i. The Health Research Council was established by Mayor Wagner in 1958 to stimulate research dealing with critical health problems.

ii. Dr. Dole, a physician specializing in metabolic disease research, was at the time a temporary member of the Council, filling in for a colleague who was on sabbatical.

iii. Tolerance is "the ability to endure, without ill effects, the continued or incresing use of a drug" (15). It is a frustrating reality to any physician who has attempted to ease the pain of a victim of terminal cancer, only to see the patient become totally unresponsive to the analgesic effects of narcotics after repeated, frequent use. With respect to methadone itself, it can be readily confirmed that tolerance develops universally to the miotic effect in maintanance patients. What is true of the pain-killing and pupillary actions of narcotics is also true of other properties, including the ability to produce euphoria.

iv. Critics of the metabolic theory have noted that in therapeutic comminities, "...these victims of a supposed metabolic defect abley carry out socially responsible and often creative social and interpersonal activities without drugs..." (17).

v. The methadone maintanance programs which have been started at Beth Isreal Medical Center, Harlem Hospital, and Bronx State Hospital were kept alive with funds provided by the New York State Narcotic Addiction Control Commission, established in the same year.

vi. a "Committee for Expanded Methadone Treatment" was established in 1968, and included in its ranks Roy Innis, the Associate National Director of the Congress of Racial Equality; Congressmen Charles Rangel and Herman Badillo; State Senator Basil Peterson; Manhattan Burough President Percy Sutton; the co-owner of the Amsterdam News, Clarence Jones; Joseph Monserrat of the Board of Education; and rent-strike leader Jesse Gray.

vii. Although the City's share of the funding was never more than 10% of the programs's total budget, with the ramainder coming from the National Institute of Mental Health, A.R.T.C. was portrayed as "the City methadone program" (23).

viii. At the time, I was the Director of the National Nutrition Survey in New York City, and had no prior experience in the field of addiction treatment.

ix. At my insistence, the projected number of admissions during the first program year had been reduced to 3500. Even this goal represented an increase of more than 100% in the methadone maintanance capacity of all the existing programs combined. Although the state ultimately approved a first year budget based on a capacity of 2000 patients, supplemental City funds were available, and in its first twelve months of operation the Program admitted 3715 patients.

x. It is intersting to note that Chase sought responsibility for this large and extremely controversial undertaking. His appointment as the first nonphysician Health Services Administrator had been severely criticized by the medical establishment (27) and by numerous community minority leaders (28). He had his hands full even without venturing into the area of addiction treatment, which logically couldhave been left to the A.S.A. As heas of the H.S.A., he was ultimately responsible for the Department of Health, the Office of the Cheif Medical Examiner, the Department of Mental Health and Mental Retardation, and all health care provided in the City's schools and correctional facilities. The combined annual budget of these agencies amounted to almost one billion dollars. In addition, he had the simultaneous role of Chairman of the Board of the new Health and Hospitals Corporation, which within six months of his appointment was scheduled to assume responsibility for operating the 18 municipal hospitals. In retrospect, Chase explained his desire to operate the methadone program by pointing out that he considered addiction the major health problem facing the City, and the need to expand methadone treatment capacity the top priority of the administration. He was convinced that the H.S.A. could implement a large-scale program more quickly and effectively than any other agency, and consequently felt an obligation and a challenge to do so (29).

xi. Others have reached the same conclusion: "Programs focused primarily on experimentation and research such as dosage level manipulation, random termination, use of placebo substitution and the like might best do this on a small pilot basis rather than in the context of a broad treatment program in the community" (30). This position was subsequently adopted by the A.S.A. as well, which in its 1972 Comprehensive Plan for the Control of Drug Abuse and Addiction stated: "In the interest of both treatment and research we recognize that these functions must be kept distinct. Our appraoch is to foster and help develop small and carefully controlled research programs while simultaneously continuing to expand the large treatment-oriented programs which must meet the existing demand... (31).

xii. Even before the organizational dispute had been resolved, the H.S.A. had tentatively identified space and backup facilities for the first 12 clinics, worked out arangements for urine toxicology to be performed by the Bureau of Pyblic Health Laboratories, and obtained commintments from other programs to assisst in the recruitment and training of staff.

xiii. This mechanism had been used previously to operate other projects carried out by the Department of Health and other City agencies.

xiv. The Board of Estimate, which must approve all contracts entered into by the City, insisted that each prposed clinic have the written endorsement of the local Community Planning Board.

