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We've Known for 40 Years How to Help Heroin Users

In the 1970s, New York City and Hong Kong figured out how to help heroin users without red tape or an abundance of experts.

Methadone ads throughout Hong Kong inform heroin users about the availability of treatment. They were based on ads that appeared throughout NYC in the 1970s. Courtesy of Open Society Foundation.Methadone ads throughout Hong Kong inform heroin users about the availability of treatment. They were based on ads that appeared throughout NYC in the 1970s. Courtesy of Open Society Foundation.America's current wave of heroin overdose deaths is not without precedent. Between 1969 and 1972, the number of heroin users in America doubled, and no place was hit harder than New York City. Of an estimated half a million heroin users nationwide during the 1970s, some 200,000 lived in NYC, and as many as 650 New Yorkers died annually from overdoses. The way New York City government responded to the crisis remains the best example of how to quickly and effectively scale up medical care for people with opioid use disorders.

While New York Gov. Nelson Rockefeller responded to the rise of heroin by signing the Rockefeller Drug Laws in 1973 and instituting the first—and initially, harshest—mandatory minimum sentences for low-level drug offenders in the history of the U.S., New York City Mayor John Lindsay decided to focus city resources on expanding access to methadone.

Methadone, which we still use today, acts on the same receptors in the brain as do heroin and prescription opioids. Rather than requiring users to quit cold turkey, which often leads to relapse and overdose, methadone scratches the opioid itch with a much milder high. In addition to helping users hold down jobs and obtain housing, methadone and its more modern cousin, buprenorphine, have been shown to reduce opioid mortality rates by as much as 50 percent. People with opioid use disorders can take methadone and buprenorphine indefinitely if they want or need to, and many do.

Lindsay wanted more methadone in New York, and the way he accomplished that will boggle the minds of contemporary public health advocates.

In 1969, after a narrow re-election, Lindsay nominated a man named Gordon Chase to oversee health services in New York City.

A 37-year-old with a bachelor's degree in political science, Chase had worked on budgets in the city's Human Resources Administration and played bit parts in the John F. Kennedy and Lyndon B. Johnson White Houses. But he didn't know anything about health care. The New York Academy of Medicine sent a letter to Lindsay saying Chase was "professionally unqualified" to run the Health Services Administration, and groups around New York echoed their concerns.

But Chase was just as committed to creating a citywide methadone program as Lindsay was. Over the next three years, he launched the largest heroin treatment program in history with the help of physician Robert Newman. Then only a few years out of medical residency, Chase told Newman he wanted him to be "Mr. Methadone" and named him Assistant Commissioner of Addiction Programs.

Newman would have all the resources the city could marshal, Chase said, but the catch was that he had to build a network of clinics faster than any expert thought was wise. According to an interview Newman gave to researcher William White several years ago, medical experts were so horrified by their plan to scale up quickly that Newman asked Chase if maybe they should put the brakes on:

Newman: Every single objection I raised—and I raised objections that I had heard from [other physicians]. They said, "Well, you need six weeks of training, and you need this. You need that. When you open the new clinic, you can't admit more than one or two patients a week for the first whatever."

Every single objection I raised, Gordon's response would be, "Is it really better to leave people on the street to shoot dope who want this treatment that you think is effective?" My bottom line answer to him was, "You're right. We have to do whatever it takes to achieve the goal." Gordon Chase's compelling argument was this: Imagine a woman barging into your office one day telling you her son, a long-term heroin addict, had applied for treatment but was turned away by your program and put on a waiting list because you had no room—and then died of an overdose. He said, "Bob, you tell me what excuse for moving slow you will give this woman that will elicit the response, "Oh, I understand. Of course you had to wait until all the furniture was placed, or of course, you didn't want to burden the new staff with too many patients. My poor son had to die, but at least I understand now that it was for a very good reason." He gave me that speech once or twice until I got it.

So Newman and Chase pushed forward despite concerns that the program was growing too fast. At one point, Newman set up a clinic in a boat anchored at battery park, transporting methadone doses to and from the makeshift center in his son's carriage. The result of their vision was that within three years, New York City was providing methadone to 10,000 patients.

New York City's methadone maintenance program would eventually be handed over to the state government due to budget cuts. But it was so successful that Newman was invited in the early 1970s to advise the government of Hong Kong—then dealing with a rise in heroin use after the British banned opium smoking—on how to implement their own methadone program. Newman recently wrote about his experience advising Hong Kong, and what America, once again dealing with a proliferation of opioid use disorder, can learn from it.

I spoke with Newman over the phone this week about what Hong Kong did, what New York City did, why those plans worked, and what the U.S. could be now doing differently to help folks with opioid use disorders who'd like to transition to a less potent drug. It will surprise few people following this issue that bureaucratic red tape is a large part of the problem.

Our conversation has been edited for clarity and length.

Reason: I want to hear about New York, but first, I'm curious about Hong Kong's decision to allow lay people to play a big role in methadone treatment.

Dr. Newman: It was pure pragmatism. I was Hong Kong's consultant, and I recommended the usual array of well-trained specialists, such as physicians and nurses and social workers. When I came back to Hong Kong a year after they'd started the program, they had 5,000 people in treatment and very few of those specialists. I asked them how they did that, and the Hong Kong folks, in their usual polite wonderful way, told me that my recommendations were fantastic, but they didn't have any social workers. They didn't have any nurses. But they also didn't want to leave people on the street who could be helped by methadone treatment, so they proceeded without those specially trained people.

It was never, "Ah, we don't need nurses! We don't need social workers!" They focused on where they had to go. The goal was to make treatment immediately available to everybody who wanted it. The only way to achieve that was to forego the professional staffing and go with non-professional staff. It was every bit as successful as other countries, including the U.S., which relies exclusively on well-trained specialists.

Reason: It seems we have the same shortage of specialists who want to provide medication-assisted therapy (MAT) with methadone and suboxone, or at least enough people who are qualified in the eyes of Health and Human Services to offer that treatment.

