administered treatment, then carries off information about this wondrous drug (and evidently carries off a good deal of the drug itself) to another subgroup which then treats itself with street methadone; this subgroup is more typical of heroin addicts as а whole. A relatively disadvantaged, drug-unwise subgroup meanwhile becomes the victims of the marketing of stolen methadone as heroin.

What about this matter of the diversion of methadone from its intended use? It is clear to us, from discussions with clients at our Clinic, that many clients of methadone programs are still actively involved in dealing opiates. "Getting on a methadone program gives you more time for dealing", is the way one person put it; "I was there for a month before they trusted me, and then..." began another account. There seems to be a failure on the part of some methadone program workers to comprehend that the normal human communication signal for trust simply do not operate among junkies; our urine-testing experience has taught us that some of the clients we had the most unshakable confidence in were most thoroughly deceiving us. For the intelligent, street-wise dealer particularly, his moral life seems to be a weird two-dimensional affair in which all sorts of marvelous ethical shortcuts become possible, if only he has the imagination to see how the straight (i.e., non-psychopathic) world is miscomprehending his signals. The strategy of shuck is fascinating, multi-layered, and almost humorous in its remoteness from the normal operation of the human psyche. In the face of it, we can only recommend to methadone program workers that they adopt an attitude of total skepticism.

One immediate possibility for future research is to determine the exact nature of the underground methadone economy. Is methadone being "skimmed off" clients' habits, or are at least some of them not really taking any of their methadone at all? Is methadone being stolen directly from clinic pharmacies? Are there any illicit laboratories producing methadone? What are the middle steps in the transmission of methadone to the knowing or unknowing consumer of it? What are the relative street costs in different parts of the country? There are many possible research designs for answering these questions. One such design involves the use of "tracers"-chemical or radioactive-by which methadone samples could be "marked" and then watched for, much as ornithologists trace the movements of birds. The detective work promises to be exciting. We will pursue it with vigor, with our twin tools of in-depth psychological counseling to gather an understanding of what goes on in the addict's street existence, and urinalysis as an occasional check as to just whose tales can be believed.

APPENDIX 12

METHADONE AND MEDICAL ETHICS

(By James F. Maddux, M.D. Proceedings, Fourth National Conference on Methadone Treatment, 1972, pp. 265–267)

(Department of Psychiatry, University of Texas Medical School at San Antonio, 7703 Floyd Curl Drive, San Antonio, Tex. 78229, and Drug Dependence Program, Bexar County Mental Health Mental Retardation Center, 527 North Leona, San Antonio, Tex. 78207.)

Physicians working in methadone maintenance programs often act as if empirical data and technical procedures represent their primary concerns, while ethical considerations represent something to be taken for granted and hardly worth discussing. Nevertheless ethical choice underlies nearly everything the physician does in maintaining drug dependence with methadone. Emotionally charged arguments for and against methadone maintenance arise more from differences in value judgments than from differences in knowledge. In this paper, an attempt will be made to identify and describe the ethical problems for the physician who maintains drug dependence with methadone. The author follows others in reporting ethical problems associated with methadone maintenance; most of the problems to be discussed have at least been alluded to by others. Some of the problems seem obvious and others

more subtle. The subtle problems have greater hazard for physicians and their patients, for value judgments may be made without awareness that ethical choice has occurred. Although it is the intention of the author to define the issues and not to advocate, his position will nonetheless become apparent.

The ethics of methadone maintenance will be considered with respect to the paramount ethic of the physician: the welfare of the patient. Divergence of opinion among physicians about methadone maintenance does not mean that some opinions are "moralistic" and others not: all opinions become equally ethical if they equally reflect concern with the welfare of the patient. But among equally ethical physicians, differences may exist in the weights given to the benefits and hazards of methadone maintenance.

The physician confronts four problems of ethics in methadone maintenance: (a) The benefits and hazards for the individual, (b) protection of human research subjects, (c) coercion to choose methadone maintenance, (d) coercion to conform with methadone.

