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COMMENTARY By John Carey	April 12, 1999

Call it the other drug war: how to deal with those enslaved by addiction. First, New York City Mayor Rudolph Giuliani waded in with a radical proposal last year to take tens of thousands of the city's addicts off methadone and shut down the programs. Substituting methdone for heroin only replaces one damaging addiction with another, Guilani argued. Drug-treatment experts were outraged.

Then, Presidential hopeful Senator John McCain (R-Ariz.) took up the same cause. Calling the Clinton Administration's reliance on methadone programs "disgusting and immoral -- an Orwellian drug swap [that] trades the shackles of heroin for the shackles of methadone," he introduced a bill in February that would limit methadone treatment to no more than six months.

IMMENSE SUFFERING. Let's give these eminent politicians credit for reminding us of the terrible toll of drug addiction. We should all care that the number of heroin addicts in the U.S. is 810,000 and growing. It brings not just immense human suffering but an annual price tag of more of $20 billion -- from increased crime and spread of AIDS to lost economic opportunities. And who could argue with Giuliani's and McCain's ultimate goal of freeing people from addiction's shackles?

Unfortunately, their proposals are wrongheaded: Achieving this goal is just not that easy. Yes, it's possible for addicts to quickly break the hold of narcotics like heroin and methadone, but the sad truth from decades of studies is that 90% of them relapse soon after. "The idea that we can detox people to solve the drug problem was discredited long ago," says Donald C. Des Jarlais, research director of the Chemical Dependency Unit at Beth Israel Medical Center.

The reason, the scientific evidence increasingly suggests, is that narcotics permanently alter the brain. Just as injecting insulin into an animal can reduce the creature's ability to make the chemical, and thus give it the disease of diabetes, heroin appears to damage the brain's system for making or responding to neurotransmitters like endorphins. The result: cravings that may never go away. Gerald Friedland, professor of medicine at Yale, explains that "addiction is a medical disease" -- not a weakness of character. "Once you accept that, it should be treated as a medical disease," he says.

FAILURE OF WILL? That's why drug-addiction experts argue that methadone, a narcotic that supplies what the brain "needs" without providing a heroin-like high does, is really no different than giving insulin to diabetics or beta-blockers to people with high blood pressure. But many politicians just don't get it. "The political right thinks addiction is just a failure of will, and the left thinks methadone is just a way of keeping people drugged," says Jeffrey Merrill, an expert in the economic costs of addiction at the University of Pennsylvania.

But methadone clearly works. One of Merrill's studies shows that addicts on methadone are one-quarter as likely as their untreated counterparts to get infected with HIV. Using methadone nationwide, therefore, would translate into savings of $1.5 billion in HIV treatment alone. And a whole raft of other studies reveal that methadone cuts the death rate of addicts by two-thirds, slashes crime, and boosts productive work -- all for a cost of $13 per day per person.

"Methadone is probably the single-most studied pharmaceutical in the history of medicine," says Dean Gerstein, senior research vice-president for substance abuse studies at the National Opinion Research Center. "The research is so clear that you have to wonder why there still can be a controversy." Gerstein calculates that a dollar spent on methadone programs brings $7 in benefits to society. Indeed, to Mayor Giuliani's credit, he backed off from his plan to cut off the drug once presented with the evidence.

NOT A CURE. Giuliani and McCain are right that methadone is far from a magic bullet. "Anyone who says they have THE answer to drug addiction is lying," says Dr. Herbert D. Kleber of Columbia University and the National Center on Addiction & Substance Abuse. Methadone causes side effects like impotence and sweating, and it doesn't keep a minority of addicts from continuing to use heroin and other drugs.

Moreover, antiquated regulations make it far more difficult and expensive to deliver the drug than necessary. And such substitute drugs are clearly only part of the solution to drug addiction. We must also provide homes, jobs, support, and hope. A few programs do just that. A McCain favorite called Ready, Willing, and Able, which was founded in 1990 in New York, is showing that, after detoxing with methadone or other methods, nearly half of all addicts who enter the program are remain drug-free two years later.

The most pressing need, however, is to do what White House drug czar Barry McCaffrey is pushing: expand methadone programs to reach far more than the current 115,000 addicts. We also need to cut the red tape and pursue promising drugs that may work better than methadone. Is this strategy just an Orwellian drug swap? No, just medical reality.

Carey covers medical issues from BW's Washington bureau

EDITED BY DOUGLAS HARBRECHT _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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