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Chemical Dependency Research Working Group

A Point in Time:

The Impact of Expanded Methadone Maintenance Treatment
on Citywide Crime and Public Health in New York City 1971-1973

by

Herman Joseph, Ph.D.

Joycelyn Sue Woods, M.A.

Abstract

In New York City methadone maintenance treatment was expanded on a large scale during the years 1971 through 1973. This expansion was associated with decreases in drug-related arrests, citizen complaints about property crimes, drug dependent deaths and serum hepatitis cases. Likewise, decreases in the number of addicts incarcerated in Hong-Kong for drug related and other offenses were reported for the years 1976 through 1980 when large scale methadone treatment was implemented. Methadone maintenance when prescribed in adequate doses has the potential to reduce transmission of HIV, eliminate the use of heroin, improve patients health and increase their productivity. Different types of programs should be implemented for different populations, such as private physicians with pharmacies for functional patients, clinics, vans, and supportive services for patients with special needs. Programs and patients outcomes should be monitored to maintain standards within the treatment system. Methadone maintenance allows patients to function within society as productive contributing individuals.

Keywords: Methadone Maintenance Treatment, New York City, 1971-73, Public Health, Heroin Addiction, HIV, Hepatitis, Drug-related Crime, Drug Dependent Deaths.

Introduction

Evaluations of the impact of methadone maintenance treatment usually address the outcomes of patients in single programs. While this information is vital for practitioners within a clinic setting or private medical practice, the larger issue --namely the impact of methadone maintenance treatment on public safety and health can only be inferred. For methadone maintenance treatment to have a measurable impact on community-wide public health and safety issues, large scale implementation of the program is required.

An example of large scale planning occurred in New York City between 1971 and 1973. Under the aegis of the Health Services Administration of the New York City Department of Health, Dr. Robert G. Newman created a sufficient number of hospital-based clinics to enable the admission of about 19,900 untreated heroin addicts into both hospital-affiliated public and unaffiliated private programs in the city. In 1971 about 14,000 patients were enrolled in methadone programs in New York City and by the end of 1973 about 33,900 were receiving treatment --an increase of about 142%.¹ The impact of this expansion on public health and safety will be the focal point of this paper. However, to give a broader perspective, other pertinent issues related to contemporary methadone treatment will also be discussed.

Prevalence of Heroin Addiction
in New York City in the 1970s

Estimates of the number of heroin addicts in New York City during the 1970s vary from about 164,000 to about 203,000.² Using these estimates for regular users, the expansion of methadone treatment in 1971-1973 resulted in the total enrollment of about 15 to 18 percent of the estimated heroin users in New York City. The assumption that those who entered methadone treatment during 1971-1973 were regular heroin users is based on the premise that they met the criteria for entry into methadone treatment which included at least two years of daily heroin addiction.

Public Health and Crime

To determine the impact of the expansion of methadone maintenance treatment on public health and safety, the following four variables were examined for the years 1971 through 1973:

• serum hepatitis^* which is transmitted through contaminated needles;



• deaths related to drug dependence;



• arrests involving drug charges including possession of drugs and drug paraphernalia (e.g., heroin and hypodermic needles and syringes);



• citizen complaints about property crimes associated with addiction (e.g., robbery, burglary, larceny, auto theft).

To offset the criticism that New York City may be a statistical anomaly for a particular period in a particular culture, drug related and other arrests in Hong Kong were examined for the years 1976 through 1980. To demonstrate a possible association between citywide statistics and outcomes in methadone treatment crime and death statistics are presented from a major follow-up study implemented in 1974 of active and discharged patients admitted to treatment in New York City in 1966, 1967 and 1972.¹

Administrative Concerns

For methadone maintenance to be successful within a large public health system, the following must be considered:

1. Networks of clinics with physicians and staff trained in the procedures of methadone maintenance must be in place;



2. Adequate daily doses of oral methadone must be prescribed that relieve narcotic hunger and block the mood altering effects of illegal opiates if tried by the patient;



3. Administrative procedures must allow for a rapid large-scale intake of patients over a reasonable time frame removing a substantial fraction of persons at risk for continued addiction, criminal activities, infection and death;



4. Social and medical services should be available either on-site at the clinic or within the community to resolve problems that patients may bring into treatment;



5. Community education should be implemented about the benefits of methadone treatment to lessen resistance to the establishment of treatment centers or large scale medical practices devoted to the treatment of opiate dependence with methadone.