1. Benefits and hazards for the individual.-Maintaining drug dependence with orally administered methadone frees the individual from the illegal hustle for heroin, from intravenous use of an illicit mixture of uncertain composition, and from use of dirty needles. But these benefits have costs: regularly administered methadone, like morphine, probably produces profound and long-lasting changes in physiological and psychological equilibruim (1). Quite possibly these changes become more severe and deeply embedded with continued daily high-dose methadone. For the individual with hope of overcoming his drug dependence, methadone maintenance may reduce the probability of his achieving an enduring abstinence. The hazard of permanent drug dependence as a consequence of methadone maintenance has not been adequately evaluated, for followup studies of abstinence following methadone dependence have not been done. Whatever the long-term followup data may show, the physician who today places a patient on methadone maintenance makes an ethical choice: he weighs the benefits and hazards, and then does what he considers good for the patient.

2. Protection of human research subjects. As long as methadone maintenance continues in investigational status, protection of the rights and welfare of human research subjects will remain an ethical requirement of the procedure. The welfare of the patient overlaps that of the human research subject in that both require estimation of risks and potential benfits, but for the research subject, informed voluntary consent becomes a special additional requirement. Yet physicians are confronted by the problem of accepting patients for methadone maintenance under legal coercion.

3. Coercion to choose methadone maintenance.-In 1969, Mrs. Albert D. Lasker was quoted as saying that judges should be able to sentence appropriate addicts to methadone as a public health measure (2). In 1971 in San Antonio, a court convicted a heroin user of robbery by assault, and then suspended the sentence on condition that the "defendant will immediately apply for and receive methadone treatment for his narcotic addiction. . . .' The ethical problem for the physician of compulsory methadone maintenance was discussed in 1970 by Newman (3), who considered it a serious danger to methadone maintenance programs. In the same year Dole (4) objected to the legal imposition of methadone maintenance stating "the rights of addicts must be respected." Since criminal sentences are imposed more for the protection of society than for the benefit of the individual, the physician who orders methadone for maintenance in response to a court order primarily serves society rather than the patient.

A more subtle coercion to enter methadone maintenance exists for the individual on probation or parole with no formal requirement for treatment of any kind: the individual may enter methadone maintenance not because he wishes to substitute methadone for heroin, but because he wishes to avoid incarceration. A similar coercion exists for patients under civil commitment for treatment of drug dependence: they have the threat of involuntary confinement in an institution. Kramer (5) has speculated that a law enacted in 1970 in California permitting methadone maintenance in lieu of commitment to the California Rehabilitation Center may "force large numbers of opiate dependent individuals into methadone maintenance programs." Overt

or subtle legal coercion restricts free choice, and the request for methadone maintenance then becomes "voluntary with legal pressure." While the individual constantly responds to inner and outer stimuli and perhaps never makes a free choice about anything, the ethical problem for the physician comes not from the philosophical question of free choice, but from external legal coercion. The problem of legally coerced choice of methadone maintenance could be avoided by accepting only patients who have no legal coercion. Indirect coercion of physicians in tax-supported programs to place heroin users on methadone comes as a consequence of selling methadone maintenance for its benefit to the community. Methadone maintenance is advocated because it allegedly prevents the theft by each addict of $35,000 to $50,000 per year (6). Convincing data have not appeared to support this claim, but even if it is half true, methadone maintenance represents a fantastic benefit for society. Probably no city or county official has ordered a physician in public service to double or triple his methadone caseload, but pressure exists for serving the community by reducing criminality with methadone.

Although controlling criminal behavior does not represent a basic duty of the physician, it does represent an essential and legitimate task of society. Criminal behavior arising from morphine-type drug dependence has become a major contemporary social problem. It may therefore be desirable that society, through its courts, order methadone or any other drug as a means of controlling antisocial behavior of drug-dependent persons. If courts order methadone, it seems pereferable that courts dispense the methadone. A physician can conceivably dispense methadone as a technician for the court; no ethical problem need exist if it is understood that society is served primarily, and the individual secondarily.