Dr. Newman: I'm actually not sure that we do. We certainly had no problems back in the early '70s recruiting physicians. We had no problem recruiting nurses and we had no problem recruiting counselors. Although, at the time, the requirements for counseling were essentially nonexistent. You didn't have to be certified. You didn't have to be accredited. You didn't need a degree. Anybody could be appointed as a counselor. But we didn't have any problem with nurses or doctors, either.

I imagine that today, if you were willing to pay the price, you could get doctors and nurses. I haven't heard of any methadone clinic anywhere in the U.S. that received approval to open but couldn't recruit the professional staff.

But in Hong Kong, they could not recruit the staff. They had a paucity of them. There were physicians who were part-timers, but they had no social workers and no nurses. And it worked out extremely well regardless. Teaching volunteers was not hard. If the order sheet called for 40 milligrams, you pulled the syringe up to 40, you squirted it into a cup, and you handed it to the patient.

For social work, they were initially subjected to all kinds of criticism by foreign visitors who came to observe their program and asked how they could just ignore the social service needs of their patients. Once again, they dealt with this criticism with enormous pragmatism. They put a sign up over every dispensing station at every clinic that said, "If you have social service needs, the nearest social service office is located at," and then they gave the address. And that was it.

Nowadays, there are more social workers available. And, again, it was not a philosophical objection to social work. They just weren't going to abandon people because they couldn't meet the requirements that I and other foreign experts said were important.

Reason: What's keeping the U.S. from scaling up treatment services? It seems like we have a weird obsession with abstinence-based treatment, we have federally imposed limits on how many MAT patients doctors can see concurrently, and neighborhoods don't want methadone clinics.

Dr. Newman: All of the above. The problem here is that there are really few, if any, advocates who are focused on the life-and-death needs of individuals who want treatment, need treatment, could benefit from treatment, but can't get it. There are patient advocates, there are program advocates, there are professional organizations representing the perspectives of care providers, but nobody is focused on the needs of people who can't get into treatment.

Two days ago, I heard a news story from Everett, Washington, which is 40 miles north of Seattle. The city is considering—despite lots of opposition—a second methadone clinic, because the only one they have right now serves 600 patients per year, and has 200 people on the waiting list. Last month, I saw articles about methadone waiting lists in California and the Carolinas.

It need not be that way! New York was able to eliminate its waiting list in 1973. 1973! It can be done if the commitment is there to do it.

Reason: Should clinics be helping more patients, or do we just need more clinics?

Dr. Newman: We need both. And we need physicians to step up. For the last 20 years, it's been possible for physicians to take a ridiculously simply eight-hour session online in order to prescribe buprenorphine, which goes by the trade name Suboxone. And yet there are very, very few physicians around the country willing to do that.

A computer-operated machine fills 100 milligrammes of methadone into a cup at the walk-in clinic of the 'Malteser Werke' in Frankfurt Main, Germany. Photo credit: Frank Rumpenhorst Deutsch Presse Agentur/NewscomA computer-operated machine fills 100 milligrammes of methadone into a cup at the walk-in clinic of the 'Malteser Werke' in Frankfurt Main, Germany. Photo credit: Frank Rumpenhorst Deutsch Presse Agentur/NewscomThe fundamental need is for some authoritative body to say, "The current situation in the U.S. is not acceptable." And it's not just waiting lists. We should have posters in every emergency room saying, "Dependence on painkillers and heroin is a treatable condition. Ask the staff about your treatment options." That doesn't exist anywhere in the country. Hong Kong has had these posters going back 40 years. "Call the following number for an immediate referral to methadone treatment."

The commitment is lacking. In addition to more physicians and more clinics, we have these federally mandated capacity limits telling doctors they can only treat so many MAT patients. Who ever heard of capacity limits in any other field of medicine? Can you imagine a prenatal clinic being bound by a federal mandate that says, "You cannot have more than X number of pregnant women that you care for"? Can you imagine a prenatal clinic turning pregnant women away and saying, "Come back in 10 or 12 months?" Only in this field do we tolerate these regulations.

A couple of years ago, Baltimore offered a pilot program in which people on their waiting list could receive methadone without any other services. It's very much like what Hong Kong did 40 years ago. And they found the results were absolutely fine. Patients who were receiving methadone while awaiting admission to the full program did every bit as well as patients receiving comprehensive treatment.

And the costs! The incremental costs to make just the medicine available was $3.50 per patient per week.

Reason: Even if the cost were $30 per patient per week, methadone on demand would still be exponentially cheaper than the abstinence-based, in-patient treatment programs that seem to receive so much funding.

Dr. Newman: It would indeed. And it would allow a substantial number of waiting list patients, many thousands of whom are willing to pay $100 a week out of pocket—essentially the full cost of comprehensive methadone treatment—to get the drugs they want and need while waiting for a spot to open. It would certainly be better than telling them, "Come back later. In the meantime, we hope a friend of yours is ready to administer naloxone."

Reason: We've lost our sense of urgency.

Dr. Newman: We sure have! We have all these people begging for treatment even though they know the federal government demands—demands!—that new patients attend a clinic daily for the first nine months and that they pee in a cup under direct supervision. One of the most amazing things to me, even after 40 years in this field, is the motivation that people have to get treated. You don't see it in any other field of medicine. And there are so many people applying for that kind of treatment, and they're being ignored. It's unthinkable.

Reason: One of things you bring up in the paper that seems like a huge obstacle here is that Hong Kong said, "Let's help the most people as fast as possible, and not let the perfect be the enemy of the good." I follow conversations among doctors who treat substance use disorders, and they seem to be concerned that if they don't do this in the best possible way, in the most comprehensive way, they'll lose ground. That if it's not perfect, they won't get a second bite at the apple. Does that strike you as new? Because your experience in New York in the 1970s was very different.

Dr. Newman: Look, it was just as oddball then as people seem to think it is now. The reason we could proceed with the good in New York—rather than wait for the perfect system—was because the guy who was the health czar of New York City was 37 years old and had no medical training. Gordon Chase was appointed by Mayor Lindsey to be basically in charge of all health and hospital services in New York City. He wasn't smart enough or educated enough to know that you're supposed to have comprehensive services, that you're supposed to go slow, that you're supposed to take your time to train people. He didn't know any of that.

