The price of black market Methadone should also be considered as a parameter of its availability in terms of the relative availability of other narcotics. At this time, the price of one ounce of Methadone, containing 30 ccs. or 300 mgs. is about $30.00 (1.00 per 10 mgs. unit). When the programs first opened the price of a 10 mg. Dolophine tablet was approximately $5.00. Since then the price of illegal Methadone has varied, but after reaching a low point during 1969, then a high point during "panic" periods when it would sell for approximately $2.00 per 10 mg. unit, it is now stabilizing at from $1.00 to $1.50. Interestingly, the price for "used" or spit out Methadone (that which has been held in the mouth and spit into a container) consistently sells for one-half the price of "fresh" Methadone.

Another indicator of the effectiveness of reaching Heroin addicts with Methadone is the percentage of previous Methadone patients seeking treatment in other types of programs such as NARA. During the past eleven months the NARA Program processed 118 applicants. Of these, 53 or 45% were last addicted to Methadone. That is, they were taking Methadone either before they were arrested or at the time they applied. Of the remaining 65 patients who had Heroin as their last drug of addiction, 33 or 36% had been on Methadone programs previously but were again becoming addicted to Heroin. In other words, a total of 86 applicants or 73% had been involved in Methadone treatment programs in the past. Out of all the patients, 3% admitted to having purchased illegal Methadone in the streets on at least one occasion and some indicated that at certain periods they were able to get it whenever they needed it, that is, whenever they couldn't get Heroin.3

SUMMARY

In New Orleans, 1800 patients are on Methadone. This is thought to represent from 30% to 40% of the entire population of street addicts. As more patients have joined the program the price of Heroin has gone down and its quality has markedly improved. One parameter in determining the effectiveness of Methadone programs in reaching a population is thought to be reflected in the quality of available Heroin and the price of black market Methadone.

Less than 5% of all the patients involved in five independent programs in New Orleans have a carry-out privilege. The carry-out privilege is seen as the key to controlling the misuse of Methadone which can be, if correctly used, a most effective treatment approach.

APPENDIX 11

METHADONE FOR KICKING AND FOR KICKS

(By John A. Newmeyer, George R. Gay, Roger Corn, and David Smith. Detoxification, Rehabilitation, and Aftercare Project, Haight-Ashbury Free Medical Clinic, San Francisco, Calif. Proceedings, Fourth National Conference on Methadone Treatment, 1972, pp. 461-464)

This paper consists of a comprehensive report of the Haight-Ashbury Free Medical Clinic's experience with methadone use in its population of heroinabusing clients. We will examine the use of methadone (both illegally- and legally-obtained) for kicking heroin habits, and the use of methadone (both knowingly and unknowingly) for "kicks." It should be emphasized from the outset that the basic research strategy of the Free Clinic is not simply centered about population description and statistical analysis. These, our basic tools, can only serve as a players' backdrop to the more crucial task at hand: the recognition and description of the inner metaphors of the drug abuser's worldview, the peeling away of layer after layer of deceptive concealment, until at last we reach and unlock the secret heart of his life strategy, of the chosen master game of his existence. Our approach in this endeavor may involve such projective or predictive modalities as testing with T.A.T., M.M.P.I., Rorschach, or other basic instruments; or the involvement of the client in

3 Personal communication with Miss JoAnne Yoder, M.S.W., Assistant Director, NARA Program, Tulane University School of Medicine, New Orleans, La.

1 Gay. G. R., Matzger, A. D., Bathurst, W., and Smith, D. E. "Short Term Heroin Detoxification on an Outpatient Basis." Int. Jour. of the Addictions, 6 (2): 241-264,

meditation, encounter techniques, transactional analysis, or hypnotherapy; or simply the painstaking establishment of trust between the client and we who, with classic disillusioned optimism, seek to comprehend him.

METHADONE FOR KICKING

The heroin panic of the press, and subsequently of the American public, has suddenly placed methadone a clinically second-rate, semi-synthetic narcotic analgesic-in the role of instant alleviator of addiction. Oversold on blanket cures, our medical as well as our general community would now adopt a "methadone overkill" philosophy in the treatment of heroin addiction. Hastily and ill-conceived programs of methadone maintenance (of the bread-line, turnstile type, with little or no rehabilitative counseling for reentry into society) would now proliferate in the hopes of controlling heroin addiction—while simultaneously introducing yet another potent drug of abuse and addiction to the street corner market. The heroin addict, in the agonies of withdrawal, simplistically views methadone as the answer to his problems. With methadone, "I know I can kick."

