Edorials
Interim Methadone Clinics: An Undervalued Approach The study of Yancovitz et al. entitled "A Randomized Trial of an Interim Methadone Maintenance Clinic" (see p. 1185 of this issue of the journal) is a significant addition to the list of controlled clinical trials on the effectiveness of methadone.1 It also is a study that is unlikely to be repeated. It shows that the medically supervised administration of a daily dose of methadone to heroin addicts on the waiting list for conventional treatment reduces heroin consumption even in the absence of the usual supporting services (intensive counseling, social assistance, supplementary medical care). By reducing intravenous drug use this minimal treatment, when combined with providing free condoms and counseling on risk behavior, also reduces the risk of acquiring or transmitting AIDS. The importance of this finding is more practical than theoretical because the phenomenon of pharmacological blockade with methadone, and the attendant reduction of craving for opiates, has been documented by many studies during the past 25 years. Not surprisingly, the purely pharmacological effects of methadone are invariant over a wide range of cultural and economic conditions. However, the full value of pharmacological support with minimal social services needs to be tested by additional controlled studies under field conditions. The present study was only a preliminary test of feasibility, which involved many administrative questions. To have a significant impact at the public health level, any program needs to be both effective and capable of expansion to reach a substantial percentage of the addicts in a community. Additional variates are acceptability of the procedure to previously unmotivated addicts and compatibility with the work of affiliated health professionals in the area. The present study unexpectedly provided information on these points. As it turned out, this was the most informative part of the result. Consider the dimensions of the problem in New York: According to best available estimates, about 250 000 persons are using heroin regularly, injecting themselves at least weekly, and in many cases, several times per day. At the present time at least halfof the addicts are infected with the human immunodeficiencyvirus (HIV) (asjudged by testing on admission to treatment programs). The deteriorated homeless addicts, unreached by any treatment
September 1991, Vol. 81, No. 9
program, almost surely have a higher rate of infection because needles are shared by large groups of destitute persons. Once infected, an addict becomes a vector for transmitting the disease to other addicts, to sexual partners, and to offspring. In New York City today, addicts are the major vectors responsible for the spread of the epidemic. On the control side, education of the public to the dangers of drug abuse and education of addicts on the avoidance of risk behavior are worthy efforts, which must be continued; but in truth it is difficult to find any evidence of efficacy in limiting the spread of AIDS. Other measures directed to prevention include the improvement of social conditions in inner cities, sex education in the schools, general counseling of the public on risk behavior, and efforts to monitor the epidemic by testing programs. All these are well intended, but they fail to address the question of what to do about the existing population of infected persons. Unlike in previous plagues, in which transmission could be interrupted by controlling rodents and insects, in this case the vectors are human beings. They cannot be exterminated. Moreover, the AIDS epidemic apparently does not generate a pool of recovered subjects who, being immune, dilute the pool of susceptibles and thus extinguish the spread. This malignant infection appears to be uniformly fatal-or nearly so-in the long run. Meanwhile the infected subjects remain capable of transmitting the disease over a period of years. Despite much effort directed at the development of an immunizingvaccine, there is at present no sign of near-term success on this front. Thus the hope of effective intervention in the near future comes down to the feasibility of large-scale treatments for intravenous drug abusers-a conclusion reached by several comniissions reviewing the problem. Among the treatments for heroin addiction, by far the most thoroughly evaluated, large-scale treatment is methadone maintenance. In fact, it is the only available modality capable of sufficient expansion in the foreseeable future to have a public health impact on the AIDS epidemic. Although methadone programs are potentially only a partial answer to the drug problem because methadone does not block cocaine, well-run maintenance programs also make a significant contribution to the reduction in
nonopiate drug abuse. In fact, the longterm reduction in use of cocaine after admission to a methadone program is comparable to the reduction achieved by programs specifically directed against cocaine abuse. The quantitative aspects of the problem are staggering when viewed from a treatment prospective. There are currently about 36 000 patients in maintenance programs in the New York City area. To have a decisive impact on the drug epidemic and on the associated spread ofAIDS, treatment capacitywould have to be doubled or tripled without sacrifice in efficacy. But most existing clinics already are operating near or over their rated capacity. Despite pleas for expansion of treatment services by almost every committee that surveys the problem, local opposition has prevented the opening of any new maintenance clinic for more than 15 years. Moreover, the state has recently announced its intention to reduce next year's budget for the maintenance treatment of drug addicts. New admissions to programs therefore will be virtually limited to replacing persons leaving established clinics. Since the relapse rate of dropouts is about 80% after they leave the programs (maintenance treatment controls, but does not cure, narcotic addiction), the net public health benefit of current administrative