275-81.