an would like to see this treatment made a condition for continued eligibility for Public Assistance. And there are those who sincerely believe that an involuntary commitment program approach which to my knowledge has never been successful and should be immediately abandoned - can be infused with new life by adding methadone to the regimen which is forced on the unlucky and unwilling recipient of services. These and other extensions of methadone maintenance treatment are, in my estimation, doomed to fail because they do not take into account the limits of this modality. In fact, there is nothing magical about the effectiveness of methadone maintenance treatment. The unique results are a consequence of the following combination of factors: 1. Patients who are incredibly well motivated to leave a life of addiction and associated crime and to regain control of their own destiny. In 2. The inherent pharmacological validity of methadone maintenance as a long-term treatment for narcotics addiction. appropriate dosage, daily administration of methadone produces a tolerance - or body resistance to the euphoria, the sleepiness and the respiratory depression of all narcotics, including methadone itself. This is no more mysterious than the experience common to most of us who have had occasion to use nose drops: while initially effective in clearing the nasal passages, repeated use leads to a total tolerance to the medication; this is not caused by the cold worsening, or the nose drops becoming weaker, but by the resistance to this drug which develops with repeated use. Additionally, methadone maintenance eliminates the physical craving for narcotics in most former heroin addicts. The mechanism for this action is far less clearly understood, but it is confirmed by the overwhelming majority of patients in programs all over the country. 3. Addicts do not enter treatment because they suddenly lose their taste for heroin. Rather, it is generally a desire to escape from all that goes with the addiction, and to resume a As has been pointed out previously, productive role in society. there are major external obstacles which exist, and a competent supportive services staff in the clinic is often necessary to help the patient achieve "success." In summary, I would like to emphasize the following points: as a uniquely effective means of treating the overwhelming majority of heroin addicts who voluntary seek this treatment modality. b. During the past 18 months the Methadone Maintenance Treatment Program of the New York City Health Services Administration has demonstrated that it is possible to expand at a very rapid pace without sacrificing quality care. In fact, we have grown from zero to over 5,500 patients in one and a half years. C. In New York City, as in virtually every other city in the nation, the spontaneous and voluntary demand for treatment remains far greater than the capacity of existing programs. d. This gap between demand for treatment and available capacity requires that the highest priority at every level of government be given to enable methadone program expansion so that all eligible applicants can be promptly admitted. e. Illicit diversion of methadone is indeed a problem, and will not be resolved until legal treatment is available promptly to all those who want and need it. Efforts at lessening the illicit supply will be self-defeating if they simultaneously diminish treatment capacity. f. In the interests of the patients as well as society at large, the existing discrimination against ex-addicts in all fields including attitudes- must be overcome; it is recognized that this will be a slow struggle. g. The limitations of methadone must be recognized along with its effectiveness. Specifically, it must not be concluded that methadone maintenance is a panacea which will solve the enormous drug abuse problem which presently exists. Methadone maintenance can not and should not be forced on unwilling subjects. Other treatment and prevention approaches should be encouraged and supported. Again, I wish to thank you for the opportunity to address this I shall be pleased to respond to any questions you Committee. may have. Senator HUGHES. The Chair calls Dr. Carl Chambers, director, addiction sciences, Department of Psychiatry, University of Miami Medical School, Miami, Fla. STATEMENT OF DR. CARL CHAMBERS, DIRECTOR OF ADDICTION SCIENCES, DEPARTMENT OF PSYCHIATRY, UNIVERSITY OF MIAMI MEDICAL SCHOOL, MIAMI, FLA., ACCOMPANIED BY CHARLES ELLIS, RESEARCH ASSOCIATE Dr. CHAMBERS. Thank you, Mr. Chairman. Senator HUGHES. We appreciate your taking the time to testify before the committee, Doctor. Dr. CHAMBERS. Thank you. With your indulgence, I brought an individual with me, Mr. Charles Ellis. I would appreciate it if he could join me. He is a research associate in the division of addiction sciences. He is also the chief drug counselor in our Metropolitan Dade County drug program. He and his wife both have been methadone patients for some 7 years. He might be able to present you with a set of empirical data that those of us who just research the problem or treat it would not necessarily have. We came here this morning to speak in favor of methadone, quite frankly, and to speak in favor of expansion of methadone maintenance in the Nation's attempt to address the problem of drug abuse. In