From the time of inception of our heroin clinic, we have specifically inquired as to the incidence of our clients' withdrawals and methods of withdrawing. "Cold turkey" was by far the most common method of withdrawal for our population, but more than one out of six (Table 1) admitted to use of self-administered methadone in the attempt to kick a heroin habit. Of this group, fifty-five percent reported repeating this method of kicking at least once. Of all of this group, none reported total success (i.e., achievement of abstinence for a period of time significantly exceeding a normal withdrawal period of four days to one week) even though many were well acquainted with proper dosage reduction for detoxification. In general, when they reached a basal maintenance dosage that is, when they started to get sick-they did not attempt to reduce the dosage further, rather holding at this level until they ran out of methadone. By contrast, less than one out of eight (Table 1) reported the experience of physician-administered methadone for withdrawal, and of these only forty-four percent repeated this method of kicking one or more times. This relatively low incidence of physician-administered methadone in our population may well be due to the rigid legal restrictions of the state of California. Methadone use in this category was, for the vast majority of cases, intended for detoxification rather than for maintenance. Indeed, in most cases, methadone dispensed by physicians was carried out in a hospital environment. In summary, then, indications are strong that our addict population, when using methadone for kicking, does so more often with methadone obtained illegally rather than legally.

TABLE 1.-INCIDENCE OF SELF-MEDICATED AND M.D.-MEDICATED METHADONE TREATMENT

Time: "The New Public Enemy No. 1," pp. 20-25. June 28, 1971. "Operating Standards in Methadone Maintenance Programs." Editorial: JAMA. 218 (10): 1565-1566, 1971.

.

Sheppard, C. W., Gay, G. R., and Smith, D. E.: "The Changing Patterns of Heroin Addiction in the Haight-Ashbury Subculture." Jour. of Psychedelic Drugs; 3 (2): 22-30, 1971.

Ramer, B. S., Gay, G. R., and Smith, D. E.: "Adolescent Heroin Addiction in San Francisco." Proceedings of the Third Nat'l Conf. on Methadone Treatment. Pub. Health Service Pub. 2172, 89-91, Nov. 14-16, 1970.

A comparison of methadone use with other interview variables was made. The heroin abuser who illegally obtained methadone for kicking appeared to be very little different from heroin abusers in general: on all of our items inquiring into demographic characteristics (family background, school and vocational experience, religious background, legal history, and drug use), virtually nothing stood out to distinguish the subgroup. The single distinguishing characteristic was the length of the habit of those "hooked" before January of 1967, twenty-six percent admitted the use of illegally obtained methadone for kicking, while only twelve percent of those hooked after January 1967 admitted such use.

The abuser who kicks by means of legal, physician-administered methadone, however, possesses considerably more distinctive attributes. Compared to our abusing population as a whole, he is more often of Eastern or Midwestern origin, of slightly higher social class background, better educated, slightly more often white and female, more prone to have used certain drugs (marijuana, amphetamines, and alcohol) after being hooked on heroin, less involved with a stable family-oriented life-style, and more likely to have made at least one suicide attempt. The picture that emerges is of a drug-wise, relatively advantaged, mobile, yet troubled person-in short, someone who fits the stereotype of a youth up-to-date on the latest medical and psychiatric techniques and willing and anxious to entrust himself to them, often as a substitute for the family structure which is missing from his own experience. Clearly, these data are best understood within the context of a "decision to medicate" model. Our particular model envisions five basic medication choices for the kicking addict: (1) "cold turkey," (2) self-medicated detoxification with medication other than methadone, (3) M.D.-administered methadone for detoxification. We postulate five major factors as determinate in the heroin addict's decision to medicate. These are, first, the medical attitudes of the addict's family of origin. A background of trust for physicians and other health professionals is expected to orient the addict toward a similar trust when he kicks. Paradoxically, the young addict and his family may have turned away from the medical profession only to embrace the well-advertised pharmacopoeia of television, the drug-store, and the street. Secondly, the locale of the addict's drug taking, particularly the initial heavy experience, where availability is an all important factor. New York junkies, with habits bred in a methadone boomtown, are found to be more methadone oriented. Thirdly, the demographic limitations of program admission policies. Older, non-white junkies with long term habits and stable urban ghetto residence patterns are expected to find more drug abuse programs-and particularly methadone programs-available to them. Conversely, the highly mobile, restless young addict, with poorly rooted family ties more often "hustles" on the street for his methadone indeed for any of his illicit medications. Fourthly, the particular life style of the addict. We find that those young addicts who are heavily exposed to other drug users and to the underground drug mythology can be expected to have a history of fewer cold turkey withdrawals, And fifthly, the individual drug history of the addict. A long and varied experience with drugs, especially barbiturates, is expected to encourage more attempts at selftreatment, with methadone as well as with multiple depressant drugs. A careful analysis of these factors and of the role played by methadone will be the subject of a future paper.

