By David C. Lewis, M.D.
Dr. David C. Lewis, a Brown University professor of medicine and community health, directs the Brown University Center for Alcohol and Addiction Studies. He also is project director of the new Physician Leadership on National Drug Policy.

His attack on methadone patients comes within a year of the landmark National Institute of Health Consensus Conference in which an expert panel affirmed the positive outcomes of this approach to treatment and recommended its expansion. Barry McCaffrey, director of the Office of National Drug Policy, swiftly and correctly countered the mayor with a strong statement in far-reaching support of methadone maintenance treatment.

Campaigns decrying maintenance are nothing new. They were the foundation of state anti-narcotic laws in the decade before the passage of the Harrison Act (1914) and subsequently of both state and national laws in the following five decades. Along with the anti-maintenance mentality came vilification of the heroin addict, denunciation of ambulatory treatment, limited access to institutional care, and a designation of abstinence as the only acceptable goal for treatment. Several maintenance clinics (mostly dispensing morphine) arose after the Harrison Act severely restricting physicians from prescribing opiates to addicts. Some, like a short-lived one in New York City, were hastily planned and suffered from administrative problems. Others, like the one in Shreveport, La., were effective and were supported not only by the medical profession but also by local politicians and law enforcement officials. But federal authorities at the newly formed Narcotics Bureau were overzealous and successful in their pursuit of these clinics. The last one closed in 1923.

Not until the mid-1960s was maintenance successfully reintroduced. This time, there were two advantages over the clinics of the early 1900s. One was the synthesis of methadone, a maintenance drug which could be taken orally. The fact that it lasted about 24 hours made the administration of the drug feasible in outpatient clinics. Second, ambulatory treatment of addiction had become acceptable.

Although methadone maintenance is no panacea, it is the most widely used treatment for heroin addiction. Currently there are 115,000 patients in programs across the nation. It is the most studied of all the treatment approaches and has been shown to be a cost-effective approach for reducing heroin use, crime and the spread of HIV. As a public health intervention for heroin addiction, it has no competition. Furthermore, many heroin addicts treated with maintenance drugs have successfully stabilized their lives, engaged in productive work, and are members of healthy and happy families.

Where do we go from here? To say "shame" to Giuliani and "cheers" to McCaffrey promotes political conflict and public interest but misses my point. Let's start with a crash course in dignity and human rights. First and foremost, remember that no matter what the headlines say, the important struggle is not between the mayor and drug czar. The major struggle is between the heroin addict and heroin addiction. To the extent that many have found health and stability through maintenance treatment, we must support their efforts.