doing so, however, we would like to point out what we, as researchers, find as limitations and point out some areas where research and evaluation still needs to be conducted. There would be no reason for me to talk to the committee about increased productivity among methadone maintenance patients, about decreases in criminality, about increases in emotional stability. You have had the best clinicians in the country before you to do that. I think, however, as clinical researchers and as methadone clinicians from some time back, we would point out that productivity is not necessarily the automatic kind of phenomenon that some clinicians and some researchers would lead us to believe it is. It is true that some 20 percent of all methadone maintenance patients when they come into a program are already productive, and that even after a year at that level of productivity they will not increase beyond 60 percent. Probably what we are getting is a group of clients who want to become productive and a group of clients who do not want to become productive. We will have to address them with that dichotomy. It is our experience, and I think we can demonstrate it with hard research data, that if you do not make your client productive or do not assist him in becoming productive within the first 9 to 12 months, you might as well give up, that it doesn't make any sense economically from a cost-benefit standpoint to continue to try to make this individual productive. It might do us well to begin to talk about going on welfare as an alternative to the kind of productivity that most of us think about. In programs where they draw from base populations where unemployment is probably already high it is unrealistic for us to demand that all of our patients go to work. I would choose that we not become too confused with the statistics on decreasing criminality as well. For example, I have contributed some statistics to the literature on decreases in criminality that I am happy to live with. It was statistics that we generated from decreases in arrest rate. Anyone who has worked with arrest statistics and police figures and prison statistics and figures knows the limitations to those things. Criminality does decrease but criminal involvement and criminality does not disappear in maintenance programs. You still have people who have spent large portions of their life stealing and in criminal involvement and this doesn't change with methadone. If large numbers of people still need money, still can't qualify for training programs, educational programs, welfare programs, then the major source of income still is in criminal involvement. Again, don't get too excited about decreases in arrest figures until we analyze what it means. Clinicians have consistently reported getting along better with families and friends. As a scientist, I have been unable to count these things. I have been unable to establish the insight that some clinicians have. I think there should be a national effort to look at how these things actually occur and what level we will be able to generate the methodological strategies necessary to look at them. At the present time, we don't have those methodologies. Methadone, if it is used properly, can and does control the narcotic addict's physical addiction, but ancillary services are needed to affect the addict's reentry into the community. Methadone alone accomplishes little. Methadone plus a motivated patient, plus a competent staff, and plus an understanding community accomplishes a great deal. Unfortunately, these extra pluses don't exist in most programs. I believe those of us who do the treating have a lot to learn about the modality, itself. We talk as if we know a great deal about the modality when in fact we do not. For example, we have never learned how to get the staff's perception of the addict and the addict's perception of treatment together. A very excellent study done last year would indicate that the addict comes into treatment and remains in treatment with the belief that his problem is primarily a physical addiction and if he transfers that addiction from his drug of choice to methadone his problem is essentially solved. On the other end of the continuum, some 95 percent of all staff dealing with addicts believe the addicts to be emotionally ill, mentally ill, and incapable of coping in the current society. Staff tends, I think, sometimes to set up situations, set up clinic goals, to keep the patient passive and dependent and noncoping within the system. I think we really need to begin to look at these goals. I think we must begin to look at the modality at a very realistic level. I still believe that we assume the modality does more than it really does. We have not learned, for example, with whom the modality works best. We have not learned how to screen patients into treatment, nor have we learned when to screen people out of treatment. I think these are areas that we have expertise in and we simply have not pursued them. We have had the modality for some 8 years now and we have gained 8 years of experience. I say we have gained very little knowledge in those 8 years about the modality. One of the things we consistently do is to continue to expect more from our clients than we do from the base population from which they come. This is totally unrealistic and we |