Criminal behavior associated with heroin traffic could be reduced more directly and economically by removal of legal control on drugs than by methadone maintenance. With removal of controls the individual could legally maintain his own drug dependence, or, if he chose, he could seek assistance from a physician. Szasz (7) has proposed that all adults should have freedom of self-medication as a fundamental right. Removal of controls on drugs would therefore serve society by reducing criminal behavior, and it would also, in Szasz's view, serve the individual by increasing freedom. 4. Coercion to conform with methadone.-All methadone maintenance programs appear to have some behavioral standards, required of patients. The standards vary from the minimum performance necessary for participation in the program, for example, taking the methadone, and providing information and urine specimens as requested, to additional broad requirements that the individual become law-abiding, legitimately employed or in school, abstinent from illicit drugs, and using alcohol moderately if at all. Failure to comply with the requirements leads to reduction or withholding of methadone, and if persistent, to termination of methadone maintenance. In the program in Denver for addicts under legal coercion, as reported by Starkey and Egan (8), repeated positive urines is reason for return to jail. Use of an illicit drug leads to loss of both methadone and liberty. Concern has been expressed about the possible use of methadone to control behavior of members of two minority groups, blacks, and persons of Mexican background.

When the physician gives or withholds methadone to obtain behavior considered socially desirable, he primarily serves society. As noted before, the physician's ethic requires that the patient come first. Newman (9) also identified the problem of using methadone maintenance to obtain socially conforming behavior. Of course society cannot survive without minimum observance by its members of established rules, and conceivably, society though its courts, could not only order and dispense methadone for drugdependent persons, but could also give or withhold the drug to obtain socially conforming behavior. Distribution of a pleasure-giving drug by government officials was a major feature of control of behavior in Huxley's Brave New World (10). Such a political use of methadone may attract or repel us as individuals, but such use appears remote from the physician's concern for the welfare of the patient.

Coercion may occur without any formal threat of withholding methadone. Some physicians and other professional persons who provide psychotherapy, social casework, and vocational assistance with methadone maintenance

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say they try to change life styles. This sounds more like reforming than helping. In two programs with which the writer became familiar, the methadone patients were required to participate in regular group therapy. One patient in such enforced therapy told the author that the patients came to therapy because it was required to get the methadone; otherwise none would come. Coercing patients into psychotherapy with methadone reduces free choice of this treatment, and may lead to passive compliance with little constructive emotional investment in the process.

Coercion may occur in more subtle form. Some patients on methadone maintenance make special efforts to please physicians and others providing the methadone. A patient in the Drug Dependence Program of the Bexar County (San Antonio) Mental Health Mental Retardation Center offered to do free yard work at the home of the physician who prescribes his methadone. At the dispensing station of this program patients have offered to buy and bring lunches to staff members working through the lunch hour. Other patients overtly express gratitude for the methadone and admiration for the physician. One calls his physician "my favorite doctor." The dependence of these patients on their methadone connections makes them especially vulnerable to exploitation. Physicians having special needs to be liked or appreciated or admired by their patients, or to exert power over others, may obtain intense emotional gratification from the drug-induce dependence on the physician. Methadone maintenance may thus come to serve the psychological needs of the physician more than the welfare of the patient. Because such a mutually manipulative interaction between physician and patient may occur unconsciously, the problem may become more difficult to identify and manage than deliberate overt coercion.

Deliberate or unconscious coercion to obtain socially or personally pleasing behavior could be reduced if the physician prescribed methadone primarily for a pharmacological purpose, that is, to substitute a methadone dependence for a heroin dependence. The patient then would become free to use or not use psychotherapy or other assistance, to work or not to work, and to steal or not to steal. Nevertheless, a completely permissive and impersonal dispensing of methadone only for its pharmacological effects is not likely to be achieved under conditions existing in 1972, for limit-setting is required, and personal interaction alway accompanies dispensing of methadone.

The physician and others in a methadone maintenance program can tolerate only a limited amount of behavior harmful to the program such as violence toward staff members or other patients, or illegal activity on the premises of the program. While disruptive behavior may require withholding the methadone, the precise limits are not easily defined. Can drunkenness at the outpatient office be tolerated once or twice or more times, and how drunk must the individual become to be considered disruptive to the program? What action should staff members take if they believe that a methadone patient is selling heroin across the street from a dispensing facility? Should they take any special action about unemployed patients who, after getting their free methadone, go to a next-door beer tavern, where their beer-drinking probably inhibits their job-seeking? Should a physician permit a patient to abuse him in obsecene language because the patient was denied a three-day supply of methadone to take home? What should the staff do about an employable patient who remains unemployed perhaps because he would be asked to pay a fee for service if he had a job? Wherever the limits may be defined, the limit-setting introduces an unavoidable measure of control of behavior.

