We do not profess to know the exact meaning of these facts, although their implication is obvious. Certain other information came to our attention during this review. The latter information also suggested a high probability of widespread and heavy Heroin traffic in the entire unit, including inpatient wards. As a result, a decision was made to contact the Methadone Maintenance Compliance Division of the Bureau of Narcotics and Dangerous Drugs for advice and assistance. This unit agreed that we should give all the information possible to them as it was developed, and they were to conduct an investigation. We have not yet received a report of their results and/or recommendations. However, we verbally obtained their clearance before releasing any of the facts not already publicly known. We have also taken reasonable precautions to prevent any release or identification of individual patient records. Even the fact that we were conducting such a review was not revealed at the time although at least one of the individuals involved must have become suspicious, as he made a conspicuous attempt to alter one of the records.

Neither one of the authors is now associated with the District of Columbia Narcotics Treatment Program, so that whether or not the situation described has been remedied is not known to us. However, we are aware of one unfortunate follow-up fact-one of the individuals involved in these unauthorized entries was later employed as a paid counselor in the same unit. This action occurred despite the fact that some of the initial data relating to this individual was definitely known to his employer, and other clinical data which was easily available concerning the same individual should have made his employment quite unlikely.

The authors' major conclusion from this experience is that the use of "ex-addict" and addict counselors in a narcotic substitution treatment program should be very carefully planned and supervised by competent professional staff. We wish to emphasize that the situation here described developed in spite of the existence of a clear-cut verbal and written policy specifically designed to prevent it. It seems to us that there is also little to be gained in trying to "blame" the counselors in this situation. We agree with the observations of Deitch and Casriel1 made four years ago. To quote them: "The demands for ex-addicts to participate in treatment programs are becoming so numerous that the extent of an ex-addict's training and self-help experience is being overlooked. The demand is not for skilled, qualified manpower, but for the label "ex-addict." Thus, anyone who once stuck a needle in his arm is coming to be regarded as possessing curative powers, or magic."

APPENDIX 10

METHADONE ON THE STREETS, AS A PARAMETER OF EFFICACY

(By William A. Bloom, M.D., E. Ward Sudderth, M.D., Lee Marcelo, Drug Rehabilitation Clinic, New Orleans, La. Proceedings, Fourth National Conference on Methadone Treatment, 1972, pp. 169-1970)

Methadone maintenance programs have been in existence in New Orleans for the past three years. Our investigations have led us to conclude first, that the cost and quality of Methadone and Heroin "on the streets" can be used as one parameter to indicate the effectiveness of Methadone treatment programs in reaching a population of addicts; and second, the cost of street Methadone is inversely related to its availability, the availability of Heroin and the number of patients on programs in a given city.

Other factors which should be studied are: the crime rates of "addictrelated" crimes, such as shoplifting and burglary; employment rates; rearrest rates; and numbers of deaths due directly or indirectly to Methadone. Also it is important to know the number of new addicts whose first narcotic of addiction was Methadone. Another indication of the effectiveness of pro

1 Deitch, D. and Casriel, D., M.D.: "The Role of the Ex-addict in Treatment of Addiction." Federal Probation-December 1967.

PATIENTS IN TREATMENT

grams in reaching people is the percentage of applicants to various drug treatment programs who have been on Methadone in the past. Furthermore, the percentage who admit to having used illegally obtained Methadone can reveal to some degree trends in diversion.

In New Orleans, where there are now 1800 Methadone patients in five independent clinics, the price of Heroin has gone down and the quality up since our program began. We also have seen indications that when the opportunities for diversion of Methadone are reduced, more patients will tend to join programs in cities where there are no longer any waiting lists for admissions.

Figure 1 shows the increase in the number of patients in New Orleans' programs in the three year period.1 Figure 2 reflects the quality of Heroin has increased; these figures are based on estimates of the average of laboratory assays made of Heroin purchased or seized by the New Orleans Police Department. We are speaking of the one or two "paper" acquisitions of "street Heroin, rather than larger quantities obtained prior to being "cut." The New Orleans Police Department has continued to be most cooperative, and without their help we would not have been able to present this information.