He assigned me the job of overseeing an unprecedented expansion of methadone treatment. And I didn't have any experience in the field either! Basically, I agreed with the guy I worked for. For us, it was a question of compared to what? I never had a reason to doubt that the good would indeed be very good, and that it would at worst be better than doing nothing.

Reason: So what explains the cautiousness of people who know how bad this problem is?

Newman: When we talk about resistance in the health care field, we're talking about asking folks to endorse an approach that is different from theirs and that is also much less costly than theirs. And there is concern, which I can appreciate, that if it's shown you can provide reasonably good treatment without all the expenses associated with a comprehensive program, that funders will then say, "Well, if this works well enough, why should we pay for all these social workers? All these comprehensive programs?"

That's a universal fear. I saw it when I was consulting in Germany, and even early on in Hong Kong. But it's a fear that's never been born out. In Hong Kong, as in New York, drug-free residential programs, as expensive as they were, continued to be supported and expanded, just as they were before large-scale methadone expansion. People think it's "My way, or the highway," but that's wrong.

I don't want to sound critical. All of these people we're talking about are dedicated to providing the best—not just good—but the best care for the patients who have come to them, for whom they are responsible. They don't want to compromise the quality of care for the people they're treating. And that's great for the people who are already in treatment!

But again, we're talking about the people who are not in treatment and who can't get treatment because there aren't enough spots in perfect programs.

I'm realistic enough to know that financial self-interest may play a role, as well as therapeutic authority and power, but I think there's a much more generous and accurate explanation, which is that these are providers who simply refuse to compromise on the comprehensive care they provide. But again, those fears have never been realized. Even when studies demonstrate that you don't need comprehensive services to save a lot of lives, we continue to support the best care at a substantial price.

And that's fine, so long as somebody cares for the people who are getting no treatment at all. There are a lot of them out there, they are dying, and we need to give a damn about them.

Photo Credit: A3602 Frank Rumpenhorst Deutsch Presse/Newscom

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  • BestUsedCarSales||

    We've Known for 40 Years How to Help Heroin Users

    No need to read the article. It'll just say "Give all the drugs to Mike Riggs instead."

  • jogibew||

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  • NobodysHome||

    Ignorant. You should be the first to read the article.

  • BestUsedCarSales||

    A couple of years ago, Baltimore offered a pilot program in which people on their waiting list could receive methadone without any other services. It's very much like what Hong Kong did 40 years ago. And they found the results were absolutely fine. Patients who were receiving methadone while awaiting admission to the full program did every bit as well as patients receiving comprehensive treatment.

    Why don't we just flood the market with methadone then? Why does this still need to be held behind doctors and public clinics?

  • Diane Reynolds (Paul.)||

    Methadone is deadly, so I'm guessing that's why. I was involved with a methadone tangentially back in the 90s and I believe that the amount of Methadone a serious addict will need to maintain his or her addiction would kill you. That's just my guess.

  • BestUsedCarSales||

    Any more or less than the equivalent amount of heroin?

  • Diane Reynolds (Paul.)||

    I don't know. I just remember it was something one of the people in the methadone clinic told me. She just said the dose that most of their patients took would kill you or me.

  • IceTrey||

    Pretty much everything is like that. You can kill yourself drinking too mich water.

  • fafalone||

    That's basic opioid pharmacology. Normal non-tolerant users get a pain pill of oxycodone for 10mg. They feel it. Recreational users might go for 20-30mg with no tolerance, they'll be high as a kite. Serious addicts, that amount won't even stave off sickness for an hour. 80mg could kill you. I took 1600-2400mg/day for years.
    That's actually a barrier to methadone treatment. Legal regulations enforce a maximum initial dose, and dosage increase rate from there, that would be non-lethal to someone with no tolerance. So a serious addict would need to supplement their methadone for so long they'd have to go well past the point where they'd be kicked out for doing so. Not the biggest barrier since that's pretty rare, but still. The biggest barrier of course being having to show up in person to someplace likely an hour or more away, every day, and not being able to take more if you need it, and being kicked out if you supplement.

  • BestUsedCarSales||

    So you seem up on this. Is there anything uniquely difficult about methadone that would bar addicts trying to ease off heroin from self-administering?

  • Mezzanine||

    No, the difficult part is that an addict has to go to a clinic to have it administered and most addicts don't live all that close to one. Also if it is like two in the morning or something and someone starts having a major withdrawal the clinics not even open. The heroin dealer however is open at two in the morning and will drive to wherever you are and deliver it in person if they have to.

  • Sedona Vortex Hunter||

    actually there is another issue with methadone that makes it more dangerous than most opiates, and which also makes it a poor candidate to flood the market with. The issue is its half-life and the peculiar way it builds up and stays in a persons system.

    A person could believe they are not getting any result from taking the methadone they are prescribed and in so believing keep upping the dose, but the reality is methadone takes longer to work for many but also accumulates and builds in a persons body longer and differently than almost any other opiate. And I am not talking about hours, but a days and days difference in half life and affect.

    Suboxone OTOH, while also having a extremely long half life has a ceiling, which when reached causes additional dosing to be pretty much benign. I don't actually know however what taking a lot of suboxone might do to an opiate naive person. I know they would get very 'high' and experience it nearly the same as they might most any other opiate (which is not that case if taken by a person who is already a heavy user of opiates).....what I don't know however is if the ceiling level for suboxone I mentioned previously lies above or below a typical opiate naive persons overdose threshold.

    From all of the above it is my guess that perhaps suboxone would be a better candidate to be offering up in a 'flood the market' scenario. I could be wrong about all of this of course, I am I am just going by what I have read and heard, I am no expert

  • NobodysHome||

    Yes. You can't get it on the street— not like a street drug. You'll maybe run into methadone once or twice every decade. It is administered by a machine, not a human. And you drink 1-3 cups of water after. The only methadone you see on the street comes from pill doctors and pain clinics, not methadone clinics.