METHADONE FOR KICKS

"Man, the 'blocking effect' is I can get just as high on [100 mg. of methadone as on smack . . . it's smoother, and the high lasts longer, so you don't have to worry so much about that next fix."

"This isn't fake stuff, man... it all comes from the program." With the mushrooming of methadone programs throughout the country, a ready source of street methadone has appeared." And with the indiscriminate, unsupervised use of methadone comes the omnipresent problem of overdose, respiratory depression, and death. We see this problem particularly in the

ress).

Gay, G. R., Winkler, J. J., and Newmeyer, J. A.: “Emerging Patterns of Heroin Abuse in the San Francisco Bay Area." Jour. of Psychedelic Drugs 4 (1), 1972 (in 7 Raskin, H. A.: "M.D.'s Urged to Fight Methadone Diversion." AMA News, Oct. Gay, G. R.: "Acute Treatment of Heroin Addiction with Special Reference to Mixed Addictions." Jour. of Psychedelic Drugs 4 (2), 1972 (in press).

25. 1971.

area of multiple abuse. The additive effects of alcohol (our ubiquitous legal drug) and various tranquilizers and/or barbiturates can produce a respiratory depression which is then potentiated to a life-threatening degree by the self-administration of methadone. The high lipoid solubility of this drug creates easy crossing into and early high concentrations in the cerebrospinal fluid (that which oils our respiratory control machinery). This fact, combined with the long duration of methadone's action, creates a potentially more lethal hazard than heroin itself. It is the individual who is already "stoned" on alcohol or other "downers" who is most vulnerable. A recent victim of alcohol plus illicit methadone was Janis Joplin. Many other less talented but no less unfortunate young people suffer similar deaths, unheralded and all but unneeded.

79

The abuse of home-dispensed methadone from reputable programs is voluminously documented. The innocent ingestion of orange-juice-methadone mixtures by non-tolerant individuals (children) has resulted in several cases of overdose and death."

10 11

Finally, however, the real danger with methadone lies in its assumed safety. ("It's not like smack, it's a cure for smack".) In any individual, no matter what level of tolerance he has developed, there is that dosage of methadone, or that unknown combined dosage of methadone plus other depressants, which will push him over the ragged edge of his existence.

Our first study was of a small group (N-21) of heroin abusers who admitted to abusing methadone for "kicks" (ie., as part of a continuous pattern of opiate abuse). The majority described simultaneous use of other, potentiating drugs, and all except one had commenced such use at some point after becoming addicted to heroin. This abuse of illegal methadone rarely took the form of "maintenance"; it seemed rather to be viewed as a stopgap measure, involving use of a desirable, inexpensive, but intermittently available opiate alternative. Analysis of the interview data from this group showed that they were distinguished from our total heroin-abusing population in the following ways: they were more often hooked in the East, particularly New York City (again, availability is seen to play a major role); they had habits of slightly longer standing, and yet of somewhat smaller daily cost; they were rather better educated, but only one of the twenty-one was employed; they used amphetamines and alcohol significantly less, both before and after being hooked; but they used marijuana significantly more after being hooked. The composite picture that emerges is of an addict who is more careful and controlled in his use of drugs than is typical. Methadone abuse is not part of an indiscriminate opiate-abuse pattern, but more part of a strategy of judicious application of stopgap, money-saving measures. Not dissimilar is the street use of alcohol, marijuana, barbiturates, tranquilizers (especially Valium), and other sedative-hypnotics (notably Doriden and Quaalude).