xv. The experience of the Addiction Services Agency in establishing its Methadone-to-Abstinence Program in 1972-1973 demonstrated that this advantage is more imaginary than real. The A.S.A. left implementation to the hospitals with which it contracted, and almost 18 months elapsed before the first clinic was opened.

xvi. The turnaround time is 36 hours; medication orders received from the clinics each Wednesday are reflected in the computer printouts delivered to each clinic on Friday, for use during the following week.

xvii. An alternative means of achieving the benefits of centralization involves the establishment of "central intake units." The advantage of the NYC MMTP approach is that papers, and not patients, are processed centrally; applicants have contact only with staff directly involved in the delivery of treatment services.

xviii. Urinalysis results are entered into each patient's computerized file on a weekly basis, from reports submitted to Central Office directly by the laboratory.

xix. Methadone programs not operated under the aegis of the City have similar constraints imposed by federal funding sources, and by State regulatory agencies which consider the "suitability" of proposed locations in the decision to license clinics and approve them for Medicaid reimbersement.

xx. Initially, a special community relations unit was planned as part of the NYC MMTP Central Office. Instead, however, the functions envisaged for such a unit were assumed by treatment staff and Central Office personnel directly responsible for establishing clinics and monitoring their operation. This organization has ensured that those who are most knowledgable about a specific facility relate to the local community, and has been considered more effective than relying upon a special community relations staff.

xxi. This has not been true of the private methadone programs in New York City, many of which have been forced to close. Here, too, the criticism has been based largely on the premise that the clinics properly belonged in some other neighborhood. Extraneous issues, such as the amount of income generated by private methadone clinics, have also received prominance. To date, however, attempts by the City Council to pass legislation eliminating all private methadone clinics have not been successful (39).

xxii. Federal regulations governing confidentiality of addiction treatment program records endorse the concept of requiring open-ended consent to disclosure as a prerequisite to "diversion" from the criminal justice system (see page 35). The paradox of labeling consent"voluntary" in these cases is highlighted by the fact that these clients are forbidden to change their mind: "An individual whose release from confinement, probation, or parole is conditioned upon his participation in a treatment program may not revoke consent [for future release of information]... until there has been a formal and effective termination or revocation of such relese from confinement, probation, or parole" (46).

xxiii. Although altruism forms the basis for the basis for the lagal rationalization, it is nevertheless clear that societal self-interest is the major factor in the involuntary treatment of addicts: "Danger to self has never by itself been made grounds for commitment or compulsory treatment. If it were, participants in every hazardous occupation or sport would be liable to commitment, and Charles Lindberg could have been permanently institutionalized for his intention to fly the Atlantic. Similarly, no law provides for compulsory treatment of cancer or heart disease or any other noncontagious physiological ailment.... If addiction is truly a 'disease,' what could possibly justify its unique legal status in relation to civil commitment and compulsory treatment?" (47).

xxiv. The same conclusion was reached by other critics, who observed that addicts "...would perfer to spend six, nine or twelve months in jail, where there is no rehabilitation, rather than risk commitment [to the State Narcotic Addiction Control Commission] for three years" (48).

xxv. According to the American Medical Association Council of Mental Health, "There is a general agreement among all students of addiction that addicts have personality aberrations and that these psychiatric conditions preceded and played an important role in the genesis of addiciton, its maintenance, and the high relapse rate after treatment..." (50).

xxvi. As the following candid statement reveals, addict-patients are considered "successful" when they are finally willing to accept whatever grim reality others consider appropriate: "From the addict's point of view, he properly perceives that the therapist is, in fact, trying to engage him in a conventional life, which will often mean low pay and prestige, continued insecurity, and poor access to the goals of our affluent society. This conformity, which society demands of the addict, is neither respected or valued when it is achieved" (54).

xxvii. The authors conclude that patients "lack the cultural background necessary to understand the nature of - or need for - psychiatric treatment" (57).

xxviii. "Increasingly, the major source of funds and the aegis for the expansion of treatment programs throughout the United States are programs closely intergrated with the Criminal Justice System in various court diversion schemes. These come primarily from the U.S. Department of Justice, and there primary focus is clear: expand treatment in order to contribute to the reduction of crime" (58).

xxix. The inconsistency and illogic of current policy in this regard are clear: "No existing law makes it a condition of commitment that a relation between the addiciton and the crime charged be shown. The addict is not even required to establish that his addiction existed at the time of the alleged crime. Thus an addict may be relieved of his obligation to answer a criminal charge even though his addiction was entirely unrelated to that charge" (61).

