Dr. Robert Newman, President of Continuum Health Partners, a healthcare system that includes Beth Israel Medical Center, where methadone maintenance began over 30 years ago and which still operates the largest program in the world, had a slightly different take on the mayor's statements than that provided in our lead article above. Dr. Newman spoke with The Week Online:
WOL: Dr. Newman, you've obviously heard Mayor Giuliani's statements regarding methadone maintenance, and his desire to see these programs eliminated. What are your thoughts?
Dr. Newman: Let me first say that my anger over this issue is not directed in the least at Mayor Giuliani, but rather at the methadone establishment. And when I say establishment, I don't mean the experts like Dr. Des Jarlais here at Beth Israel, or patients' advocates like Jocelyn Woods at NAMA. I mean the majority of providers, who have a total monopoly over distribution and whose desires to maintain that monopoly drive their actions. Nor do I include all providers in my criticism. My own hospital, after all, Beth Israel Medical Center, is the single-largest provider of methadone in New York, and perhaps in the country, with over 8,000 patients.
The attitude of the majority of those who represent the establishment as it relates to methadone treatment is my way or the highway. They have fought tooth and nail to encourage and maintain every government regulation that is now in place that constrains the distribution of methadone. Their way has given us the current situation in which seven out of eight heroin addicts have absolutely no access to this treatment, and under which only government-approved "comprehensive programs" can exist.
Why are they upset by Giuliani's statements? It is not unreasonable and doesn't take too much cynicism to believe that at least part of the answer relates to the desire to protect their turf. They have been so thoroughly invested in maintaining control over the treatment of the 15% of heroin addicts who have access to their programs that they have been willing to write off the other 85%. Since they never looked for or even permitted serious discussion of ways to try to reach the 85% that can't be accommodated in their programs, I think they have little credibility when they profess such concern over the 15% that have been lucky enough to get admitted.
Now why is it that of all medical treatments, of all long-term drug regimens, methadone is the only one that is totally under the control of government-approved and largely publicly funded, bureaucratically-managed programs? Why on earth can't someone who has been on the program for years, who is gainfully employed and raising a family, who is otherwise drug-free, get methadone from his or her doctor? Why do such people -- and there are many, many people who are living normal, productive lives with the help of methadone -- why must they be required to show up at a clinic daily, or at least several times a week? Why are they required to continue with often-unnecessary counseling in order to stay in the program? For that matter, why can't any patient receive methadone from the physician of his or her choice?
There has been a concerted effort to keep community-based practitioners out of the prescribing of the medication. It's also true that providers' budgets depend upon the comprehensiveness of all these services, and the requirements that these services be provided to and accepted by every single patient. It has nothing to do with the needs or wishes of the patient, and these requirements have become the primary obstacle for people who would otherwise, by all measures and appearances, be living very ordinary, very healthy lives. I know some lip service has been given to "pilot studies" to allow a tiny handful of patients, always under the watchful eye and the control of the programs, to get methadone from generalist physicians. But the numbers that could be accommodated are meaningless!
WOL: So, when Mayor Giuliani says, for instance, that there is no reason why people in these programs shouldn't be required to work, just like other welfare recipients, you would agree with that?
Dr. Newman: Absolutely. Without getting into any sort of discussion of welfare policy itself, which is an issue in which I am certainly not holding myself out as an authority, I believe that people in methadone treatment should be treated the same way as everyone else. Besides, it is a little-known fact that fully half of the people who are on methadone maintenance are employed, and thus never even enter the welfare debate at all!
As I alluded to, a big part of what makes it difficult for methadone patients to work is the absurd requirements, the hoops they are made to jump through. In a lot of places in the country, where there are clinics at all, they are spread so far and wide that people end up spending half a day, every day, just traveling back and forth. Now, this speaks, I would argue, to the remarkable level of commitment that these people have to avoiding relapse, to insuring that they are not going to feel compelled to go to the street for relief. So we end up with many, many people, traveling great distances to clinics which often are open for only a short time every day, just so someone can hand them a cup of medicine. We need to open up the system so that people can live more normal lives, much as they would if they were on any other long-term medication regimen.
WOL: So there's nothing inherent in methadone treatment which would compromise someone's ability to lead a normal life?
Dr. Newman: Absolutely not! There are patients who are earning six-figure salaries, people who have been on methadone for years and who function normally and productively in every way.
The question is, do they need to be required to undergo continuous counseling? Do they need to be watched by a paid counselor to ensure that they are taking their medication? Of course not. What they need is freedom from absurd restrictions put into place by one bureaucracy, government, at the behest of another bureaucracy, the methadone establishment. But the methadone bureaucracy, in that wonderful self-serving tradition of all bureaucracies, considers these people too sick to function without the constant help of the people whose livelihoods depend upon the system. Is that to say that many people who are in methadone treatment don't benefit from counseling? Of course not. But these determinations are not being made based upon patients' individual needs. Again, only a monopoly could sustain a system like this.