Inappropriate personal coercion of patients cannot be completely eliminated in present programs, but it can be reduced by self-conscious attention to the problem by staff members and by staff discussions about their attitudes and behavior toward patients.

The whole complex of problems of political or personal coercion by giving or withholding methadone could be eliminated by removal of legal controls on drugs. As already noted, removal of legal controls would also eliminate the problem of coerced choice of methadone maintenance. If controls were removed, individuals could freely choose to use methadone, or morphine, or heroin, while their behavior, like that of other people, would be regulated by the normal sanctions of society. Removal of legal controls would have the cost of a probable marked increase in the prevalence of drug dependence of the morphine type.

SUMMARY

The physician in methadone maintenance confronts four ethical problems. First, he estimates the hazards as well as the benefits, and makes an ethical choice of what he considers good for the patient. The hazard of possible permanent drug dependence consequent to methadone maintenance has not been adequately evaluated. Second, as long as methadone maintenance continues in investigational status, protection of human research subjects, primarily through informed voluntary consent, is required. Third, legal coercion of patients to choose methadone maintenance restricts voluntary choice, and tends to serve society rather than the patient. Fourth, giving and withholding methadone to obtain socially desirable behavior also tends to serve society rather than the patient.

The problem of legally coerced choice of methadone maintenance could be avoided by accepting only patients free from legal coercion. The problem of coercion of behavior with methadone could be reduced by giving methadone primarily for its pharmacological effects. Both problems of coercion to choose methadone maintenance and corecion with methadone could be eliminated by removal of legal controls on drugs, but at the cost of probable marked increase in the prevalence of drug dependence.

REFERENCES

1. Martin, W. R.: "Commentary on the Second National Conference on Methadone Treatment," in Methadone Maintenance. Edited by Einstein, S. New York City, Marcel Dekker Inc., 1971, pp. 199–205.

2. Yuncker, B.: "Methadone: Can It Get Them Off the Hook?" in Drugs. Edited by Milbauer, B., and Leinwand, G. New York City, Washington Square Press, 1970, p. 140.

3. Newman, R. G.: "Methadone Maintenance Treatment: Special Problems of Government-Controlled Programs,' 'in Proceedings Third National Conference on Methadone Maintenance. Public Health Service Publication No. 2172. U.S. Government Printing Office, 1970, pp. 121–124.

4. Dole, V. P.: "Planning for the Treatment of 25,000 Heroin Addicts," in Proceedings Third National Conference on Methadone Maintenance, reference 3 above, p. 111.

5. Kramer, J. C.: "Parole, Probation, Police, and Methadone Maintenance," in Proceedings Third National Conference on Methadone Maintenance, reference 3, above, p. 104.

6. Trussell, R. E.: "Treatment of Narcotic Addicts in New York City," in Methadone Maintenance, reference 1 above, pp. 6-7.

7. Szasz, T. S.: "The ethics of addiction." Amer J Psychiat 128: 33-38, 1971.

8. Starkey, G. H., and Egan, D. J.: "Combined Treatment of the Criminal Opiate Addict by Medical and Law Enforcement Officials," in Proceedings Third National Conference on Methadone Maintenance, reference 3 above, pp. 108-110.

9. Newman, reference 3 above.

10. Huxley, A.: "Brave New World." New York, Harper and Rowe, 1932.

APPENDIX 13

THE PRIVATE PHYSICIAN IN THE FUTURE OF METHADONE TREATMENT

(By J. T. Payte. Proceedings, Fourth National Conference on Methadone Treatment, 1972, pp. 263–264)

(San Antonio Free Clinic, Inc., 1136 West Woodlawn, San Antonio, Tex. 78201, and Department of Pharmacology, University of Texas Medical School at San Antonio, 7703 Floyd Curl Drive, San Antonio, Tex. 78229.)

The premature introduction of the private physician into methadone treatment is likely a reaction to the shortage in existent treatment facilities. The methadone modality has rapidly achieved a high level of acceptance