Kicking the Habit

James LeBlanc, 32 and white, has been a heroin addict for ten years, dur ing which he has thrice been convicted of larceny. Each time he robbed, he says, it was to buy a fix. Now he is in New York City's Beth Israel Medical Center where, seven days a week, he takes an orange drink laced with gradually increasing doses of methadone.

Enrique Blanco, a 29-year-old Puerto Rican, has been through that routine and now goes five days a week to a storefront clinic run by Beth Israel's Morris J. Bernstein Institute. There he takes a maintenance dose of methadone and leaves, in exchange, a sample of his urine; on Fridays he receives a napa of two methadone drinks to take over the weekend.

William White, 30 and black, goes to one of Harlem Hospital's community clinics, where his daily methadone dosage is being stepped up to his ultimate maintenance level. He is in a pilot program designed to see whether the early hospitalization can be cut out.

To anyone who knows that methadone itself is an addicting drug, the immediate and inevitable question is: Why is it being given to these real (but fictitiously named) drug addicts? Many reputable physicians have despaired of getting any substantial number of hard core heroin addicts to kick the habit even after long-term confinement and psychiatric treatment -- 80% to 90% soon relapse. So the doctors have concluded that the best thing to do is to fight fire with fire.

Rough Challenge. The idea originated with a husband-wife team, Dr. Vincent P. Dole, a specialist in metabolic research at Rockefeller University, and Dr. Marie Nyswander, a psychiatrist. As a substitute for heroin, which may cost the addict $50 a day and is virtually certain to lead him to crime, they hit upon methadone. It is a synthetic painkiller, widely prescribed for cancer patients and for people who have undergone surgery. Such prescriptions are not renewable, since it is undeniably addicting. But physical dependence on methadone is less stubborn than that on heroin or other opium derivatives, and patients who take it do not experience either euphoric highs or hellish lows. Moreover, methadone costs only about 10$ a dose, in bulk.

The exact mechanism by which methadone works is not known, but it involves tolerance and cross-tolerance, or blockade. The patients who take carefully stepped-up doses of methadone be come tolerant in the sense that they observe no outward effect from it. Presumably because methadone works on the same brain centers as heroin, it induces a cross-tolerance to heroin and blocks its effects. A methadone patient can be challenged with a massive mainline fix and show no response--except enormous relief at the knowledge that now he can take it or leave it alone. He can watch his old friends shooting horse and feel no desire to join them.

Physicians are naturally ultracautious about giving an addictive drug to known addicts. So Drs. Dole and Nyswander began conservatively, with small numbers of patients. They insisted then, and still do, that the addiction must have persisted for four years, that all patients have records of arrests as a result of their habit, and must have failed in using previous cure methods. At first, the doctors met vociferous opposition from fellow physicians and laymen who worried about the morality of giving drugs to addicts. Yet as the number of successful cases grew, they won not only increasing professional tolerance but also prestigious support.

Crime Cut. The program has now been under way for five years, and Drs. Dole and Nyswander report in the A.M.A. Journal that in the first four of those years: "The number of criminal addicts who have been rehabilitated is enough to empty a moderate-sized jail." More than a thousand other addicts are now waiting for the treatment. Of the first 723 male patients, only 15% were employed before treatment. Within three to six months, the proportion rose to 53% at work or in school, and now hovers near 70%. An additional 20%, though not employed, are rated by Dr. Nyswander as "socially acceptable," while 12% are frankly listed as failures. Before treatment, 912 men had been averaging a conviction every two years, and, say the doctors, "for every conviction, the usual addict has committed hundreds of criminal acts for which he was not apprehended." Now, the conviction rate has been cut by an impressive 90%.

The standard treatment program begins with four to six weeks in an unlocked hospital ward, where the methadone dosage is built up, in twice-daily installments, to the blockade level. After that, the patients are discharged but required to report to a clinic regularly for at least a year--daily at first, later tapering off to once a week if they stay clean. "Clean" means that their urine samples reveal no heroin on analysis. On these visits, patients are required to drink a full dose of methadone to show that they have been taking it at home and have retained their tolerance. This precaution is continued indefinitely, even after patients have held a job for a year or more. In the pilot program, in which hospitalization is omitted, preliminary results appear to be as good as those from the original method.

Possible Biases. To some extent, the program's good showing may reflect the fact that the patients are older than the average addict and more likely to be motivated to seek a better way of life. Then too, by design, all of them are volunteers. The sample is not exactly representative: it contains proportionately more whites (48% v. 25% among addicts generally), with 33% Negroes and 18% Puerto Ricans. Even with allowances for bias, the results are so good that an impartial study group set up at Columbia University calls them "most encouraging" and recommends expansion of the program and including younger patients. New York City's Health Research Council and Beth Israel Medical Center were early supporters of the program; now it is backed financially by the state's Narcotic Addiction Control Commission.

While some may continue to disapprove of any addicting drug, methadone appears far preferable to horse for the individual and for society.

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