policy is negligible. This is the background against which the present studywas planned. Ironically, from the time of its first proposal the concept of minimal-service, low-cost clinics was vigorously attacked by supporters of methadone maintenance as well as by the usual opponents of this modality-both sides apparently fearing the political consequences if the clinics succeeded. Proponents of maintenance treatment were concerned (understandably) that even partial success would serve as an excuse for further budget cutting, leading eventually to the elimination of full-service clinics. Opponents of the modality, including neighborhood groups who rejected plans for any additional treatment ofaddicts and others who were concerned that massive outlays for maintenance clinics would drain resources from other essential services, joined forces to oppose minimalservice maintenance clinics. The net effect of these pressures was the development of a modest study plan intended to avoid these large implications. There are two critical questions with reAmerican Journal of Public Health 1111
Editorials
spect to the AIDS epidemic: (1) Could an immediately available, nonpunitive maintenance program attract into treatment a significant number of presently unmotivated addicts and reduce their risk behavior? (2) If a large number responded, could clinics of this kind expand fast enough to meet demand, while keeping a balance with other programs providing full service? The authors approached these questions by restricting the study group to addicts on the waiting list of an established full-service program, with the understanding that they would be released from the study when an opening became available in the conventional program. Even with this reduction in scope, the study was vigorously opposed by the treatment community and by the New
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Vincent P. Dole, MD, is Professor and Senior Physician, Emeritus, The Rockefeller University, 1230 York Avenue, New York NY 100216399. He can be contacted for reprints at the above address.
Reference 1. Yancovitz SR, Des Jarlais DC, Peyser NP, Drew E, Friedmann P, Trigg HL, Robinson JW. A randomized trial of an interim methadone maintenance clinic. Am J Public
Health. 1991;81:1185-1202.
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1112 American Journal of Public Health
September 1991, Vol. 81, No. 9
Interim Methadone Clinics: An Undervalued Approach The study of Yancovitz et al. entitled "A Randomized Trial of an Interim Methadone Maintenance Clinic" (see p. 1185 of this issue of the journal) is a significant addition to the list of controlled clinical trials on the effectiveness of methadone.1 It also is a study that is unlikely to be repeated. It shows that the medically supervised administration of a daily dose of methadone to heroin addicts on the waiting list for conventional treatment reduces heroin consumption even in the absence of the usual supporting services (intensive counseling, social assistance, supplementary medical care). By reducing intravenous drug use this minimal treatment, when combined with providing free condoms and counseling on risk behavior, also reduces the risk of acquiring or transmitting AIDS. The importance of this finding is more practical than theoretical because the phenomenon of pharmacological blockade with methadone, and the attendant reduction of craving for opiates, has been documented by many studies during the past 25 years. Not surprisingly, the purely pharmacological effects of methadone are invariant over a wide range of cultural and economic conditions. However, the full value of pharmacological support with minimal social services needs to be tested by additional controlled studies under field conditions. The present study was only a preliminary test of feasibility, which involved many administrative questions. To have a significant impact at the public health level, any program needs to be both effective and capable of expansion to reach a substantial percentage of the addicts in a community. Additional variates are acceptability of the procedure to previously unmotivated addicts and compatibility with the work of affiliated health professionals in the area. The present study unexpectedly provided information on these points. As it turned out, this was the most informative part of the result. Consider the dimensions of the problem in New York: According to best available estimates, about 250 000 persons are using heroin regularly, injecting themselves at least weekly, and in many cases, several times per day. At the present time at least halfof the addicts are infected with the human immunodeficiencyvirus (HIV) (asjudged by testing on admission to treatment programs). The deteriorated homeless addicts, unreached by any treatment
September 1991, Vol. 81, No. 9
program, almost surely have a higher rate of infection because needles are shared by large groups of destitute persons. Once infected, an addict becomes a vector for transmitting the disease to other addicts, to sexual partners, and to offspring. In New York City today, addicts are the major vectors responsible for the spread of the epidemic. On the control side, education of the public to the dangers of drug abuse and education of addicts on the avoidance of risk behavior are worthy efforts, which must be continued; but in truth it is difficult to find any evidence of efficacy in limiting the spread of AIDS. Other measures directed to prevention include the improvement of social conditions in inner cities, sex education in the schools, general counseling of the public on risk behavior, and efforts to monitor the epidemic by testing programs. All these are well intended, but they fail to address the question of what to do about the existing population of infected persons. Unlike in previous plagues, in which transmission could be interrupted by controlling rodents and insects, in this case the vectors are human beings. They cannot be exterminated. Moreover, the AIDS epidemic apparently does not generate a pool of recovered subjects