    Those that get take homes get them after 5+ years you are allowed about 2 weeks worth. And that is after absolutely all clean drug screens, a good relationship with your physician, and counseling. And not missing days. After coming every single day for 3 years, you get one take home on a Sunday's here.

    How bad does that sound to you? You'd have to be pretty dedicated to show up every day somewhere early for years on end. Never missing a day. Never. Pretty motivated. All clean drug screens.

    That's the ease of self administering lol at the methadone clinic.

  • NobodysHome||

    That's why you see a doctor and.... that picture.... is a machine. That machine dispenses the methadone. You don't get some super high dose right from the get.

  • NobodysHome||

    Right. The ignorance here is stifling.

  • SQRLSY One||

    Doctors and clinicians and therapy-nags, social workers, and other hangers-on need to suck at the public's tits, THAT is why!

  • DRM||

    Methadone has some drawbacks and its own potential for abuse. What would work even better is to flood the market with OTC suboxone tablets.

    But suboxone's hyper-regulated by the FDA, complete with that rule doctors have to take a special (eight hour) course to be allowed to prescribe it. It's also denounced as Pure Evil by the usual moralistic twelve-step programs.

  • NobodysHome||

    Suboxone is a partial agonist. Methadone is a full. They don't effect the brain in the same manner, that's why most don't adhere to suboxone. It's not some miracle drug like big pharma tries to market. Peoples wouldn't take it anyway. Methadone fills the same receptors but doesn't ... overflow them (like when you use heroin) if that makes sense. That's why methadone is sort of the better option. It really does just makes you forget to even want to use drugs. Suboxone does not have that effect.

  • ||

    Methadone is the worst drug ever invented & the government gives it out like candy. Then the user is wholly dependent on the State. Reason is way off base on this sh*t,legalization is the ONLY answer. That used to be their mantra.

  • NobodysHome||

    It does not need to be legalized like a doctor can just hand out a methadone script. That's not really why the program works. It motivates you to make it to the clinic and change ones lifestyle. Maybe you don't understand that not coming from the lifestyle of a drug addict with no sense of routine.

    The whole point of this article is saying that they don't give it out like candy. You must not have read it. Clinics have patient limits. Regular Physicians do not. There's no some unlimited resource, there is a cap. Hence... this article.

    Why is methadone the worst drug ever? Have you taken it or been personally effected by it?

  • Bacon-Magic glib reasonoid||

    Methadone is just a government controlled heroin. I see the zombies walk around my city's streets now. Same problem just less chance of an overdose.

  • Diane Reynolds (Paul.)||

    The reason that there's opposition to these things-- which is probably where the federal "limits" on patients came from is people and residents are afraid of what happens to a neighborhood when you tolerate heroin, or meth, or safe-shootup spaces-- whatever you want to call them.

    The pure humanist side which is strictly concerned with saving lives has that logic on his side. Methadone saves lives. Safe injection sites save lives, but there's not a lot of evidence that it failes to deal with the externalities. The reason no one wants a "safe injection site" in their neighborhood, or there's reticence about putting in methadone clinics is people are afraid that by making it easy to maintain an addiction, or eliminating the consequences, what you end up with is urban squalor, zombie drug addicts wandering about, and the crime that goes along with it.

    It certainly has something to do with why supporters and politicians pushing these programs often don't want them placed in their own neighborhoods. So it's the quintessential hot potato.

    There certainly aren't a lot of people who will risk turning their neighborhood, or a large multiblock section of town into a squalor-infested no-go zone even if it can be proven to save lives.

    "I support a safe injection site... in your neighborhood".

  • SQRLSY One||

    I think ya nailed it...

    Flat-out selling methodone at costs plus slight profit, to all willing buyers, would go a LONG way towards fixing thins, though! See if Roy Moore and Jeff Sessions and Emperor Trump will buy on, though... Good Luck!

  • AB1979||

    I work in that business, bupenorphine not methadone, but we're out there trying every day.

    Patients hate having to do the work required to stay in MA programs instead of being able to get maintenance medication quickly and easily.

  • BestUsedCarSales||

    I don't understand why Seattle doesn't take the one here. It seems the most obvious one since they're the biggest homeless haven anyway. I know they're hypocritical but I barely see anyone call them on it.

  • SezWhom||

    My daughter lives in Portland. Thousands of people move there because of lax drug laws and liberal social programs. If you build the methadone clinic, they will come. But do you want them? They are spending your tax dollars and wrecking your neighborhood. They are breaking into your house and your car to get money for drugs. This is not hypothetical, this is the way it is. None of which was discussed in this article, because, as usual, honest taxpayers don't matter.

  • Kefka||

    I live in a town (or small city whatever) dominated by progressives, the Green party regularly wins many local seats here, even occupying the highest office at one point*, hell Jill Stein even came here for a big local Green Party event.

    Thus we have an abundance of social services for homelessness, various mental health problems, Multiple drug addictions treatment type places of various forms, free clothes/furniture/appliances charity (think Salvation Army but free and we have a SA in town as well) , a very good soup kitchen that alongside the 1st Baptist Church in town means there is free breakfast/lunch and dinner almost every day plus a no freeze shelter that also serves as a needle exchange (plus numerous other supplies) so your syringe and other drug paraphernalia for shooting up are free as well.

    The local economy which was in ruins for years finally collapsed in the 1985 when the last big textile Mill shut down. We went through a period of significantly increased crime, further loss of business, and gained a reputation as a place to avoid culminating in a 60 minutes story about are drug addict issue.

  • Kefka||

    In recent years there has been a dramatic improvement, we have more new business opening and staying open (at least for a while) than we have had in decades. There are far more community events, some of which draw in thousands of people from here and the surrounding area, these events not only make living here nicer they provide a big boon to the local economy.

    Our local university has dramatically expanded (and provided a lot of jobs) the chronic issues regarding hookers, dealers and drug addicts being a public menace and visual blight (shooting up was common for example in a Gazebo on the town green right near main street) Have dramatically diminished. The town is a better, safer and more productive place than before the big wave of services came into play.

