Drug Abuse

PRACTICAL PROBLEMS OF HEROIN MAINTENANCE

PRACTICAL PROBLEMS OF HEROIN MAINTENANCE

John Kaplan

John Kaplan is the Jackson Eli Reynolds Professor of Law at the Stanford Law School. He is the author of various books and articles on criminal justice, the law of evidence and drug control. His books include: Marijuana, The New Prohibition (World Publications, 1970) and a recently completed work on heroin.

Although many people argue that heroin maintenance is the best solution to minimize the total social costs of heroin use and the enforcement of Laws aimed at preventing it, there are serious practical problems in any heroin maintenance scheme. Any scheme that makes it convenient for addicts to get their heroin will make diversion of legally supplied heroin a serious social problem. Similarly, any system which reduces heroin diversion to manageable proportions will prove to be too cumbersome for most addicts. Finally, the cost and other disadvantages of heroin maintenance have been grossly underestimated in the past.

Heroin maintenance is, in many ways, like euthanasia. It is a very good idea if all the details can be worked out. Unfortunately in both cases, it turns out that there are sticky problems that simply do not yield to the kind of line drawing which a legal-and social-system such as ours must do, and, in both cases, the problems appear to be 'intractable. To use a metaphor, each solution to either problem seems like too small a blanket on a cold night. It may be good enough to cover part of the matter adequately, but when it does it leaves other parts dangerously exposed. This article, as its context indicates, will focus not upon euthanasia or upon blankets, but upon heroin maintenance.

In this paper I would like to discuss the practicalities of "heroin maintenance." Although to a greater and greater extent this arrangement is coming to be advocated as overall the best method of minimizing the social costs associated with heroin addiction, (Chein, et al., 1969; Bayer, 1977; Waldorf, Reinarman, 1974; Rector, 1972) it is likely that the logistics involved raise problems even more serious than those associated with illegal street use of the drug.

A complete discussion of heroin maintenance would involve measuring the costs and benefits of our present system against those expected from various heroin maintenance proposals. In this paper, I will go over only one-half of the equation, leaving out-because of space limitations-a discussion of the costs and benefits of our present system. I will also resolutely leave out any discussion of the British system. Such a discussion is unnecessary for two reasons: first, it has been done again and again; and, secondly, if such experience, assuming it was successful, is applicable to this nation, with by most estimates different kinds of addicts, one-hundred-and-fifty times as numerous and a vastly different social and medical system (Judson, 1975:19) then much that I say will be untrue. The way to determine the accuracy of my analysis, however, is not to make inferences from the very different British situation, rather it is to examine carefully the factual statements I make and the inferences I draw from them.

In this discussion, let us take a closer look than is usually taken at two quite different ways of maintaining addicts on heroin-the prescription system and the on-premises system. Each has its own advantages and problems. In this article, no attempt will be made to examine the even more complex issue of whether some variation of one or both will involve a better balance of cost and benefits than does either of the extremes. It may be that this can be done-but, if so, the burden of proof that some combination of two unsatisfactory alternatives can be made attractive lies upon the advocate of any particular plan.

The Prescription System

Let us first examine, at one extreme, the model of heroin maintenance which the British used in 1969, in the early stages of the clinics.

Heroin clinics at that time would prescribe heroin based upon the clinic physician's assessment of the addict's need, and the addict would then pick up his supply at a pharmacy of his choice. Such a system would probably have a strong appeal for the great majority of addicts. The amount of time and energy they would have to spend in getting their heroin would be vastly reduced and they would be getting a safer and far cheaper drug (Waldorf, 1978).

Moreover, such a system would lower those particular social costs imposed by heroin prohibition. The addict would not have to steal to afford his habit. Hopefully, he would stabilize his dose, thereby becoming a more productive citizen as well as lessening his drepidations against society. Even if he could not be stabilized, however, the price of his drug would still remain quite small-and if he continued to steal, at least the demands of his heroin habit would not increase the amount of theft. Finally, the system would not be very expensive, in financial terms, for us to administer. The best recent estimate of the cost per addict, including medical care and some supervision and counseling, is about $2,500, or about one-fifth more than a well-run methadone program costs today (Judson, 1975:135).

The Problem of Illegal Sales

The prescription system, however, has one major and intractable disadvantage. The addicts who pick up their supply of heroin at extremely low cost will have a strong incentive to resell at least part of their supply, and the more they can sell, the more closely will the maintenance system then approximate free availability. This problem of leakage is not a mere consequence of sloppy administration which could be corrected by sufficient controls. It is inherent in any system which allows 'he addict to possess low-cost heroin outside the confines of a guarded clinic, laboratory, or hospital.