xxx. Not to be overlooked is the fact that during this same period of time Japan experienced the most extraordinary economic growth in world history.

xxxi. See reference (64).

xxxii. The revised federal confidentiality regulations promulgated in July, 1975, incorporated the NYC MMTP recommendation in this regard: "...a single member of the program staff should be designated to process inquiries and requests for patient information..." (66). It is critical that a specified individual, preferrably the director, be responsible for release of information to ensure that a program's reponses will be consistent, and that the consequence of failing to comply with subpoenas and other requests falls squarely on the individual with ultimate responsibility for the program's operation.

xxxiii. I later learned that Corporation Counsel had urged City Hall to fire me if at this point I refused to drop the case and supply the photographs to the District Attorney. The press coverage in the early stages of the case undoubtedly played a role in the Administration's decision to ignore Corporation Counsel's advise: reports of the lower court proceedings in the Daily News (70) and the New York Times (71) were objected, subdued, and nonjudgemental. The only editorial comment in the New York City newspapers appeared in the Post, which applauded the refusal of the NYC MMTP to comply with the subpoena (72).

xxxiv. Under this Act, directors of research projects studying the effect of drugs could apply to the Attorney General for special, absolute privileges against enforced disclosure of patient information. It was subsequently learned that the NYC MMTP was the first addiction treatment program to request and receive such a Grant of Confidentiality.

xxxv. The balancing test was designed to guide the courts in determining whether a program should be permitted to release patient information without consent: "In assessing good cause the court shall weigh the public interest and the need for disclosure against the injury to the patient, th the physician-patient relationship, and to the treatment services" (79).

xxxvi. The federal confidentiality regualtions promulgated July, 1975, clearly recognized the need for adequte legal representation: "...[E]xperience has demonstrated that independent council may be of crucial importance. The leading case construing 21 U.S.C. 1175, People v. Newman... would never have been presented to the courts but for the fact that legal council for Dr. Newman was furnished on a pro bono publico basis by a private law firm. In an entirely different case, a United States District Court appears to have issued a wholly inappropriate order under 21 U.S.C. 1175 in a case in which the treatment program was operated by an agency of the United States Government, and either was unrepresented, or was represented by the same attorney representing the agency seeking the order" (83). Because of this recognition, the new regulations specifically state: "Any application [for a court order to secure confidential information]... shall be denied unless the court makes an explicit finding to the effect that the program has been afforded the opportunity to be represented by council independent of coucil for the applicant, and in the case of any program operated by any department or agency of Federal, State, or local Governement, is in fact so represented" (84).

xxxvii. A survey of attitutdes of police chiefs in 27 major cities of the United States concluded: "The prevailing tone [with respect ot addiction treatment] inthe interviews was one of skepticism. Treatment hadn't worked" (85). Methadone treatment, in particular, was "... controversial in police circles, and among the chiefs interviewed the predominant attitude was not favorable" (86).

xxxviii. The experience of the NYC MMTP is that the enquirer's primary interest almost invariably is limited to determining whether an individual is enrolled in a program, and what his (her) address is. An additional and somewhat related question, asked especially by parole and probation officers, is whether the individual has been discharged from treatment.

xxxix. For several years, addicts were required by the New York City Department of Social serivces (D.S.S.) to prove that they were enrollred in addiction treatment programs to be eligible for welfare assistance. When confirmation was provided by the Program, pursuant to written authorization of the patient, it bacame part of the client record maintained by D.S.S., ,which refused to apply any special confidentiality provisions to such data.

xl. For example, a woman whose pocketbook was st5olen took it for granted that the thief was a patient in one of the patient's clinics which happened to be in the neighborhood; the Unit Supervisor, in flagrant violation of Program policies, permitted her to view photographs of all enrolled patients. Ironically, this incident took place in the midst of the court battle stemming from my refusal to divulge photographs subpoenaed by a Grand Jury in connection with a homocide case (see Chapter 6).

xli. The same rationale was restated by the Special Action Office for Drug Abuse Prevention in introducing the specific confidentiality regulations authorized by the 1972 Act: "If society is to make significant progress in the stuggle against drug abuse, it is imperative that all unnecessary impediments to voluntary treatment be removed.... The only effect of [the addict's] enrollment is to diminish the liklihood of his continued criminal conduct, and if the price of this is to isolate the records generated by the enrollment itself, this is a small price to pay indeed in light of the social benefits" (91).