    Of course, these developments also helped steer upper middle-class hippies to my town who are the primary customers of places like the Fancy Coffee shop (forget the name), Juice Bar, Swift Waters an artist cooperative that runs a store front on Main street selling all handmade, handcrafted, etc stuff made by local artists of all kinds (fiber artist, musicians, writers, whatever)

  • Kefka||

    Then there is our ever increasing and expanding hippie/vegan/organic/non-GMO/ethical raised, local and not corporate super market: The Food Co-Op (which in the last 20 years has expanded 3 times, each time dramatically and now they are expanding again, and again it will be a big expansion), plus we have numerous other expensive and overpriced places of various sorts that seem to have staying power (most have been around at least 3 years now many much longer).

    Hell, we got one shop just for artisan muffins (must be close to 4 years they lasted) we turned an old factory building in to a place to rent out to local artisans, artist, etc as a studio for interesting business like a boxing club, a dulcimer making shop, the local Mural artist has his studio there and more I can't recall.

    Do people come here just because of our reputation for social services? Yes, they do all the time. Most are passersby's who know in the short term, food, shelter, clothing will be on hand to get them by in the meantime. They hang around for a while then move on. Many others also come here on a short-term basis but with more specific reasons why than just passing through, for example to help them get through a rough time (drug treatment being the big draw here, but other things as well, there is a battered women's shelter and various other kinds of short term aim).

  • Kefka||

    Part 4...
    For those that stay, a portion of them are a permanent net loss from an economic perspective. They have serious mental health problems (notably Schizophrenia), some are old (more health issues) and some have already screwed up their lives so much no one wants to hire them, they have no skills and spent a lot of time in jail. The others that stay tend to be a bit younger and try to make an honest go of it, for most they are never likely to be a big net contributor (except for those that do the school option and succeed) as the jobs they will hold don't pay much.

    But there is one other side to this story. Of the people that come here those who most often stay tended to come from two extremes. The homeless/addicts/metal health problem people and then the more affluent people who have college degrees and often work professional jobs at one of the two colleges in town or work at UCONN less than 20 minutes away (there is a bus!). Plus, some students decide to stay here after school is done (which as the town gets more nice things convinces more of them to stay) also many local artists/artisans in the wider area having been moving into the town and closer to where most of their business will be made.

  • Kefka||

    Conclusion.

    It's very complicated to sort out what did what. It is clear OD's went down (the "crisis" goal) and it is also clear that for many once they got rid of there addiction problem, they could resume a normal life, get back to work and be a productive member of society again. One who contributes to the local economy and pays taxes.

    The Methadone Clinic has been a clear net positive to the community over the course of time it has been here, not neutral and certainly not a net minus it terms of hurting the local economy.

    *(first select-person which no longer exists, a weaken version of the job has been named Mayor)

  • Diane Reynolds (Paul.)||

    but there's not a lot of evidence that it failes to deal with the externalities.

    Should read: not a lot of evidence that it deals with the externalities.

  • Mezzanine||

    That argument makes no sense, neighborhoods that need a methadone clinic already had a heroin problem in the first place.

  • Robert||

    It makes perfect sense in the context of there being just a few clinics to serve as many as they can. They'll draw them in from mi. around. Neighbors not happy. Same as having a red light dist.

  • Robert||

    Imagine if when they repealed booze prohib'n, they'd replaced it w a system of having all the liquor dispensed for on-premises consumption at a few mega-bars. No matter how "wet" neighbors might be, no way they'd want that in their neighborhood; many of them would prefer hooch sub rosa.

  • SIV||

    Methadone kills around 4000 people a year. It's more deadly per-dose than any other "opioid". Riggsy just wants a bunch of rent-seeking "addiction medicine specialists" getting rich off of Medicaid. Legalize drugs and very few (if any) people will use methadone.

  • AB1979||

    Cash based Medically Assisted Treatment, where still able to exist profitably, is a huge business. Removing the DEA limits on bupenorphine would basically drive consumer cost down to the price of the drugs themselves as physicians fight for patient volume, the same way pain clinics do with the promise of easy scripts.

    Get rid of the regs and let patients pay cash and I'm out of a job and addicts have easy access to their maintenance medication.

  • Kefka||

    I went to a Methadone clinic for a while and what you actually see are the majority of patient have jobs, lives, families are normal people. You would have no clue they were ever addicted to anything or user of anything. There is also say 10-15% turnover constantly. These are likley the people you see, that I saw. They didn't give treatment a chance they kept using other drugs (and weed/alcohol did not count unless you came in drunk) those folks tended to have very serious life issues beyond drug addiction.

  • ||

    You are either deluded,or a liar.

  • Kefka||

    I am not deluded the drug war has long been a focus of mine. I understand the issue. But you need to be more specific regarding which claims I made you thought were delusional or apocryphal? I will note that the 10-15% number was just a rough guess based on what I can recall of Clinic population numbers when I was there 5 years ago. Year to year they always went up I recall, but since then buprenorphine availability has dramatically increased. This could have an impact on the composition of the clinic population if the regulars decided to switch.
    .
    So to clarify at any given time the majority of the folks that go to the clinic are the successful people who don't go back to the streets and blend back into the general population. In other words, the clinic does more than saves lives, it enables many folks to improve their lot to the point of being a functioning member of society again.
    .
    Perhaps the best example I recall: There was a significant population of white working class folks at the clinic from the surrounding country towns. These folks if they stayed in treatment 90% or more of the time went back to work and a productive life many even owning or starting small business. The same was true for most middle class folks that went to the clinic.

  • Kefka||

    Part 2:

    The lower classes did less well, they always were the bulk of the "temp" crowd, breaking all the basic rules/ requirements then getting kicked out, later coming back, then kicked out again. Methadone is great in regards to addiction issues related to Opiates. But there are other addictions and other life problem issues.

    For example the poor far and away suffered more from mental health issues and lack of support to get themselves on their feet compared with the folks from more affluent backgrounds. It is very hard to work your way back up without a base to work from. Dealing with that problem is a separate matter.