Social conditions, the political climate and economic limitations may preclude the ideal implementation of drug treatment. There may be differences in the quality of programs and physicians, staff may not be adequately trained, services may not be available to assist dysfunctional patients and community opposition to the establishment of methadone treatment can impede the development of programs. Nevertheless despite limitations, the large scale unprecedented expansion of methadone treatment proceeded in New York City during 1971-1973.

Effect of Expansion of Methadone Treatment
on Public Health and Crime
During the Period 1971-1973

With the expansion of methadone treatment from about 14,000 to about 33,900 patients decreases in public health problems and addict-related crimes were noted. Table 1 summarizes the rate of decrease per 1,000 patients admitted to methadone treatment in community-wide public health problems (serum hepatitis and drug dependent deaths) and criminal activities (major property crimes and drug related arrests) associated with heroin addiction.^{3, 4, 5} The drop in serum hepatitis cases bears noting. It is transmitted through shared contaminated needles --the same route of administration as the transmission of HIV within an addicted injecting population.

Figure 1 shows the association between the increase in admissions to methadone treatment in New York City and the reduction in citywide drug related arrests and citizen complaints for burglary, robbery and grand larceny.⁵ Figure 2 shows the decrease in arrests per person year for a sample of 1500 patients entering methadone treatment in 1966, 1967 and 1972. ¹ The pre-treatment arrest rate is higher for patients who remain in treatment less than one year as compared to patients who remain in treatment over one year (1.5 vs. 0.8 arrests per person year).¹ However, patients who remain in treatment less than one year have a higher rate of rate of arrests during treatment than patients who remain in treatment for more than one year (0.55 vs. 0.10 arrests per person-treatment year).¹ The citywide reduction in crime, therefore, appears to be associated with the reduction of crime within the methadone patient population. Also, socially dysfunctional patients may have higher arrest rates both prior to and during treatment and lower retention rates than more socially stable patients. Nevertheless, irrespective of the rate of pre-treatment arrests, there is a reduction in the rate of drug and other arrests per person year while patients remain in treatment.

Figure 1. Association between increase in number of addicts treated in methadone clinics and reduction in criminal activity in New York City.

Figure 2. Number of arrests per person year of patients before and after entering methadone treatment in New York City.

This major impact on public health and crime in the period 1971-1973 may be criticized as an anomaly unique to New York City unrelated to the effect of methadone treatment. However, a significant reduction in crime was noted in Hong Kong during the period 1976-1980 when a large network of methadone programs was established: ⁶

1. An 83% decrease in the number of narcotic addicts entering the jails of Hong Kong for all offenses.


2. An 85% decrease in the number of narcotic addicts entering the jails for drug related offenses over a four year period was reported.

/figure 3. Reduction in number of narcotic addicts entering prison in Hong Kong since introduction of methadone maintenance program.

Figure 4 shows the association between the increase in admissions and the decrease in serum hepatitis cases and drug dependent deaths in New York City from 1971 to 1973. These citywide figures reflect trends that were noted in methadone treatment. Improvement in overall health status among long term methadone patients has been documented. ^7,8 In the 1960s and 1970s, the post-treatment death rate from all causes for discharged patients was about 2.3 times greater than the death rate from all causes of patients who remained in treatment (35 deaths per 1000 post treatment years vs. 15 deaths per 1000 patient years). Narcotism^** was a major cause of death for discharged patients who relapsed to heroin use. However, narcotism as a cause of death is greatly reduced and eliminated for patients who remain in methadone treatment. The overall declining death rate for drug dependence in New York City may be associated with the large number of heroin addicts who entered and remained in methadone treatment during this period.

Figure 4. Association between increase in number of addicts entering methadone treatment and reduction in serum hepatitis and drug dependent deaths in New York City.

Methadone Regulations

Methadone maintenance treatment is highly regulated in the United States. The following three tiers of regulation exist at the federal level:

1. The Drug Enforcement Administration (DEA) oversees dispensing and security (e.g., safes for storage of methadone) and is concerned about diversion of methadone from clinics, hospitals, physicians, and pharmaceutical companies into the street black market;



2. The Food and Drug Administration (FDA) establishes regulations of safety, quality and standards of treatment, dose prescribed and admission criteria;



3. Department of Health and Human Services (DHHS) is responsible for setting special standards applicable to methadone treatment.

