New York Mayor Rudolph Giuliani is determined to change the national debate over the treatment of heroin addiction.
In a move that shocked the substance-abuse treatment community nationwide, New York's mayor announced this month the city would toss out its 30-year policy of shifting addicts from heroin to methadone, a prescription drug that users take indefinitely. Instead, the city will switch to a program aimed at abstinence from any kind of drug within 90 days.
The controversial move comes at a time when heroin use has increased among some young adults, prompted by the easy availability of a cheaper, purer form of the drug. While use by teenagers leveled off in 1997, it hit an all time peak in 1996, according to the National Household Survey on Drug Abuse.
"It will be a shame if [the mayor] does what he says he's going to, and very, very foolish," says Douglas Lipton, a senior fellow at the National Development and Research Institute, one of the nation's leading nonprofit drug-treatment research centers in New York.
Bucking the trend
The Republican mayor is also at odds with the federal government and other states working on substance-abuse treatment, which are working to expand access to methadone maintenance programs in response to the new surge in heroin use. Methadone maintenance is one factor that has been credited with cutting overall heroin use by 70 percent since the 1960s.
Mr. Giuliani contends his critics are the "politically correct crowd" and stands by his decision. "If you're going to keep someone permanently enslaved to methadone for the rest of their lives, then I have real questions about your common sense," he says.
At the heart of the dispute are two fundamentally different approaches to the problem of heroin addiction. From the mayor's point of view, methadone maintenance simply substitutes one drug for another: Abstinence, in his mind, is the more decent and appropriate goal for recovering addicts.
But critics, who variously characterize Giuliani's plan as "misinformed" and "ridiculous," contend the mayor is imposing a moral judgment on what is fundamentally a medical problem. Heroin users, unlike those addicted to most other illegal drugs, need to be treated with methadone to "normalize" heroin-induced changes in the brain, says Dr. Herman Joseph of New York State's Office of Alcoholism and Substance Abuse Services.
Studies show that the longer a person stays on methadone, in a regimen that includes random drug testing and counseling, the better the likelihood of kicking heroin addiction altogether. Only 15 to 20 percent of the people in methadone-to-abstinence programs succeed in staying free of heroin over a long term, studies show.
But the mayor and his health advisers believe that's because abstinence is not currently emphasized in drug treatment.
"We're changing the goal of our program from giving out methadone, no questions asked, to emphasizing abstinence and giving each of our 2,000 patients a caseworker," says Luis Marcos, president of the New York Health and Hospitals Corp. "Not everyone will succeed, but if we offer the right incentives, there are those that will."
Dr. Marcos acknowledges there is little scientific data backing the city's approach, but his anecdotal experience leads him to believe that counseling, along with the use of alternative drugs to treat depression, is a viable alternative.
Most of New York State's 250,000 heroin addicts reside in Manhattan, but the mayor holds control over only 2,000 of the 36,000 heroin-treatment slots there.
More access to methadone
Still, the city's new plan bucks the nationwide trend for treating heroin addiction. In Connecticut, Maryland, and Washington, pilot programs are under way to allow private doctors to dispense methadone to patients. Currently, people must go to clinics to receive the drug. Nationwide, 130,000 people are in treatment for heroin addiction, out of an estimated 1 million users.
"Methadone is the most successful treatment for heroin addiction we have to date," says David Biklen, executive director of the Connecticut Law Revision Commission. "If the goal of our drug policy is to reduce drug use and attendant criminal behavior, it's the most effective and cheapest way."
An addict's view
Anthony Russo agrees. The successful film editor and recovering heroin addict says he'd "panic" if he were told he had three months to wean himself off methadone.
"I don't know how it works, but it satisfies your body somehow," says Mr. Russo. "But there's no way ... it makes you feel like you're high on heroin."
Russo started using heroin recreationally more than 20 years ago. Last year, his wife noticed $20,000 missing from their joint account and confronted him. Russo realized his problem had careened out of control.
Now, he's on a methadone maintenance program at Greenwich House, a private drug-rehabilitation center here.
"I haven't taken heroin or cocaine for more than a year," he says.
Russo says he wants to start lowering his dosage and eventually get off methadone. But it's a process he'd like to take slowly, with the advice of his doctors and drug counselors.
Ironically, Marcos, in charge of the city's treatment program, says that if some patients want to stay on methadone indefinitely, they should have that right.