    The methadone clinic helped a lot of people in my town (which was given the title of "Heroin capital of CT" in a piece down by CBS and airing on 60 Minutes like a decade and a half ago). Not just from lowering OD rate's but also helping most long-term patients to return to being a functioning, productive tax paying member of society.

    Note: I am just talking about things happening in the real world right now. In my fantasy world of drugs being completely legal to buy on my own volition (no doctors note needed) the rules of the game change.

  • NobodysHome||

    You are very right. These people are probably doing better than half the people commenting here. There are Mercedes, range rovers, brand new f 150s at mine. It's crazy the stigma

  • ||

    The government gives it away,why would anyone buy it?

  • NobodysHome||

    I pulled up to my clinic today and parked between a Range Rover and two brand new f-150s right next to each other.

    Seems like people got their lives together pretty well I'd say.......

  • Rich||

    A computer-operated machine fills 100 milligrammes of methadone into a cup at the walk-in clinic

    "So you're saying there's a chance of hacking it?"

  • BestUsedCarSales||

    Hack it and make it distribute in Imperial Units. THIS IS AMERICA

  • Diane Reynolds (Paul.)||

    That was my relation to the methadone clinic I mentioned above. We wrote the software that controlled one of the methadone dispensing machines. Yes, hackable. The reality of it being hacked? Probably near zero.

  • Longtobefree||

    Because yeah, lots of heroin addicts so far gone they will accept treatment are certainly competent hackers.

  • AB1979||

    The street value of methadone would make it worth someone's while potentially.

  • NobodysHome||

    Gtfo of here. You have too much time on your hands.

  • Sugarsail||

    And still no address of the psychological roots of addiction. Our society seems to know how to master the biology of addiction but psychology of addiction? Meh.

  • Diane Reynolds (Paul.)||

    Building the New Soviet Man is hard.

  • Eidde||

    Poverty, disease, death, bad jobs, no jobs, personal conflicts...all sorts of things can tempt people to a chemical route to happiness.

    If we change the psychology so everyone's a Stoic, an enlightened Buddhist, or an otherworldly Christian, maybe these things won't be so tempting.

    Or we could operate on the assumption that such massive psychological changes aren't in the immediate future.

  • Bra Ket||

    Does our society have a clue about the psychology of anything?

  • Mickey Rat||

    Biology is more readily understandable than psychology, and will likely always be so.

  • Longtobefree||

    No mention of the terrible flaw in those so-called successful programs; no politicians got rich, no lobbyists got million dollar consulting contracts, no real estate agents received huge commissions for finding locations to use.
    For Pete's sake, all that happened is a bunch of addicts got treatment! Where's the payoff in that?

  • NobodysHome||

    Yup bc it's an old drug. There's no money in it from any aspect and itd drive the incessant need for rehabs covered by insurance companies down. Profits profits.

  • SIV||

    Fuck methadone.

  • SIV||

    IIRC, junkies on methadone have the same mortality rate as junkies on street-heroin.

  • NobodysHome||

    Not even close. Who are you

  • SIV||

    Why is this shit in reason? There's nothing remotely libertarian about it as a "public health policy".

  • StackOfCoins||

    Indeed. I fail to see how using tax dollars to keep junkies on a milder high is in any way libertarian. The libertarian thing is to sell them drugs and let the losers die.

  • AB1979||

    Especially since there is a viable cash market for bupenorphine treatment in states where it is still legal. West Virginia, one of the states with the worst opioid problems, has forced cash-based programs to charge only what Medicaid would reimburse instead of the market rate. I wonder why people from WV flood KY, PA and OH to find the help they want? It's almost like entrenched medical interests are more important than doing anything about the actual problem.

  • ||

    Legalizing the crap is the ONLY answer.

  • Robert||

    It's in Reason because it represents an increase in freedom. It would let more people do what they want to do. Plus it would save tax $ over current policy.

  • DajjaI||

    There are a lot of them out there, they are dying

    WRONG. They are out there because they want to shoot up and heroin is cheaper than pills and it's more fun than working and if they tell you otherwise then they are LYING. Also heroin is relatively harmless and it's hard to overdose on it alone. So no they are NOT dying.

    Who is dying? People who want to kill themselves often because they can't get the pain relief they need or they are angry at their boyfriend or some other stupid reason (and take every drug in the house).

    The key to reducing opiate mortality is not 'treatment' but decriminalization. Disappointed that Reason fails to endorse this basic libertarian position.

  • fafalone||

    Few serious addicts use heroin alone. Add in the popular synergists alcohol or alprazolam, and accidental ODs abound.

    And decriminalizing would only be of marginal help; if you really want a reduction in ODs you'd need a legal supply, not just no possession penalty.

  • Bra Ket||

    From what I've read, people overdose on heroin by being heavy users and building up a huge tolerance, then quitting a while and losing their tolerance, then having a relapse and taking their old dosage which they can't handle anymore.

  • Kefka||

    The most common cause of overdoes is adulterants (Fet lace stuff more commonly,less common any kind of random filler/cut that is very dangerous to the body).

    The other major cause touches on your point it is dosage issues you don't know the strength of what your getting. You can't make good choices. Imagine drinking Vodka yet at any given purchase the strength could be anywhere from pure-90% pure and you can't taste the difference? Yikes.

    So an addict buying from dealer x needs two bags to cure his dope sickness. This he knows due to the past 4 days of going to him. But today in another day for various reasons!

    First, Lo and behold your hustle has gone well today, you decide to Party! You go to dealer x again (or dealer Y) regardless in the meantime they re-upped and the shit is hot fire. You don't know, it looks the same. So you wanted to get messed up you take 5 bags, pushing it slightly but your good with some wiggle room...you think.

    But alas you are not because the last stuff was garbage ( pure) and this is that Red Lobster shit son and not much cut at all (u). It is 4 times the potency! (note: these is a very realistic common scenario facing users/addicts)

    You end up taken the equivalent of 24 or so bags of the prior stuff. You die (unless you got a bud nearby with Naltrexone).

