THE DETOX PARADOX

Controversial Methadone Treatment Centers Give Heroin Addicts A Better Life
While Still Dependent

Mike Franz can never forget the years he spent addicted to heroin, a
dependence so deep-rooted he nearly lost everything.

After what seemed like a lifetime of shooting up dope, Franz fought his way
into detox, where he was given daily doses of methadone to ease his
withdrawal from a career spent wasting away.

These days, Franz is free from the binds of his longtime drug addiction. He
runs a recovery center in El Cajon that aims to help others as sick as he
once was.

But no thanks to methadone.

The constant gulp of medication never cured his compulsion. Instead, it
took courage, therapy and a diligent 12-step program to keep Franz away
from the needle.

"Methadone probably serves a purpose, but it's our philosophy that it's a
form of dependency on its own," said Franz, 51, a director at the McAlister
Institute rehabilitation facility. "It's more addictive than heroin."

With heroin surging in popularity -- sharpest among young people who snort
or smoke the drug -- methadone therapy is a profitable industry that
flourishes with little public notice despite the hundreds of millions of
dollars taxpayers spend on treatment each year.

But in greater San Diego, where three people own all five of the clinics
that dispense methadone, patient rolls have remained steady for years.
State regulators allow just 2,000 addicts in drug therapy here.

Now a Los Angeles clinic owner wants to treat an additional 500 heroin
addicts locally, an increase of 25 percent. At the same time, some experts
are questioning whether methadone is even an answer to getting straight.

Greg Hayner is chief pharmacist at the Haight Ashbury Free Clinic, a
nonprofit San Francisco medical center founded in 1967. Methadone is not
among the tools counselors there use to keep people off drugs.

"What we try to focus on are quality of life issues," Hayner said, "and the
fact that you can be doing a lot better things than chasing drugs all the
time."

A synthetic drug first devised by German chemists seeking new pain-relief
medication for soldiers waging World War II, methadone in the 1960s was
found to blunt cravings for heroin without providing a sense of euphoria.

In San Diego County, patients apply for methadone directly at one of the
privately owned clinics. They are approved or denied after an interview
with counselors based on their history of drug use. Other counties
administer drug therapy programs of their own.

Methadone users typically go to clinics five days a week and are tested
randomly for illegal drugs. A few patients with clean test results are
given a week's supply at a time.

Clinic owners say about half of their patients pay for treatment themselves
while the others rely on state health insurance.

Some clinic owners, with sprawling distribution networks, cultivate
political connections that give them sway over drug policies. Still,
investigators have uncovered evidence of serious fraud and abuse in the system.

In 1998, for example, three local operators admitted to felony charges
related to their practices. But they remain open for business and continue
to pile up millions of dollars in private and government earnings.

More opt for methadone

Many addiction specialists swear by methadone as a useful means of fighting
heroin dependence, both for short-term detox -- usually 21 days or less --
and as daily medication that continues for years.

And despite the stagnant number of patients San Diego County sees in
treatment, more and more addicts across California are opting for methadone
therapy.

The state Department of Alcohol and Drug Programs, which oversees narcotic
therapy, has 38,857 treatment "slots" available statewide -- up from 31,831
in 1995, a 22.1 percent spike in five years.

But drug-policy officials say the number of heroin users in California is
far greater than 38,857.

Patients routinely drift in and out of recovery programs, making the total
number of addicts in treatment difficult to quantify. Thousands of others
never seek help. At a meeting in April of the American Methadone Treatment
Association, White House drug czar Barry McCaffrey said fewer than 180,000
of the 1 million heroin addicts in the country are in treatment.

Drug therapy fails more often than not, however. A majority of methadone
users drop out within their first year, studies show.

Worse, experts say half of all methadone patients continue to use illegal
drugs while in therapy. Recovering addict Stacy Tyndell of Ocean Beach
thinks that estimate may be low.

"Most of the people I see are still using," Tyndell, 35, said outside the
Home Avenue clinic in southeastern San Diego she has used for four years.
"They just do this so they're not sick in the morning."

Cheaper in the long run

The high drop-out rates do not deter methadone supporters, who point out
that drug therapy is far cheaper than locking addicts behind bars.

Daily doses of the drug -- the most strictly regulated in the country --
allow tens of thousands of addicts to lead more productive lives without
resorting to robbing or stealing to pay for expensive street drugs, they say.

"With the stable use of methadone, the life problems are fairly light -- if
at all," said Dr. Mark Schuckit of UCSD Medical Center, a nationally
regarded expert in addiction medicine.

"You are indeed physically dependent, but you're no longer behaving as an
addict," he said. "You're not seeking out drugs, you're not spending all
your time using."

Dr. George Woody agreed. An expert from the University of Pennsylvania
School of Medicine, Woody said methadone allows many addicts to reclaim a
sense of normalcy lost in their lives.

"For a great majority of those people, when placed on methadone, they got a
lot better," said Woody, who said the drug also reduces the spread of HIV
and other infectious diseases because fewer addicts share needles.

"With a substantial portion of them, their drug use stopped completely and
their crime went down."

Diane Martinez of San Diego has taken methadone for the last 11 of her 36
years. Like so many others, Martinez worries about weaning herself from the
medication one day, but for now she is thankful to have it.

"I'm better now because it's legal," she said after swallowing her morning
dose at a San Diego clinic. "I don't have to be robbing anymore to get money.

"I'm trying to get off, though, because I need to get on with my life."

Methadone therapy is likely to grow even more popular in coming years, if
current trends in heroin use are any indication. The number of young people
experimenting with heroin and other hard drugs has soared in the last
decade, according to a survey commissioned by the National Institute on
Drug Abuse.

