The nation's failure to tame the drug epidemic ravaging cities such as Baltimore has brought Mayor Kurt L. Schmoke's advisers to a stark admission: Many people are going to remain addicts, so society ought to reduce the harm they cause themselves and others.
In the wake of the sweeping proposal made Wednesday by a mayoral panel, Health Commissioner Peter Beilenson said the goal of any new drug policy will be to get people off drugs for good.
But he admits that the proposal places heavy emphasis on programs aimed at reducing crime, disease, joblessness and alienation even as people continue to abuse illicit drugs.
"It's valid that some of this is harm reduction," Dr. Beilenson said. "We realize that for time immemorial, societies have had problems with addictive substances. You have to realize that some people are not going to get off drugs, and you have to reduce the harm -- crime as well as HIV.
"Not just harm to the individual but harm to society."
The recommendations made by the Mayor's Working Group on Drug Policy Reform would, as Dr. Beilenson puts it, "put treatment into the mainstream" by relying more on primary care doctors and clinics to take on a role now performed almost exclusively by drug treatment programs.
Money to train doctors about drug addiction, to run a needle exchange, to expand methadone in clinics and to start a "methadone bus," as the panel has also suggested, would probably have to come from private sources such as foundations. The policy recommendations come at a time when the slots in treatment programs have been cut back to the lowest point in years.
"There are some addicts who can stop being addicts, and we want to encourage that," said Kevin B. Zeese, a panel member who is vice president of the Drug Policy Foundation. "But there are also addicts who are unable to do that for whatever reason. We want to find a way to get these addicts out of the cold and put our arms around them and help them as well."
'Interested in life'
Doubling or tripling the number of addicts taking methadone, as the panel has suggested, might get many people off heroin. But they may have to be given methadone, a more benign narcotic, for years.
"By allowing a maintenance alternative you get a person in the door, functioning, out of the routine of having to acquire illegal drugs," Mr. Zeese said. "The goal is to get them interested in life."
Establishing a clean-needle exchange might, according to some studies, reduce the rate at which addicts transmit the AIDS virus by sharing dirty syringes. By recommending such a program, the panel is conceding that many addicts are going to continue to shoot narcotics no matter what.
Although the principal aim of the "needle exchange" is to curb the spread of AIDS, Dr. Beilenson wants professionals not only to hand out clean syringes but also to refer addicts for treatment. At present, public and private clinics are able to treat about 5,000 addicts in Baltimore at any given time. This number includes slots in detoxification centers, methadone maintenance programs and counseling programs that stress abstinence.
About half of the slots are in methadone programs, which turn away addicts every day because they lack funding to treat everyone. Dr. Beilenson said the city could probably double or triple the availability of methadone by asking primary care doctors and community health clinics to supply it.
This could not happen overnight. The city would train doctors in the proper administration of methadone; the doctors would then have to apply for federal and state permits to prescribe the drug.
Laura Hardesty, a caseworker at Sinai Hospital's methadone program, said there is strong evidence that the drug helps people lead productive lives, but the public needs to redefine its definition of success.
"What I consider success is someone who has stopped using illicit drugs, has a job, no longer is on social services and is working hard to change their lives," she said. "If that means being on methadone for the rest of their lives, that's fine with me. I see that as no different from insulin."
Slow road to recovery
She added, "If the goal is for people to get on methadone and then detoxify, it's the rare bird that doesn't relapse."
Dr. Frank Evans, Sinai's clinical director, said about 30 percent of the 300 addicts under treatment at any given time can be expected to eventually get off all drugs, including methadone.
Rarely is that goal reached quickly. Many addicts take methadone for years before they can even think about giving it up. Then, it can take another two years to get off methadone -- a process achieved by gradually lowering the dose.
Dr. Evans said he doubts that private physicians would have much success delivering methadone to their patients because the job requires a multidisciplined approach. The Sinai program, which treats some 300 addicts, relies primarily on counselors and social workers to help addicts remain clean.
He said community health clinics -- there are nine in Baltimore -- probably have greater potential than private doctors as effective sources of methadone. But even the clinics might have to broaden their staffs.
"Working in a methadone clinic is a very, very different experience," Dr. Evans said. "A community health clinic could do it if they were set up for it. You cannot run this like a hypertension clinic."
A good portion of the city's drug addicts inject cocaine, and methadone does nothing to block the craving for that drug.
The mayor's panel, however, recommended that clinics seek permission to try experimental medications that hold some promise as weapons against cocaine.
WORKING GROUP ON DRUG POLICY REFORM
DAVID M. ALTSCHULER, Ph.D. -- Research scientist, the Johns Hopkins University Institute for Policy Studies
PETER BEILENSON, M.D., M.P.H. -- Baltimore commissioner of health
ROBERT M. BELL -- Judge, Maryland Court of Appeals
TRACY BROWN -- Lawyer, executive director of Mayor's
Coordinating Council on Criminal Justice
ROBERT C. EMBRY JR. -- President, the Abell Foundation
RIPLEY FORBES -- Senior staff, Subcommittee on Health and the Environment, U. S. House of Representatives
HOWARD LAVINE -- Lawyer, Assistant for Communications to Mayor Schmoke
CLARENCE LUSANE -- Author
WALLACE MANDELL, Ph.D. -- Chairman pro tem, Department of Mental Hygiene, the Johns Hopkins School of Hygiene and Public Health
PATRICK V. MURPHY -- Director, the Police Policy Board, the U. S. Conference of Mayors
ETHAN A. NADELMANN, Ph.D. -- Assistant professor of politics and public affairs, Princeton University, Woodrow Wilson School of Public and International Affairs
SIDNEY H. SCHNOLL, M.D., Ph.D. -- Chairman, Division of jTC Substance Abuse Medicine and professor of medicine and psychiatry, Medical College of Virginia
RONALD M. SHAPIRO -- Lawyer, political adviser to Mayor Schmoke, treasurer of political campaign fund
SOLOMAN SNYDER, M.D. -- Distinguished service professor of neuroscience, pharmacology and molecular sciences and psychiatry, the Johns Hopkins School of Medicine
ERIC E. STERLING -- Lawyer, president of the Criminal Justice Policy Foundation
LINDA THOMPSON, Ph.D. -- Chair of Maternal and Child Health, the University of Maryland Medical System School of Nursing
ARNOLD S. TREBACH, Ph.D. -- President, the Drug Policy Foundation
KEVIN B. ZEESE -- Lawyer, vice president, the Drug Policy Foundation