  • Robert||

    You do have a point in that a great many opiate-related deaths are recorded as accidental, because suicide is so embarrassing to the families & friends.

  • IceTrey||

    Or we could just legalize it.

  • Robert||

    I want a pony too. Even though I'd have no place to put one (although there are a lot of horse farms around here) & my lease doesn't even allow dogs or cats.

    If we were limited to discussing what we really wanted, we would've exhausted the subject long ago. Besides, the process of figuring out what kinds of compromises might be achievable in a given place & time are interesting.

  • Fooseven||

    The key lesson here is that an "unqualified" guy was able to create valuable change simply by ignoring the "industry wisdom".

  • plusafdotcom||

    Spot On, Foo!
    For normal government programs, the goal becomes "follow the procedures, precedents and policies we'd set up," NOT "ok, how do we fix this problem?!"

    Specifying classes for physicians that aren't necessary maintains organizations of teachers who aren't needed; Hong Kong proved that, but hey, the Union of Socialized Social Workers and Physician-Instructors would go batshit if they found out their dues-paying ontourage might be trimmed because they weren't needed in the first place.

    A lot like having hair-braiders take months of training to do something that moms have been doing for their kids for ages!

    Critical Thinking is DEAD.

  • Bra Ket||

    Just like with taking decades to approve treatments. Thousands dead who couldn't get treatment in time is not as bad for the medical profession's image as one dead patient due to a mistake. And their wallets, to be fair, given our litigious system nowadays. Never heard of a class action lawsuit against a drug company for being too careful and not launching a new product faster. Sure a lot of the other kind though.

  • Robert||

    YES! As in the Onion piece, "Fuck 'em, We're Going for 5 Blades." Recently I used a razor that had 7 blades!! (1 was for under-nose use because you couldn't fit the 6-blade head under there.)

  • Sedona Vortex Hunter||

    yep, exactly. We have a major case of experetitis in the US (and the world, but it seems especially acute in the US), and its both annoying and destructive. I think it is often pushed forward and defended for financial and legal reasons.

    It is then adopted and entrenched by the public because it sounds so reasonable as well as both completely obvious and true that a trained and studied expert would always have a better answer to some problem than someone untrained and inexperienced in whatever the issue at hand happens to be.

    But in reality I often find the experts to have the absolute worst, out of date, and most damaging positions when the eventual outcomes to some predicament can be studied or understood. But of course the problem is many or perhaps even most problems are very hard to pin down and don't have a simple non-partisan, non controversial solution. Such a reality is a great petr-dish where expertitis can exist and thrive.

  • Telcontar the Wanderer||

    "Lindsay nominated a man named Gordon Chase to oversee health services in New York City."

    He nominated a blonde Aussie to run around silently hitting people with a crowbar?

  • No Yards Penalty||

    Great. A bunch of zoned-out methadone junkies wandering the streets, shitting in doorways, setting up tent cities.
    MUCH better than heroin junkies.
    I am all for legalization of all substances. But along with legalization comes full personal responsibility. Nobody forces anybody to became a crackhead. You choose that route. You pay for that route.
    Fuck me if my taxes are gonna go to keeping crackheads high.

  • RafaelGuzman||

    As you know though, your taxes are *already* spent on tactics that have far less benefit than such clinics. I think the real point here though is that the government could be far more helpful by getting out of the damn way when it comes to regulating something that saves lives.

    As far as legalization goes, I wonder if it might be more politically realistic to legalize stimulants before something which more or less makes you worthless. I may have some individual bias here (not that it's important to legislate based on that), but to me things like coke and amphetamines seem to have upsides (or mitigating qualities) that make them less odious as a category of drug.

  • Dead inside||

    Off topic, but here we are again; PA man =Fl man.

    http://triblive.com/state/penn.....-day-early

  • Robert||

    Vote drunk, early, often, & often drunk!

  • AB1979||

    I work in the Medically Assisted Treatment market and the only reason that there isn't a bupenorphine clinic on every corner is the DEA's need to regulate prescription counts and NIMBYism. Patients will pay cash out of pocket to see physicians rather than jump through the hoops Medicaid makes them jump through to get help for free.

    More correctly, it isn't so much that Medicaid is making the patients jump through hoops as it is providers needing to bill as many encounters and codes as possible to make any money....so they pull the strings and the patients dance.

    If the DEA got rid of prescription limits on bupenorphine there would be no more of these clinics because docs would write the scripts the same way they do for the pain meds getting people hooked.

    Methadone is a different story...methadone addiction is real and is a huge OD risk.

  • C. S. P. Schofield||

    So, what this looks lime to me is that, as with so many social problems, if we told the government to take a freaking hike and let private charities do things they way they wanted to the problem would be under control....but no bureaucrats would be employed at good salaries and with hefty pension benefits and that would be Just Awful.

  • AB1979||

    That's the crazy thing! It doesn't take private charities! Addicts are willing to shell out their own hard-earned cash to stay in programs that fit their lifestyle rather than participate in the charade of multiple billings and unnecessary services that Medicaid and providers make them participate in. The market in health care does work...cash-based addiction programs that have more patients than Medicaid clinics downstairs in the same building prove it.

  • FreedomIsBetterThanLiberty||

    Sounds like a great program. When did you people start believing the government should be buying people's methadone?

  • Robert||

    As soon as we found out gov't was buying other tx for them that cost many X more.

  • Galane||

    But why not use Ibogaine and *cure* the heroin addicts?

  • ||

    There are tons of methadone clinics,we have 3 in Hartford,Corrupticut alone. It is just free dope to mostly welfare recipients. It is the most horrible program ever created.It keeps people addicted with no hope of recovery.

  • Whorton||

    You do raise a valid criticism that I have had for the programs for years. They make no effort to migrate the person OFF of the narcotic addiction. But perhaps, due to human nature, that is the best available solution. For most people, if it keeps them from committing crime to feed their habit, and keeps the addicts out of sight, a societal good has been achieved.