Heroin use more than doubled among American 12th-graders, from less than 1
percent in 1991 to 2 percent in 1999, the study found. The figures were
more alarming among eighth-graders: Last year, 2.3 percent reported trying
the drug.

To help fight the rise in illegal drug use, the federal government has
poured more and more money into methadone and other treatment programs
across the United States.

In California, 148 clinics dispense methadone to tens of thousands of
patients every day. Treatments generally range from $240 to $400 a month
per client. The state spent more than $55 million on methadone therapy in 1999.

Filling a niche

The five methadone clinics in San Diego County are owned by Robert B. Kahn,
Joyce Howerton Ray and Galen E. Rogers. A huge chunk of their income comes
from taxpayers. Last year, Kahn and Rogers received $3,037,515 in
government payments for treating San Diego patients, state officials said.

Even after their guilty pleas of two years ago, Kahn and Rogers remain
major players in the methadone community. Between them, they own dozens of
clinics and oversee about 13,500 patients.

"The treatment works," said Rogers, whose El Cajon center was among the
nation's first to accept patients who finance their own treatment. "All
we're doing is using medication to treat a brain disease."

The four-year investigation culminated in allegations that companies owned
by Rogers, Kahn and Howerton Ray overbilled state health insurance
providers by at least $5 million, court records show.

As part of the subsequent plea bargain, the defendants agreed to pay about
$3 million in restitution and re-examine their billing practices.

Kahn, president of the methadone providers association that spent tens of
thousands of dollars lobbying state lawmakers in recent years, blamed the
charges on confusing regulations. Rules were so complicated that even state
bureaucrats did not always understand what reimbursements were allowed, he
said.

Because of the investigation and eventual settlement, Kahn said he no
longer offers medical services at his clinics -- strictly medication and
counseling.

"I didn't want to face that kind of problem again," he said. "I can't
afford that kind of exposure."

Woody, the University of Pennsylvania researcher, said some clinic owners
are more interested in reeling in new clients than providing the counseling
and other services that are critical to kicking drugs.

"Cut down your overhead and you increase your profit," he said.

More than one patient at the Home Avenue clinic that Kahn and Howerton Ray
own said counselors provide zero incentive to get off the drug and spend
little or no time with clients.

Al Medina, director of the San Diego County Alcohol and Drug Services
office, is not concerned that so few people own the local methadone centers.

"What would be a concern to me is if this office received complaints from
those who can't get into treatment or are dissatisfied with treatment
they're getting," he said. "And that has not been the case."

Room for more?

County officials do not approve or disapprove the number of patients
methadone clinics can treat. But they recommend to the state whether
clinics should be allowed to treat more patients.

San Diego County has not seen a rise in methadone users for years, even
though a dozen or so residents die from heroin overdoses every month. Stan
Sharma wants to treat hundreds of new addicts anyway.

"When you have only one provider, you have only one slant on how treatment
can be provided," said Sharma, who operates 13 clinics in Los Angeles and
Kern counties.

Medina is reviewing Sharma's application, but he said there is little
evidence that methadone clients are underserved. State regulators say San
Diego almost never surpasses even 90 percent of its treatment capacity.

Earlier this year, the Journal of the American Medical Association reported
that long-term methadone therapy -- combined with psychological counseling
- -- is more effective treating addicts than short-term methadone use.

Drug policy officials like McCaffrey are beginning to advocate loosening
federal restrictions on methadone and reversing laws in the eight states
that prohibit its use as a narcotic therapy.

A new program in Seattle has doctors doling out a month's worth of
methadone to select users. Those patients not only avoid the daily chore of
traveling to a clinic, they no longer mix with other methadone clients.

Legislation pending in the California Senate would allow physicians to
dispense a methadone alternative called levoalphacetylmethadol from their
own offices. Gov. Gray Davis has not said whether he would sign the bill.

Barnaby Hopkins, for one, said he would have appreciated such an option.

The longtime heroin addict from Orange County said part of what took him so
long to clean up was the negative influence of people he met during visits
to his drug clinic.

"With methadone, you're still in that environment," said Hopkins, 34, who
struggled with methadone for years before finally quitting drugs at the
unconventional William Hitt Center in Tijuana.

"You're still associating with street people," he said. "It doesn't change
your thinking. I still didn't have any emotions."

Instead of using methadone to cure heroin addiction, Hitt mixes amino acids
and vitamins into IV drips he gives patients for 10-day stretches. At
$5,000, it is a pricey therapy that is not approved in the United States,
but patients such as Hopkins are convinced it cured them.

"This is a no-brainer," Hitt, 73, said of his treatment strategy. "Years
from now, I can't think of anybody doing anything but this."

Maybe so. But better-known experts are quick to point out the lack of hard
data to support such an approach.

"You can't evaluate whether any treatment is worthwhile unless it's studied
carefully," said Schuckit, the UCSD Medical Center researcher.

La Jolla physician John Sack is among those who believe the government
overregulates drug therapy. Doctors need more leeway treating heroin
addicts, rather than simply steering them into methadone clinics, he said.

He takes credit for curing 1,700 drug abusers with an unorthodox mix of
medications he prescribes in a four-day period. But his medical license was
suspended after an Imperial Beach woman died in his care three years ago.

Even so, clinic owners and politicians have little incentive to reform the
existing methadone distribution system, Sack said.

"Methadone treatment is big business," he said. "The people who are
profiting from that business don't want to see anything change."

Franz, the longtime addict who helps run the nonprofit McAlister Institute
in El Cajon, said he has no problem with people making a lucrative living
off other people's addictions.

"It's a business and they approach it like a business," he said. "Methadone
didn't work for me, so my point of view is biased against it. But it does
work sometimes."