In addition, and I think this is the problem rather than the views attributed to the Mayor, we have a situation where many of the providers themselves behave as if they don't believe in or understand the treatment. Three-quarters of the programs in existence knowingly keep patients on sub-optimal dosages of methadone. Now, if I, as a doctor, were to systematically prescribe a sub-optimal dosage of any other medication, I'd lose my business and probably my license to practice. But in the monopoly that controls methadone distribution, no one is at risk of losing their business, at least until a politician focuses on the expenditure and questions its justification.
Further, more than half of the clinics in operation push patients toward total detox, many after only six months. And if you ask them is there any evidence, is there a single scientific study, which shows that pushing people off of this medication will be successful? Do we have any indication that the majority will not relapse into heroin? That they will not go to the street and buy whatever they can get their hands on to relieve their suffering? That they will not be right back where they started, along with the increased risk of AIDS and other diseases? And they'll say, no. But we simply don't believe in allowing people to stay in for more than six months. And they can do this, they can randomly endanger and destroy people, because they have absolute power. They're the only game in town, and they know it.
WOL: But if the providers are dependent upon their patients, why would they be so eager to push people out of the programs?
Dr. Newman: Oh, the slots don't go empty. Each clinic is allowed to treat only a specified number of patients, and there are so few slots for so many addicts that there's always a waiting list. There's no necessity to do it right, to operate in the best interest of the patients, to care what patients think. There's zero "power" for consumers in this field of medicine, because the demand is so much greater than the availability. Again, I stress that this orientation is not universal, and I pride myself on the compassion, common sense and caring that is reflected in the staff of Beth Israel.
So here comes Mayor Giuliani, or some other politician, and sees methadone not as just another medication like, say, insulin, but as a very big line-item in a budget that goes to a big bureaucracy, and he questions it. There's nothing whatsoever surprising or inappropriate about that! And he looks at the people who have been in these programs for years and what he sees is a group of people who are still required by regulations and by the views of the clinicians to receive intensive counseling, who are still required to be urine-tested (in many programs, under direct supervision of the staff -- they are not even trusted to pee into a bottle without someone "monitoring" them!).
There can be only one conclusion: our government regulators and -- most significantly -- the treatment providers believe they are no better off, no more trustworthy, no less "junkies" than when they started the program. Seeing that, why shouldn't the mayor conclude that there is no progress being made? Why should we expect the mayor to challenge the medical judgment of the experts, the folks who provide methadone treatment? I sure haven't heard many of my colleagues say, "Let's demand the government stop requiring us to impose counseling on patients who no longer need or want it; let's demand an end to this wasteful and demeaning requirement that patients pee in a bottle so they can prove to us that they are not using drugs."
WOL: But the mayor has couched this in terms of a moral rather than a budget issue. In fact, as you know, the vast majority of funding for methadone in New York City comes from the state and federal governments.
Dr. Newman: But the city is spending at least some of the money here, and so it does come up as a budget item. In addition, given the strong negativism towards methadone even (perhaps especially!) among those who prescribe it, it's no surprise that public sentiment also is against it -- so criticizing this treatment is politically attractive. The point is that if there were no programs, if methadone was treated more like other medications that doctors can prescribe to people who will benefit, the politicians wouldn't even waste time on it.
As radical as it sounds to the methadone establishment, I strongly maintain that doctors are quite capable of responsibly treating patients -- even those with the disease of addiction. Certainly, this has been the experience overseas, where many countries have thousands of former heroin addicts receiving methadone from general practitioners.
WOL: Barry McCaffrey, the U.S. Drug Czar, recently came back from visiting with his counterparts in Europe and said unequivocally that we need to expand methadone maintenance in this country, but he added the caveat that it should be tightly controlled. His concern, and it's one that is shared by a great many people apparently, is that methadone not be diverted to the black market. Aren't you concerned that easing restrictions on methadone would lead to an
Dr. Newman: Actually, the logic there is completely backwards. A long time ago in this country we had a huge and deadly black market in penicillin. There was an enormous illicit demand from people who couldn't get it through legitimate channels because of inadequate supply. The street market for methadone is an exact analogy, and reflects the fact that people who need it can't get it legitimately. Heroin is vastly easier and more convenient to get!
Why are people buying black market methadone? Because they're trying not to do heroin. If anyone who needed it were able to get it from a licensed physician, and not just those who were lucky enough to have their name come up on the waiting list, we'd most likely see an end to the street trafficking, just as penicillin's black market came to a total halt as soon as supplies were sufficient to meet the clinical demand.
Imagine the black market in Viagra if it were accessible only to 15% of those who might want and need it -- and those 15% had to jump through hoops to get it from "comprehensive impotence programs"? And talk about NIMBY, and the fears that the "Viagrans" would mug us and rape our mothers and grandmothers! Wow!
