Advertisement
SOCIAL STUDIES
A Fix For Addicts -- And For Drug Policy
Methadone treatment has quietly proved its worth.
That sound you hear is ice cracking. Chunks of America's frozen drug policies, long dysfunctional and at best semi-rational, are breaking off and falling into the sea. In November, Michigan became the 13th state to permit the use of marijuana for medical purposes, and Massachusetts decriminalized possession of small amounts. New York has moved to relax its fiercely punitive drug sentencing laws, once a point of pride. In February, three former Latin American presidents declared the war on drugs a failure. Last month, Secretary of State Hillary Rodham Clinton said, "Clearly, what we've been doing has not worked."
What does work? From Capitol Hill, hopeful models seem far away. One, however, is quite nearby -- less than 2 miles down the street.
Early one cold morning, Sally Satel drives me to the Oasis Drug Treatment Center, a methadone clinic in Northeast Washington, almost literally in the Capitol's shadow. She is a public intellectual and resident scholar of the American Enterprise Institute, and, more relevant for today's purposes, a practicing psychiatrist who has been treating addiction for 20 years. As the Capitol dome recedes behind us, we enter a land of used-car dealers, nail salons, and transmission shops.
We pull up behind a pink building that looks like a warehouse. It bears no sign or identification of any kind. The parking lot is ringed with barbed wire. Through an unmarked steel door in back, we pass the entrance of what was once a parking garage upstairs, now disused. Another door admits us to the clinic.
It is clean but stark. No effort has been made to doll it up. Furniture is minimal, decorations almost nonexistent. The Betty Ford Center this is not. Early in the morning, the interior is still cold. Satel, who is on retainer as the consulting psychiatrist, wears a sweater -- and several protective layers of wariness. I soon see why.
She leads me into a room dominated by a conference table. Two doctors and an addiction counselor are plowing through patient files, deciding who can have "take-home." Oasis is a private clinic: Most patients pay their own way, starting at $20 a day (declining to $12 on good behavior). For the first three months, the only way they can get methadone is to come in every day. If they stay off street drugs (they're tested), they can graduate to bringing home a week's or even a month's supply.
One patient wants take-home for a five-day holiday. Approved. But the next file raises eyebrows. Why is the patient taking Tylenol 3, which contains a narcotic? Why doesn't the file include a diagnosis? Why can't they read the name of the prescribing doctor? "We need the urine, like, tomorrow," says Charles Clark. He is the clinic's owner and medical director, a 55-year-old physician and seventh-generation Washingtonian. "I just don't like being blindsided," says his brother, John Clark, the assistant medical director, also a physician. Request denied.
"We trust everyone who walks in here, but we verify," says Charles Clark. Addiction is a disease, which is why the clinic makes a point of having "patients," not "clients." But you can't just dispense methadone. "There's a behavioral component to this disease," he says. His brother adds, "It's all denial. That's the biggest challenge, getting them to understand the part they play in their own addiction."
In 25 years of treating 200 to 400 patients a year, Charles Clark has seen maybe five people who walked in sincerely seeking help with addiction. Most come in because they're tired, or out of money, or out of veins. Methadone is just the beginning. Then comes getting away from a dope-dealing boyfriend, breaking bad habits, finding a job, dealing with depression -- often, Satel says, rebuilding a life.
I've arranged to sit in while she interviews patients. The first is a woman in her 40s. She dresses like a professional, expresses herself well, but her affect is subdued, flat, as if joy has eluded her for many years. She has three kids by two fathers, neither of them around. Has been on and off heroin for 20 years. Decided to come to the clinic because she wants a good start at her new government job. Says she plans to be on methadone temporarily, maybe six months, while she detoxes. She says all the things a drug counselor would want to hear. Her story, though, has inconsistencies. Is she working an angle? Satel will put a note in the patient's file and keep an eye on her.
Next, a 50-something computer engineer and former musician. He is well dressed, articulate, agreeable -- initially. He started heroin in his 20s, became a hard-core user, then cycled on and off methadone, getting sick after each taper ended and going back on drugs.
So why not stay on methadone? It's expensive, he tells Satel, and it's stigmatized. He thinks he was fired by an employer who found out -- which is why he won't use his company health plan to pay for methadone. (This, unfortunately, rings true. "You still have a tremendous sense of prejudice around methadone," says Ethan Nadelmann, the founder and executive director of the Drug Policy Alliance Network, a reform advocacy group.)
As the interview goes on, the man gets impatient. "What are you looking for?" he asks, implying that he will tell Satel whatever she wants to hear. "Let's cut to the chase." He wants methadone, not a psychiatric exam. Rising to go, he turns to me. "Everyone who is addicted to something," he admonishes, "is not an asshole with a gun."
The third patient is perhaps the most interesting, a youthful-looking man of 37, with a cheerful manner and a refreshing frankness. He works as a deejay, is married, has a house in Virginia, and recently bought a new car. He has been on methadone for 10 years, and he is "not going to go off, either." His wife weaned herself, but he cannot tolerate withdrawal syndrome. "It's medication," he says of methadone. He expects to stay on it "for the rest of my life."
"That's fine," Satel tells him. For some people, as she later explains, methadone is medication, almost like Prozac.
"The first thing to say about methadone is that methadone works," says Mark Kleiman, a drug policy scholar at the University of California (Los Angeles). "What differentiates methadone from all other drug treatments is that people come to it." And they stick with it. Put people on your best cocaine treatment, he says, and in three months 75 percent will have dropped out. (They don't want treatment, Kleiman says; they want drugs.) On methadone, 75 percent continue.
Methadone is a synthetic opiate, addictive like the heroin it replaces, but it is long-lasting and creates no euphoric rush. People can use it indefinitely with virtually no harmful side effects. Some can taper off it gradually. Others, like the young man Satel and I just met, take it much as diabetics take insulin. Either strategy can support a fully functional lifestyle and reduce or eliminate the use of street drugs.
A curious place, this -- so I think as Satel and I leave Oasis. The treatment protocol demands that patients behave like grownups while they are monitored like children. The clinic is licit but stays semi-underground, fearing that even a sign on the door would stigmatize patients or annoy the neighbors. The medication is one of the safest known to science but is regulated as if it were one of the most dangerous.
Most drugs can be prescribed by doctors, but methadone is shunted into its own separate network of dispensaries. Only one other sector of the medical system -- abortion -- is nearly as segregated and ostracized, Nadelmann says. Regarded as stepchildren by both the medical establishment and the law-enforcement community, Oasis and other clinics like it cling to the fringes of both.
Copious research shows that methadone treatment improves overall functioning and reduces heroin use, HIV infection, crime, and death. Yet the treatment reaches, according to prevailing estimates, only 10 percent of opiate addicts. "It's absolutely a crime," Kleiman says. "I have never heard anybody outside the drug-warrior world debate the proposition that methadone is overregulated, and in particular that we way underprescribe it." Clinics are common -- 40 or so operate within 5 miles of the Capitol -- but they go almost unnoticed, shadowed by the country's ambivalence. In a country at war with drugs, they represent an uneasy truce.
But the political climate seems to be changing. "We're heading in a direction where we'll see the number of people locked up for drug offenses declining," Nadelmann says. "We're moving away from the notion that people should get incarcerated simply for drug use or possession." Methadone treatment, having quietly proved its worth, may begin to come in from the cold. The compromise it strikes -- cure addiction where you can, manage it where you can't -- points to a more rational future.