    But seriously, consider the recidivism rate for narcotic users. Save for the overdose program, the rate is very high, and although I have no data, I suspect it correlates well with mental health issues. It comes down to the question, why does one person become a junkie and another never touch the stuff. . . There are some serious societal issues we are still missing here.

  • Kefka||

    "They make no effort to migrate the person OFF of the narcotic addiction."

    The main goal of any treatment for an addiction problem is get rid of that problem entirely (take x pill to cure your Hep C) or to suppress it by treating the symptoms thus defacto ridding you of the problem. MAT is best way to deal with opiate addiction.

    As for making an effort to migrate people off that would be contrary to good medical advice it would be like telling a diabetic to stop taking there meds.

    Also as to societal issues that is a part of it but genetics plays a big role as well, addiction is now understood in medical community to be a chronic issue regarding a misfiring of the reward system and impulse control. You don't get "it" when you try crack for example, you already had it (at least for most well adjusted people that get hooked, societal issues and environment come into play much more for poor folks). And if you don't have it you will likely notice it playing a role in you daily life but won't be a cause for alarm unless you encounter something that has really bad side effects if you use it a lot.

  • Kefka||

    In addition I recall reading a while back their are a minority of the population (perhaps can't recall well) that seem to be wired to better handle some of the side effects of opiate use (for many people opiates hurt more than help because of nausea and they do not much care for the high), those folks often use the drug in a different or less common way. They view opiates as an upper, they are not looking for the nod they want energy (to party more or to work), freedom from pain physical works requires, freedom from the tediousness of that work.

  • Whorton||

    "Well, if this works well enough, why should we pay for all these social workers? All these comprehensive programs?"

    Generally speaking, that is a big part of the problem, "Social workers" with their overinflated sense of importance. In more than 20 years in the healthcare field, I have known few IF ANY social workers that justify their paychecks.

  • Kefka||

    "legalize stimulants before something which more or less makes you worthless."
    .
    Making you worthless is the opposite of what MAT does. Users that follow through with it (and its success rate is way higher than other methods) have very good outcomes in term integrating back in to normal society. It makes them not worthless but productive. Those that did not suffer from concurrent issues (poverty or mental health issues) in a short period of time go back to being productive citizens, working, having families and just living there life as normal person would.
    .
    Those other folks would have a bigger hole to clime out of so they succeed less in significantly changing there overall circumstances. Also opiates are very safe drug in terms of long term harm caused by it, while coke is much worse in that regard as well as various forms of speed. I think all drugs should be legal mind you.
    .
    But on a harm scale regarding regular (but controlled and understood) use.

    It is something like: LSD Weed Opiates --------------- stimulants (not coke) ---------cocaine-------- crack/Alcohol
    ---------------------------- Least Harmful ----------------------- ------------------------------ -----------------Most Harmful

  • Eman||

    "Junkie" should be required reading in high school. On the other hand, my friend who introduced me to Burroughs said it made him want to do heroin, and he did. A lot.

  • NobodysHome||

    Methadone is a life saver. It's no different than insulin, an antidepressant, seizure med, etc. There is a misunderstanding of how a clinic works and a bad stigma that follows. Most are in a very nice part of town, located centrally near the hospitals. Counseling is mandatory, so you also get some additional guidance and build a relationship with both your counselor and doctor.

    The biggest misconception is.... do you ever hear of people addicted to methadone on the street? No. Why? Because a machine dispenses it. It takes about 2-3 minutes and you walk out. It takes up to over 5+ years to get only 2 weeks worth of take homes.... so by then you are getting clean (supervised) urine screens, good counseling feedback, a positive honest relationship with your doctor, and you're not likely to sell or distribute those 2 weeks of take homes because you need them yourself responsibly. The methadone on the street if you ever come across it comes from pain clinics and pill doctors. After 3 years you only get Sunday take homes at my clinic! And that's if you do everything right.

  • NobodysHome||

    I mean come on people. You think this is some junkie shooting gallery outside around the corner ruining the neighborhood. In our parking lot there are brand new f-150s and multiple range rovers, Mercedes. The solidifying reason I signed up was because I saw how well dressed and confident these people carried themselves. Yeah there's the few rough ones but... that's life. That's the world. Is it perfect? Not at all.
    It's insane the stigma. When I saw this article it was exactly what I have been thinking. Methadone has been universalized. I can go on vacation and stop at any state, and have it set up to get my doses. I can travel internationally to Europe and be okay. It's alright. It does no long term harm to internal organs. Causes no disease. I mean think of what's in heroin! And all these fillers in pills that you take coming from over seas. And you want to judge some cherry flavored syrup dispensed by a machine and a kind nurse who says, "how are you doing this morning?!! Nice to see you, you look great."

  • NobodysHome||

    People are ignorant. Methadone gives people a physical reason and routine to get out of bed. No it's not 4 am lol. It's reasonable 5am-1230pm and some clinics have afternoon hours. I hope that this information shows you that methadone clinics are not the horrifying place you've always thought are going to break up the neighborhood. Because what's going to do that is big pharma and your neighborhood doctor spilling out suboxone scripts that the insurance company covers for free now and the junkies trade/sell for dope while people are finally starting to come around to suboxone. But hate on methadone like it's the devil. People are dying and you all just wanna stand around and complain of the effects. The effects of high health care. The effects of finding needles in Central Park. But you dog the logical ones who have solutions that won't even reach the street... what you think some junkie is going to steal the methadone machine system and start dispensing cups rofl. But hey, let's all keep complaining and paying high premiums and talking bad about these millennials that are milking the system. Grow up. Open your mind, and quit giving the rest of us a headache.

  • NobodysHome||

    In a methadone program you are screened for drugs, and there are consequences. But unlike suboxone programs, you can try and try and keep trying with a methadone clinic. They will never give up on you. Would a doctor quit you for diabetes? Would they refuse to treat you. I just hope that one day there are no waiting lists, no protests of clinics, and cheaper or free payment options. Methadone is much cheaper than these rehabs.

    It's ridiculously expensive in the states and mostly free in Europe. We are so behind, as people with a conscious and our pattern of thinking. We want change but our ignorance stifles it.

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