Of course, the clinic staff will try to lower the amount of heroin the addict can sell by prescribing no more than he needs. The problem, however, is one related to the "once an addict, always an addict" myth. Even where the addict is prescribed a stable, "correct" dose, he will still have a considerable degree of control over the portion of this he will actually use and, indeed, may even stop using for a while. If the addict wishes to "earn" money by selling part or all of his supply, he can lower his use, either temporarily or permanently, and simply get along on less (Caplovitz, 1976; Mitcheson and Hartnoll, 1976; Gerstein, 1976).

Though we have little statistical or experimental-as distinguished from anecdotal-data to prove this point with respect to heroin addicts, we know a good deal about the ability of alcoholics to abstain from drink. One researcher, for instance, found that even chronic alcoholics could refrain from drinking for a week if they were paid enough for their abstinence (Cohen, et al., 1972).

Moreover, we do know that today's addicts have all learned how to get along on wildly fluctuating heroin dosages (Hunt, 1976; Caplovitz, 1976; Gerstein, 1976; Waldorf, et al., 1974). Their intake varies enormously when times of heroin glut are succeeded by shortages, and, even during periods of stable price and supply when their income changes. Presumably, methadone will always be somewhat available on the street, at a much lower price than heroin, so the addict can use that drug to stave off withdrawal, while he sells the far more valuable heroin that he has received from the maintenance system.

Unfortunately, we cannot rely on the threat of detection to prevent the addict from selling some of his heroin supply. Though the clinic can use urine tests to monitor whether he uses street heroin cut with various substances, it cannot determine whether he has used all that has been prescribed for him. As a result, urinalysis would be a deterrent only to the addict's selling all of his supply.

Nor can the police do much either. There are far too many addicts to watch; they will be legally in possession of their heroin; and their sales will typically take place in private (Moore, 1977:5-41). In fact, heroin trafficking through diversion from a prescription maintenance system would be much more difficult to contain than is our present illegal distribution system. Usually, the best hope of disrupting an illegal system of heroin distribution is to intervene at the higher end of the chain. Though this is quite difficult, nonetheless, if the police do manage to seize a large shipment of heroin, put a large ring out of business, or disrupt cultivation in a foreign country, there will be a sizable-if temporary -con traction in the heroin supply (J. Heller, 1973).

Where the principal manufacturer, importer, large-scale wholesaler and smallscale wholesaler are all the maintenance system itself, the vary shortness of the illegal supply chain-from 'the addict in maintenance to his customer-would make the illegal market virtually untouchable by law enforcement.

Indeed, the prescription heroin maintenance system may create a wholly new and very large class of regular sellers who will make heroin more accessible as well as cheaper. Today, although virtually all street level sellers are addicts, the converse is not true. Most addicts may sell to accommodate a friend or, if they suddenly gain access to more than they need, but they do not sell the drug regularly, often because they lack a low-cost connection. A maintenance system may now become just that low-cost connection and by supplying cheap heroin to large numbers of addicts, may greatly increase the number of sellers of the drug.

It is not merely the numbers of heroin sellers we must worry about; we must be concerned with their distribution throughout the society as well. Freeing addicts from the need to pursue their own heroin requirements allows them better to integrate themselves into more areas of our society--indeed that presumably is one of the purposes of heroin maintenance. We might greet this prospect with equanimity, were it not for the fact that so many addicts are without legal job skills and more adept at illegal methods of earning income. The likely prospect would be that a sizable percentage would either earn a living, or at least supplement their income, by selling some of their prescribed heroin, often to their new non-using associates.

Even among the -relatively non-criminal English addicts, one study showed that 12% regularly sold part of their heroin supply (Mitcheson and Hartnoll, 1976). In the United States, one would expect the figure to be far higher. The effect of this would be to expose a much larger segment of the population to access to heroin and to lower not only the financial but the informational cost of the drug as well.

Finally, the opportunity to sell prescribed heroin acts as a subsidy to non-addicts to become addicted and then enter treatment. The almost automatic provision of welfare payments to those in methadone programs in New York has been alleged to be a socially damaging inducement to addiction (Fleetwood, 1977). A prescription heroin maintenancy system not only would provide a far more euphoric drug but also, in all probability, a considerably greater and more socially damaging income.

