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While politicians and public health officials in Vancouver, British Columbia, are weighing the risks and benefits of a controlled heroin prescribing trial, the mayor of America's largest city is making a bid to end all city-funded methadone maintenance programs with the aim of forcing addicts into abstinence.
New York City Mayor Rudolph Giuliani, who has gained accolades for his successful efforts to make New York a more civilized city, dropped a bomb on that city's addiction-treatment community with an offhanded remark during a July 20 speech on ending welfare. The mayor's office did not return calls from Psychiatric News, but according to accounts in the July 21 and July 22 New York Times, Giuliani said he would end methadone programs in New York City over the next four years and force all city-funded heroin treatment programs to follow an abstinence model.
Richard Frances, M.D., is chair of the Public Policy Committee of the American Academy of Addiction Psychiatry and consultant to APA's Council on Addiction Psychiatry.
"Perhaps Mayor Giuliani's coming out against methadone maintenance has led other municipalities to consider other measures, such as legalized prescribing of heroin," Frances remarked. "What he's doing is based on seeing opiate addiction as a moral problem rather than a medical problem. It is bad enough we have managed care dictating to doctors what they should do with patients; to have politicians stepping in and saying we can't use scientifically proven treatments makes no sense at all."
An estimated 36,000 patients are on maintenance methadone in New York City, nearly one-third of the estimated 115,000 methadone patients nationwide, according to the National Center on Addiction and Substance Abuse (CASA) at Columbia University in New York. But the vast majority of methadone programs located in the city-about 90 percent-are funded through federal and state agencies beyond Giuliani's control, according to CASA.
General Barry McCaffrey, director of the federal Office of National Drug Control Policy, issued a statement condemning Giuliani's proposal. The mayor's statements about methadone "are at odds with the conclusions of the nation's scientific and medical community," said McCaffrey. "The problem isn't that there are too many methadone programs; it is that there are too few."
McCaffrey cited the findings of a recent National Academy of Sciences study concluding that methadone treatment "is more likely to work [for heroin addiction] than any other therapy."
Because New York is so often a bellwether for what may occur elsewhere later, the mayor's proposal is cause for grave concern, said Frances. If he wants to test his hypothesis on abstinence, he should try a controlled program in which an enriched abstinence model is balanced against an enriched model of methadone, Frances added.
The antimethadone proposal runs counter to Giuliani's goals of reduced crime and lower unemployment, said Frances. "If he wants to put [unemployed heroin addicts] back to work, the best way to do that is through a methadone program combined with a job program." If Giuliani implements his proposal, it will have the opposite effect, and will result in more crime and more joblessness, said Frances.
While methadone works best when combined with psychosocial counseling, housing assistance, and job training, it is an essential element of many addiction programs for addicts unwilling or unable to remain abstinent, he added.
Relevant Web sites on methadone include those of NIDA at www.nida.nih.gov/NIDA--Notes/NNVol12N6/NIHPanel.html, National Alliance of Methadone Advocates, www.methadone.org, American Methadone Treatment Association, www.assnmethworks.org, and Lindesmith Center, www.lindesmith.org.
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