xlii. It is of interest to note that in the case of venerreal disease records maintained by the Department of Health, the New York City Health Code precludes the release of information even with patient consent (93). This absolute prohibition against disclosure under any circumstances also applies to information contained in the New York City Narcotics Register. The rationale is persuasive: if individuals are empowered to authorize disclosure of sensitive information, they may readily be coerced by others to do so even when it is not in their own best interests.

xliii. This issue has particular relevnce in the case of addicts who are released from custody by the criminal justice system on condition that they enroll in a treatment program. With respect to such patients, the Federal confidentiality regulations not only permit, but expressly mandate, that the initial open-ended consent to disclosure be irrevocable (94).

xliv. The experience of the NYC MMTP agrees with that of methadone programs in Washington, D. C., where only 20 alleged cases of attempted multiple enrollment were uncovered by a centralized "footprint registry" in the course of processing some 5000 admissions (96).

xlv. For instance, several follow-up studies which hava been implemented in New York involve determining the current status of former patients with the help of the police department, parole and probation agencies, Department of Social Services, the Social Security Administration and other agencies. The program has refused to permit names of patients or former patients to be submitted by researchers to any outside agency. Disclosure by researchers to third parties was eventually prohibited in revised Federal confidentialty regulatons which went into effect in August, 1975 (101).

xlvi. This blanket authority of state agencies to demand unlimited access to patient information for alleged research purposes is in direct conflict with the stated intent of the regulations, "...to leave [the decision to make disclosure for research purposes] for interpretation on a case-by-case basis by those who must apply it in practice: the researchers who seek the information, and the programs which supply it" (107). Also, the Federal regualtions state: "Patient identifying information may nmot be disclosed to a funding source, as such, whether with or without patient consent.... [I]t is clear that Congress did not intend funding sources, as such, to have access to patient identifying information" (108). Nevertheless, it is solely through the threat of withholding funds that the New York Office of Drug Abuse Services has been able to compel programs to submit "research" data.

xlvii. The epilogue to this case is that the police, armed with the identifying information, failed to apprehend the thief; several months later he was shot and killed following an attempted robbery of another methadone program in New York City.

xlviii. The program in Palo Alto, California, while maintaining a double-blind dosage protocol, found that "...a majority of patients in all [dosage] groups regard their dose as toolow" (110). The experience of the NYC MMTP, and others, was that patients were concerned about being given too much as well as too little medication: "Patients are not supposed to know their dosage of methadone, and they resent this. One girl [sic!], for example, complained that she was feeling high and suspected that the nurse had increased her dose. She felt that her dose was her business and that at the very least she would be informed so as to know what to expect.... [P]atients continued to negotiate for more or less methadone on the basis of perceived side effects" (111).

xlix. "Disket" is the trade name of an Eli Lilly methadone preparation, a scored 40-mg tablet which can readily be broken by hand into four 10-mg quarters.

l. The same experience was reported by the Palo Alto program: in the course of a researchj project, patients were not only advised of the precise amount of methadone being prescribed, but permitted (within limits) to make adjustments at will. With the uncertainty removed, very few patients availed themselves of the opportunity to change dose, despite their previous conviction that the dosage was inadequate (112).

li. The NYC MMTP has always administered medication in solution for consumption in the clinics. In addition to ensuring that patients actually drink the methadone given to them, the Disket used by the Program was known to cause gastric irritation if taken without prior dissolving.

lii. Just prior to the conversion to Diskets, the NYC MMTP arranged for samples of medication prepared by pharmacists in the various contract hospitals to be quantitatively analyzed; discrepancies were found to be the rule rather than the exception, and in some cases amounted to as much as 30%. This generated considerable concern not only with respect to possible diversion of the drug, but on grounds of clinical safety and efficacy; these findings added to the urgency with which the NYC MMTP changed to tablet methadone.

liii. The Program's experience is that maximum control of methadone supplies can be assured only through the use of tablet-form medication, which permits an exact accounting of how many milligrams are received, administered and dispensed by the individual clinics.

liv. To ensure that analysis of patient retention in the Program would be meaningful, the NYC MMTP continued to define the "official termination date" as the date of last medication.

lv. This experience has been reported by other methadone maintenence programs as well, and is reflected in the difficulty of obtaining follow-up information on patients after detoxification (117-119).