Prior to June, 1968, when Dr. James T. Nix opened New Orleans' first Methadone Clinic the quality of Heroin remained fairly steady at from 2% to 4%. In fact, it was so poor that at times peddlers were accused of "selling cures." In spite of increasing narcotic arrests, the quality of Heroin has in

1 Personal communication with Mr. Edward Alderette, M.S.W., Executive Director of the Louisiana Narcotics Rehabilitation Commission, New Orleans, La.

2 Personal communication with Sergeant Henry Spako, Commander of the Narcotics Squad, New Orleans Police Department, New Orleans, La.

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creased until now 10% is a very conservative estimate of quality. For example, a statistical average of ten randomly selected papers of Heroin from those obtained by the police during April was 6.4%. In August, 1971, ten randomly selected papers assayed at an average of 18%. The quality of Heroin remained good except for periods of "panic" on the streets when for one reason or another Heroin was not being supplied to local pushers.

The price of Heroin has gone down 17% since 1968. Papers which used to cost $12.00 now regularly sell for $10.00 except for periods of panic when, of course, the price may be much higher. The price has gone down in the face of at least a 300% improvement in quality. Put in other terms, in New Orleans a "bag" averages 300 mgs. in weight and in 1968 this meant $1.25 per mg. of Heroin as compared to thirty cents per mg. in 1971.

The price of black market or illegally purchased Methadone has fluctuated and we speculate that it follows a similar supply and demand curve, in addition to reflecting influence of what we call "program stabilization." Various estimates of the numbers of addicts in New Orleans leads one to believe that there are probably no more than 6,000 and most certainly no fewer than 3,000 Heroin addicts in the metropolitan area. We hypothesized that the numbers of patients coming onto programs in a city such as New Orleans (where there are no waiting lists, and where programs are relatively available and inexpensive) will in time equal the numbers of patients dropping off the programs. This is the addict population "saturation point,' 'or Methadone stabilization point, in a given community. We feel that this will occur when about half of the addicts in a given population become patients. In other words, many addicts won't consistently take Methadone, even if it is available.

Returning to Figure 1 showing the number of patients coming into the clinics over the past three years, we saw what we thought was a tendency towards this "stabilization point" in the summer of 1971. However, this did not prove to be the case. Indeed, there has been a more rapid influx of patients during the past six months than at any other time. On further investigation we realized that in the summer of 1971 all the programs began "tightening up" their dispensing practices and the new admissions represented in part addicts who had to some degree been maintained "on the street" with diverted Methadone. We anticipate that this curve in New Orleans will again begin to slope off when approximately 2500 patients have been stabilized on our programs.

As a result of our experiences the directors of the various programs have agreed to curtail "carry-out" privileges and to dispense medicine seven days per week to all but the most reliable patients, and these would be allowed only a three day privilege. All these patients are now required to obtain a notarized affidavit which they must carry on their person whenever they are transporting the Methadone home. The affidavit declares their status as a Methadone patient, as well as their pledge not to allow it to be diverted. Obviously, promises can be broken, but we are of the conviction that this type of formal declaration is a good thing. Less than 5% of all patients in New Orleans have carry-out privileges.

STATE OF LOUISIANA

PARISH OF ORLEANS

AFFIDAVIT

BEFORE ME, the undersigned authority, personally

came and appeared man who, after being by me duely sworn did depose and state the following:

Affiant presently resides at Room #15, 749 St Charles Street, New Orleans, Louisiana. But that due to his mother's illness, he must travel to her residence at

Jackson, Mississippi, where he

will remain for a period of one woek, begining, December

31, 1971 and ending January 7, 1972 at which time họ will Return to New Orleans, Louisiana.

is

currently a patient at the Drug Rehabilitation Clinid, 3604 Tulane Avenue, New Orleans, Louisiana and parti=

cipates in the Methadone program.