Our second study involved the analysis of a random sample of urines from our client population during the fall of 1971. Urines were collected from every new client, and from every fifth continuing client by the randomization method described by Goldstein," and tested by means of thin-layer chromatography. Of seventy-one clients tested on their first visit, ten (14.0%) tested positive for methadone; of these, two also tested positive for methamphetamine, and one for morphine. Of 122 clients in the random sample, twentynine (23.8%) tested positive for methadone; of these, seven had amphetamine or methamphetamine, two had morphine, and one each had cocaine or quinine in their urines. It is notable how very common, then, methadone use appears to be in our population: much more so than our client interviews had indicated. In fact, methadone was the most common urine adulterant, much more even than morphine itself. Only slightly more than a fifth of our clients reported ever knowingly using methadone, either illegal or legal, for kicking or for kicks-and here is the same proportion showing up in a random testing at a single point in time! Are our clients lying to us in the interviews? This

Dobbs, W. H.: "Methadone Treatment of Heroin Addicts." JAMA 218 (10): 15361541. 1971. 10 Dole, V. P., Foldes, F. F., Trigg, H., Robinson, J. W., and Blatman, S.: "Diagnosis and Treatment of Methadone Poisoning." New York State Jour. of Med. 71 (5): 541543, 1971.

11 Jaffe, J. H., Fritz, K., and Kaistha, K. K.: "Methadone Disks." Arch Gen. Psychiatry, 25: 525-526, 1971.

12 Goldstein, A., and Brown, B. W.: "Urine Testing Schedules in Methadone Maintenance of Heroin Addiction." JMA 214 (2): 311-315, 1970.

may be the case-but an odd aspect of the urine results indicates an even more remarkable possibility. Half of the clients with methadone-positive urines admitted to their counselors that they had shot up junk in the previous 48 hours. No mention was made of methadone. Now, this group would surely not admit to use of a more forbidden drug (heroin) if they had knowingly used a less forbidden one (methadone); thus we are forced to the conclusion that the greater mendacity has been between the client and his connection, not between client and counselor. In other words, people are being sold methadone as heroin.

Why should this happen? The connection's motive is obvious-he can sell the inexpensive methadone, obtained usually more or less directly from local methadone clinics, in place of heroin which he would have had to obtain from abroad through many price-multiplying middlemen. The consumer, however, has to be someone who can be fooled into paying $10 or $15 a bag for phony heroin.

Our observation is that such a consumer population has come into existence in the Bay Area: a "new junkie" characterized by a history of careless and indiscriminate drug use, a proneness to anti-rationalist philosophies in general and psychophysiological suggestibility in particular, and experience confined to a degenerate heroin economy which markets very low purity (1%3%) heroin adulterated by a variety of substances. Our observation is also that most, if not all, of the methadone available on the street is somehow diverted from methadone clinics, clinics which have proliferated in number and in quantity of methadone dispensed during the last five years. These conditions are new to the history of opiate abuse, and hence suggest that the present phony-heroin market is a novel phenomenon.

A study of the phony-heroin consumer was carried out. The medical records of thirty-nine clients with methadone-positive urines were carefully inspected and separated into three subgroups: those who admitted to use of heroin in the last 48 hours, those who admitted to use of methadone, and those who claimed to be clean of opiates. Twenty-one clients fell into the first group, nine into the second, nine into the third, and one could not be classified. The first group (the phony-heroin consumers) was then studied intensively. Half of them had further adulterants, usually amphetamines or quinine but sometimes morphine, in their urine-possibly due to the connection's attempts to potentiate the action of the methadone, or to give it a bitter taste or a good initial "rush", or otherwise to make his product more indistinguishable from the real thing.

The interview data showed that the phony-heroin consumers differed from the contemporary population of clients in the following respects: they were older by an average of two years at the time they visited our Clinic; they had become hooked at an older age; they tended to have had more unstable living arrangements and sexual-partner arrangements, and yet had had slightly more children; their parents had had significantly fewer years of education and fewer white-collar jobs; they themselves had held distinctly less prestigious jobs (only one of the twenty-one had ever held a white-collar job); they had drunk more alcohol, particularly before becoming hooked; and they had attempted suicide more commonly but, peculiarly, had suffered overdoses less commonly. The composite picture is as might be expected: of someone even less advantaged than the typical heroin addict, and consistently less together in his adjustment to the heroin life-style. Their drug history indicates they have been more or less out of it as far as the underground drug culture is concerned. "Losers" in as strong a sense as we have found in our experience with addicts, they are now a population set up for exploitation by a new kind of unscrupulous dealer. Phony heroin now exists and has found its market.

What we have found, then, is that methadone use has been increasing recently among heroin addicts, such that methadone is now found in almost one out of four client urines at the Clinic. Though there is no evidence of methadone abuse separate from heroin abuse-none of our clients had tried methadone prior to becoming hooked to heroin-methadone is rapidly gaining a most-favored position for addicts, both for self-treatment and physiciantreatment. Our data indicates that this pattern of use has been transmitted in a particular demographic way: a relatively advantaged, drug-wise subgroup initially patronizes the sources of legal methadone for physician