The Institute of Medicine organized a committee to study methadone regulations that has urged reassessment of the risks and benefits of methadone treatment in the following statement:

"Current policy, in the committees view, puts too much emphasis on protecting society from methadone, and not enough on protecting society from the epidemics of addiction, violence and infectious disease that methadone can help reduce."
(Federal Regulation of Methadone Treatment, 1995)

Yarmolinsky and Rettig ¹¹ have shown that methadone sold by patients is used primarily by untreated street addicts mostly for self medication (e.g., self withdrawal from heroin or short term maintenance). However, the amount of methadone diverted is quite small in comparison to the major drugs sold on the street --heroin, cocaine, marijuana, etc. Methadone is ranked last of the twenty controlled substances monitored for emergency room episodes.¹⁰

Current Number of Heroin Addicts
and Percent in Methadone Programs

As of 1995 there are an estimated 500,000 to 1,000,000 narcotics addicts in the United States. ¹² However, nationwide only about 115,000 (15 to 23% of the estimated addicts) are in methadone treatment.¹³ There are about 250,000 heroin users in New York State. About 40,000 patients (16% of the estimated addicts in New York State) are enrolled in about 125 methadone programs throughout New York State with about 90% of the methadone patients treated in New York City.^{14, 15} Community resistance to methadone treatment and other social service programs has prevented their establishment, thus limiting the availability of treatment. Clearly then, the clinic system is reaching only a small proportion of the heroin addicts both nationwide and in New York State. To increase the availability of methadone treatment, the American Medical Association supports further research that would permit physicians to prescribe methadone in private medical practice to selected socially rehabilitated patients.¹⁶

Proven Effectiveness of Methadone Treatment

Methadone maintenance has been thoroughly evaluated over the last 30 years. The overall trends are the same when an adequate dose is prescribed (e.g., 70 to 100 mg/day or over) -increase in productive behavior related to work or school, reductions in criminality, eventual elimination of heroin use and overall improvement of health. ^{17, 18} These improvements occur over varying periods of time in treatment. Some patients need counselling to achieve their goals. McClellan et al ¹⁹ showed that methadone patients maintained on doses over 60 mg/day improved dramatically with enhanced services (e.g., counseling, vocational assessment, family therapy) as compared to those who received either limited or no services.

The health of patients has been monitored since the inception of the program by Dr. Mary Jeanne Kreek of The Rockefeller University and others. There are no toxic effects with high dose long term methadone treatment. In general, the health of patients improves over time with restoration of impaired immune functioning in HIV negative patients.²⁰ Recent studies by Ball and Ross¹⁷ and Hartel and colleagues²¹ have validated the greater effectiveness of high dose methadone (e.g., greater than 80 mg/day). However, the effectiveness of the program can be compromised by the serious social, medical and polydrug problems that patients bring into treatment and the lack of adequate services to address these problems (e.g., homelessness, chronic unemployment, HIV, cocaine/crack addiction, alcoholism).²²

Methadone and the Prevention
of the Transmission of HIV

In New York City, intravenous injectors of heroin and/or cocaine comprise the major group diagnosed with AIDS. Also, the incidence of new AIDS cases is highest in the drug injecting group.²³ Methadone treatment at adequate doses appears to be a most effective method to prevent the transmission of HIV within a heroin using population. In a study conducted with 58 long term-socially rehabilitated methadone patients, none were found to be infected with HIV.²⁴ Hartel et al²⁵ in the South Bronx and Blix and Grondbladh²⁶ in Sweden have shown that those who entered treatment before 1983 had significantly less HIV infection and AIDS than those who entered after 1983. Both investigators concluded independently that methadone treatment had a protective effect in preventing the transmission of HIV. Weber et al²⁷ in Switzerland have shown that the progression to AIDS is slower in HIV infected methadone maintained patients then in HIV infected heroin addicts. Abdul-Quader et al²⁸ have shown high risk behaviors pertaining to the injection of heroin use can be reduced and eventually eliminated through the proper dose of methadone. In Frankfort am Main Hofmeister-Wagner et al²⁹ have demonstrated that the risk of HIV transmission associated with prostitution can be curtailed with the enrollment of heroin addicted women in methadone treatment.

Prevalence of HIV among admissions to methadone treatment in New York City varies from 20 to 61 percent according to the location of the program.³⁰ Drug resistant TB first appeared among untreated, homeless, HIV infected heroin addicts.²² Methadone programs now offer special services to patients infected with HIV and drug resistant TB.