who, being immune, dilute the pool of susceptibles and thus extinguish the spread. This malignant infection appears to be uniformly fatal-or nearly so-in the long run. Meanwhile the infected subjects remain capable of transmitting the disease over a period of years. Despite much effort directed at the development of an immunizingvaccine, there is at present no sign of near-term success on this front. Thus the hope of effective intervention in the near future comes down to the feasibility of large-scale treatments for intravenous drug abusers-a conclusion reached by several comniissions reviewing the problem. Among the treatments for heroin addiction, by far the most thoroughly evaluated, large-scale treatment is methadone maintenance. In fact, it is the only available modality capable of sufficient expansion in the foreseeable future to have a public health impact on the AIDS epidemic. Although methadone programs are potentially only a partial answer to the drug problem because methadone does not block cocaine, well-run maintenance programs also make a significant contribution to the reduction in
nonopiate drug abuse. In fact, the longterm reduction in use of cocaine after admission to a methadone program is comparable to the reduction achieved by programs specifically directed against cocaine abuse. The quantitative aspects of the problem are staggering when viewed from a treatment prospective. There are currently about 36 000 patients in maintenance programs in the New York City area. To have a decisive impact on the drug epidemic and on the associated spread ofAIDS, treatment capacitywould have to be doubled or tripled without sacrifice in efficacy. But most existing clinics already are operating near or over their rated capacity. Despite pleas for expansion of treatment services by almost every committee that surveys the problem, local opposition has prevented the opening of any new maintenance clinic for more than 15 years. Moreover, the state has recently announced its intention to reduce next year's budget for the maintenance treatment of drug addicts. New admissions to programs therefore will be virtually limited to replacing persons leaving established clinics. Since the relapse rate of dropouts is about 80% after they leave the programs (maintenance treatment controls, but does not cure, narcotic addiction), the net public health benefit of current administrative policy is negligible. This is the background against which the present studywas planned. Ironically, from the time of its first proposal the concept of minimal-service, low-cost clinics was vigorously attacked by supporters of methadone maintenance as well as by the usual opponents of this modality-both sides apparently fearing the political consequences if the clinics succeeded. Proponents of maintenance treatment were concerned (understandably) that even partial success would serve as an excuse for further budget cutting, leading eventually to the elimination of full-service clinics. Opponents of the modality, including neighborhood groups who rejected plans for any additional treatment ofaddicts and others who were concerned that massive outlays for maintenance clinics would drain resources from other essential services, joined forces to oppose minimalservice maintenance clinics. The net effect of these pressures was the development of a modest study plan intended to avoid these large implications. There are two critical questions with reAmerican Journal of Public Health 1111
Editorials
spect to the AIDS epidemic: (1) Could an immediately available, nonpunitive maintenance program attract into treatment a significant number of presently unmotivated addicts and reduce their risk behavior? (2) If a large number responded, could clinics of this kind expand fast enough to meet demand, while keeping a balance with other programs providing full service? The authors approached these questions by restricting the study group to addicts on the waiting list of an established full-service program, with the understanding that they would be released from the study when an opening became available in the conventional program. Even with this reduction in scope, the study was vigorously opposed by the treatment community and by the New
.
.. . .. ............. .. ....... . ::.:::N:.
'j:'.::.::I
York State Division of Substance Abuse Services-a result that provided an unequivocally negative answer to the question of feasibility. Although in principle it might be argued that addicts are a heterogenous mixture of persons with widely different social needs and therefore that a range of different programs (including special facilities for pharmacological induction and social evaluation during the first month of treatment) are needed for the efficient use of resources, the treatment community and governmental adnministration have spoken with a virtually unanimous voice: Minimum-service programs will be prohlbited, even as preliminaries to full-service programs. On May 23, 1991, the US Public Health Service working group on metha-
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Vincent P. Dole, MD, is Professor and Senior Physician, Emeritus, The Rockefeller University, 1230 York Avenue, New York NY 100216399. He can be contacted for reprints at the above address.
Reference 1. Yancovitz SR, Des Jarlais DC, Peyser NP, Drew E, Friedmann P, Trigg HL, Robinson JW. A randomized trial of an interim methadone maintenance clinic. Am J Public
Health. 1991;81:1185-1202.
.... .............
.................................................................
...............................................
done treatment rescinded plans for a regulatory change that would have permitted the operation of interim facilities for addicts on waiting lists of licensed clinics. The goal for the future, apparently, is to eliminate the embarassment of waiting lists by discouraging narcotic addicts from applying for treatment. 0 Vunent P. Dok, MD
...............
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1112 American Journal of Public Health
September 1991, Vol. 81, No. 9