WOL: The mayor, in his comments as well as in the days immediately after, made a point of mentioning a couple of abstinence-based drug treatment programs by name, programs like Phoenix House and Day-top Village, saying that abstinence-based treatment is inherently superior to methadone, and that this is what we should be aiming at. Being that these programs don't offer methadone, is it possible that there is another economic dynamic at work here?
Dr. Newman: (Laughs.) Well, certainly that's possible. And if methadone were to be eliminated as a treatment option it would very likely mean more patients, and more income for those programs. But I'm not going to speculate as to their influence on the mayor, or their motivation. And for sure I would never denigrate any other treatment approach that offers help and hope to those in need, especially in as notoriously difficult and deadly a problem as addiction.
The fact is, however, that methadone maintenance has been found throughout the world to be the single most effective treatment for heroin addiction known to science. And that's not just me talking. It has broad backing in the medical community. Furthermore, even if one believed a different treatment approach is "better" -- whatever that means -- there is no way whatsoever that the tens of thousands of methadone patients in New York City could be accommodated in any alternative treatment setting; they'd all go back to shooting dope, stealing, killing themselves, getting and spreading AIDS, etc. That's not speculation or bragging or anything else but simple reality.
I certainly value a substance-free recovery, but I see that as no better and no worse than recovery accomplished with the assistance of a dose of medication each day. If it were your son, would you care in the least? Boy, I sure wouldn't! My only prayer would be that he survive, and get out from the clutches of heroin dependence and all the horrors that that entails, including the ever-present threat of death. Heroin is tough to kick under any conditions.
With methadone, people are able to resume their normal lives, outside of the restrictions placed on them which I've mentioned, and be productive and healthy. If that doesn't constitute success in medical as well as social terms for the individual and the community, than I don't know what does. If you are a diabetic, you are pretty much destined to need insulin for the rest of your life. If you go off of it, you're going to have problems, plain and simple. And yet, insulin is rightly understood to be a very successful treatment. The same is true of the wonderful support that AA offers to alcoholics, support that ideally (according to AA advocates) continues life-long.
WOL: But can you truly equate heroin addiction with diabetes? People only become heroin addicts after first making a choice to try heroin.
Dr. Newman: Granted, in most cases there is a behavioral aspect to becoming a heroin addict, but at the same time there is growing evidence that some people have a genetic predisposition to such addictions, so there's also an uncontrollable risk factor that is at play. And regardless, there are innumerable diseases and conditions that have behavioral components. Do we in the medical community turn away heart attack victims who are obese through overeating? Or cancer victims who smoked? We can certainly disapprove of those behaviors, but we don't punish people in an advanced society by withholding effective treatment for illnesses they brought on themselves.
WOL: Is that, to some degree what the methadone establishment is doing?
Dr. Newman: To the extent that providers treat their patients in ways that would be unacceptable in dealing with other types of patients, yes. But again we are back to the problems inherent in a monopoly over a life-and-death medication.
In New York City, it's estimated that there are over a quarter of a million people who are addicted to heroin. But there are only about 35,000 methadone slots. Now, because the establishment has fought tooth and nail to make sure that doctors cannot prescribe this medication, to make damn sure that they were the only providers -- and the government is certainly not going to increase funding for drug addicts by a factor of seven or eight -- over 85% of the addicted are shut out and will be shut out to their dying day! It amounts to saying, "We are not going to allow you to get methadone except through us -- and if you die, you die!" I respect pride in one's own therapeutic efforts, but this kind of attitude is arrogant. I'ts immoral. It's sick.
WOL: That's a pretty stinging indictment, especially coming from a major provider.
Dr. Newman: You're not the first one to tell me that. And I'd like to make clear yet again, because it bears repeating and emphasizing, that not every provider is high-handed and self-serving. I know the staff of Beth Israel best, of course, but the same is true of lots of other programs, I'm sure, and that is the commitment to do as good a job as possible, given the restrictions. And I'm not saying that some programs, for some patients, are not superior to the prospect of having a doctor prescribe methadone.
Certainly there is an element of control that would be given up. But I also oversee one of the finest centers for the treatment of breast cancer in the world, and yet I would never say you have to come to Beth Israel or one of its partner institutions, and if you can't you should go untreated rather than be allowed to get care in a less "comprehensive" center of excellence. That would make the best the enemy of the good. That's what we're doing by insisting on exclusive reliance on programs to prescribe methadone. It's arrogant. It's costing lives. And it results in politicians looking at the treatment as it's been mandated and questioning whether it's justified and should be continued.
(See our methadone topics section at http://www.drcnet.org/methadone/ for more commentary by Dr. Newman. Also, visit the National Alliance of Methadone Advocates at http://www.methadone.org.)