lvi. This view has been consistently expressed by Dole and Nyswander in subsequent papers: "In the treatment of addiction and other chronic diseases, medicines should be prescribed only as part of a larger program of rehabilitation" (121). "The medical procedure - stopping heroin addiction with methadone - is simple, but the social problems of the street addict will continue to disable him unless effective social helps are also given" (122). "In the complex task of rehabilitating an addict, methadone (or any other medication) is only an adjunct.... The main services needed by a methadone program ... are helps in housing, school placement, job training, and employment. Without such help the patient is like;ly to be trapped in his past, even if he stops using heroin" (123). "...[O]ur programs are usually called 'methadone maintenence programs.' This popular label puts the emphasis on what is merely the medicinal aspect of the treatment. More importently, the clinics should be rehabilitation programs, not merely dispensaries.... Specifically, the program must help open the way to better jobs and housing for patients, provide oppotunities for education, defend patients against injustices" (124).

lvii. Reflecting the popular consensus among those involved in methadone treatment, regulations of the Federal Food and Drug Administration since 1972 have explicitly required that ancillary medical and social services be part of the treatment regimen (125). Nevertheless, methadone maintenance continues to be criticized as a "...new conceptualization of what addiction is and how it is best treated, i.e., with medication rather tyhan rehabilitative therapy" (126).

lviii. Thomas Szasz, a psychiatrist, has cogently argued that both "drug abuse" and "mental illness" do not even exist except as functions of popular morality (128, 129).

lix. Prior to the Legislature's action, the Mental Hygiene Act employed a definition of "addict" which excluded individuals who were physically dependent upon narcotics "...taken under the supervision of a physician in the course of accepted medical practice." The exclusion no longer applies to those whose medical treatment is related to previous drug abuse.

lx. Almost three years later, the Postal Service was ordered by a Federal Court to lift its ban on employing methadone patients (133).

lxi. The assertion that methadone patients are "still addicts" is a widely heard criticism, and the rationale for much of the persistent discrimination. Even in a strictly technical sense, "...the term addiction has been used in so many ways that it can no longer be employed without furthur qualification or elaboration" (138). As commonly employed, however, the implication of the rubric "addict" goes far beyond physiological phenomena of tolerance and dependence: "Addiction and addict have been ued so often that the words have developed a cultural rather than a scientific meaning, connotating disapproval and deprecation" (139). This connotation is in accord with the popular definition of addiction as "The compulsive and uncontrolled use of habit-forming drugs, beypond the period of medical need, or under condotions harmful to society" (140). It also agrees with the criteria of "drug addiction" proposed by the World Health Organization: "(i) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (ii) a tendency to increase the dose; (iii) a psychic and generally a physical dependence on the effects of the drug; and (iv) detrimental effects on the individual and on society" (141). Most other definitions are similar, and stress the harm to the individual and society associated with "addict" drug use (142, 143). Clearly, none of these definitions apply to the methadone maintenance patient.

lxii. One notable exception was the Program's role in persuading the New York City Department of Personnel to adopt the following policy: "No ex-addict, methadone-maintained or drug-free, will berefused employment solely on the basis of his previous addiction ... except where current medical requirements bar such employment" (144). The qualification refers primarily to the uniformed services (fire, police, an sanitation), but even those agencies have recently begun hiring ex-addicts to fill nonuniformed positions (145). Other programs ion the State have not been so fortunate in eliminating conflicting policies of local governmental agencies. The experience of a county- funded methadone program in Syracuse, New York, is not atypical: "...a county department fired an employee when it learned that she was on methadone, apparently without realizing the irony involved in one county agency undermining the efforts of another and, by so doing, forcing a person onto county-funded work relief" (146).

lxiii. With respect to certification, the New York City Commission on Human Rights, following extensive hearings on the question of job discrimination against rehabilitated addicts, noted: "...[T]here is something fundamentally repugnant about certifying an individual as an 'ex-addict.' Most of the drug treatment experts who testified at the hearings were reluctant to endorse a certification process, no matter how constructed. Certification runs not only the risk of stigmatization but also places too much dependence on the judgement of a single individual who may or may not be objective, fair or qualified to make a valid assessment of job readiness (147)."

lxiv. This position was warmly endorsed by the Bureau of Narcoticss in a "Concurring Statement": "The Bureau is pleased to note that the American Medical Association has reaffirmed its position opposing the establishment of community ambulatory clinics for ... the continuing maintenance of addicts on narcotics" (152).

lxv. An article by the same author, in which he states that methadone maintenance involves "... simply substituting the euphoric action of methadone for the euphoric action of heroin by administering massive doses o the former," (156) was reprinted in 1968 by the New York State Narcotic Addiction Control Commission as an "especially noteworthy article on narcotic addiction" which deserved a wider audience (157).