Cocaine Addiction, Needle Exchange Programs and Therapy

Needle exchange programs also play a role in lessening transmission of HIV among heroin and cocaine injectors.³¹ While methadone maintenance has been shown to be the most effective pharmacological treatment for opiate addiction, there is no comparable effective pharmacological agent for cocaine/crack addiction. Methadone programs therefore, must treat not only heroin but the compulsive use of cocaine/crack.³² The only methods employed to treat this particular problem to date include individual and group counselling but with modest successful outcomes. In summation, with adjunctive services and the prescribing of adequate doses in methadone programs, it is possible to control and virtually eliminate heroin use and to reduce somewhat the compulsive use of cocaine.

Treating Methadone Patients
in Private Medical Practice

In 1983 Drs. Marie E. Nyswander and Vincent P. Dole of The Rockefeller University initiated medical maintenance. Medical maintenance is the treatment of socially rehabilitated methadone patients in private medical practices of hospital-based physicians.^{24, 33, 34, 35} Table 2 shows the type of employment that 67 patients enrolled in medical maintenance are engaged in by their level of methadone dose. The patients are employed in occupations that span the labor market, and several own their own businesses. While an adequate dose is important for the individual, the level of dose bears no relationship to the range of tasks and acquired skills performed by this group of employed patients. Similar skills are found at every level of dose (e.g., skilled laborer, entrepreneur, professional, etc.).

Not all methadone patients may be suited for private practice. Some may not have the economic means to meet monthly payments. Others may present problems that are better suited to the environment of a clinic where special services can be delivered or appropriate referrals can be made.

Discussion

The problems regarding addiction in Belgium are on a different scale than those of New York State. Belgium does not have an estimated 250,000 heroin addicts nor the extent of homelessness, HIV infection, drug resistant TB, cocaine/crack addiction and social deprivations that we see among the untreated heroin addicted population in New York City. It is therefore possible with the cooperation of physicians, clinics, pharmacies and hospitals to set up a network of services that will bring into treatment a large number of addicts within a short period of time. These include the establishment of special clinics for patients with a variety of social and medical problems, treatment in private medical practice for employed patients who are not in need of adjunctive services and the delivery of methadone in vans or buses for street addicts who will not cooperate with physicians or hospital clinics. If a patient is not successful in private practice then a referral to a clinic setting may be appropriate. Conversely, clinic patients who show improvement may be transferred to private physicians. For many indigent addicts the acquiring of job skills and meaningful employment is probably the most important social service that can be provided. It enhances their self esteem and removes them from a life of dependency and crime on the streets. It is important to set in place a research evaluation or monitoring system to record admissions, transfers, discharges, duration of treatment episodes, to determine outcomes of treatment and to ensure high standards of services delivered are maintained. Accurate record keeping would also help eliminate duplicate registrations of patients.

The specialty that makes the most sense for incorporation of methadone treatment into mainstream medicine would be a general practice in internal or family medicine. This is the consensus of the physicians who are now working in medical maintenance. However, physicians and ancillary staff have to be educated about methadone maintenance and correct prescribing procedures. Although methadone maintenance is a safe simple procedure it is not simply substituting one addiction for another. There is a well documented 30 year literature with new concepts about physical dependency, physiology and pharmacology that should be mastered by physicians and staff who choose to enter this type of specialty. Therefore, staff training is essential if the program is to succeed and if methadone patients are to be treated with dignity and not as hedonistic addicts with serious character flaws. When used in maintenance therapy methadone does not act as a mood altering narcotic --it functions as a normalizer of a deranged physiology that permits patients to stabilize their lives. The alternative to the suppression of methadone treatment or the inadequate provision for its distribution is an increased incidence and prevalence of HIV with the possibility of the emergence of drug resistant TB in a group that can transmit lethal viruses to the general population.

One final word --no other medication in modern medicine with the proven potential of methadone has been subjected to so much stigmatization, trivialization and distortion. Successful patients in the United States who are members of the National Alliance of Methadone Advocates regard methadone as a medication for the treatment of chronic heroin addiction --not substituting one addiction for another. They see themselves as having a specific medical condition that although not fully understood is of physical origin within the central nervous system. Methadone for successful patients is a legitimate medication that allows them to function within society as productive contributing individuals.

Footnotes

* Prior to classification of hepatitis all drug users were assumed to have serum hepatitis which is today classified as hepatitis B.

** This is a general term that includes heroin overdose and heroin mentions on autopsy. This term may be used when there are multiple causes of death (i.e., chronic narcotism and chronic alcoholism).

References

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4. New York City Department of Health. Annual Vital Statistics Report. New York: Bureau of Epidemiology and Vital Statistics; 1974.



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