The Effect on the Heroin Demand

Although many advocates of a prescription heroin maintenance system have had to recognize that it would make control of heroin supply more difficult, they argue that this disadvantage would be more than offset by the effect of the program upon the demand for heroin. The assertion is that it does not matter if heroin is diverted from the maintenance system or illegally imported so long as there is no one to buy the drug. The argument, in other words, proceeds on the apparently self-evident view that no one would buy illegal heroin at a high price, when it would be available to him at a much lower price through the maintenance system.

The fallacies in such reasoning, however, are numerous. It assumes that all the addicts would be in the maintenance system at any one time; they would be the only users of heroin; and, finally, that all the heroin they used would be provided to them by the system. In fact, none of these is likely to be the case.

The assumption that all addicts will be within the heroin maintenance system is dubious at best. The British experience gives us reason to believe that even the most permissive programs may still be unattractive to many addicts. Even when heroin was prescribed by the clinics, there were at any one time a considerable number of relatively new addicts who, for one reason or another, had not acknowledged their condition or otherwise persuaded themselves to take the important step of appearing for maintenance. In addition, there were other long-term addicts who did not register because they did not wish to be "tamed" by the system. Though the number in Britain was rather small, it would probably be much larger in the United States.

Moreover, addicts are not the only possible customers for heroin. There are not only large and growing numbers of controlled moderate heroin users, but, at any one time, a good number of non-addicted users on their way to addiction. And, finally, to this total we should add all the non-users who would be willing to try the drug if it were cheaper and more easily available, especially if their friends were already using, either in or out of the maintenance system (Waldorf, 1978; Hunt, 1976; McGlothlin, 1977; Judson, 1975; Johnson, 1977; Gerstein, 1976; Preble & Casey, 1972).

The self-image as an outlaw, a "righteous dope-fiend" or a "stand-up guy" may be one of the satisfactions of the American addict's life, and those who value this may find many reasons not to accept our treatment (Preble and Casey, 1972). No matter what legal arrangements we make, the addict in maintenance will be socially stigmatized. His former associates, or some number of them, will say he has "sold out" and the outer society will still regard him as a "dope fiend." Those who would reject the label of "sick," as well as those who feared disclosure of their addiction, would probably not come forward willingly, even if maintenance seemed, as a practical matter, to their advantage.

Finally, there are problems even in the perfectly rational assumption that an addict receiving cheap, pure heroin would not be in a market for more of the drug at a higher price. First of all, many of those who would get their heroin from the maintenance system may still continue to live the addict's lifestyle because of its other satisfactions. It is certainly possible that this will continue to include the use of extra, illegal heroin.

Entirely apart from any social forces impelling the addict in maintenance to use additional heroin, there is the pharmacological fact that many addicts seek euphoric doses of the drug (McAnlotte and Gordon, 1974). It is certainly true that some addicts could be stabilized on fixed dosages of heroin, but if the British experience is any guide, they would be the most stable and least like the majority of American addicts. For those who desire euphoria--as do most American addicts-the clinic efforts to stabilize their doses will most likely fail. Rtither, as their tolerance develops, they will want more and more heroin in order to continue receiving the feelings they desire.

Of course, in a sense, there is a kind of "wash" transaction where one addict on maintenance merely buys some of the supply of another. No new addicts are created by this transaction. It does, however, add to the market for heroin; encourage the seller to get an illegal income from selling his supply, and make it more difficult for both the addicts buying and those selling to stabilize their doses. Finally, it imposes upon at least some addicts the requirement of coming up with the price of illegal heroin--a burden the whole maintenance scheme was designed to remove.

Despite the fact that there would probably remain a sizable market for illegal heroin, even in the presence of the most permissive heroin maintenance scheme, there is no doubt that, at least among present users, heroin maintenance would decrease the demand for the drug. There are those who have argued that maintenance would do more than that, and would, in fact, lessen the total amount of the drug sold to all purchasers.

One contention is that the cheap availability of heroin, once a user became addicted, would so take the hope of profit away from the pushers who actively attempt to create addicts, that the number of new users would drop (Moore, 1976). Obviously, this view is based on the pusher mythology, and, as has been demonstrated by one study after another, the street-level seller today is not a major spreader of addiction-except in the sense that he makes heroin available to the peer group which does spread the use of the drug. Diversion from the maintenance system, however, could easily provide the supply for that purpose.

Nor can one argue persuasively that heroin maintenance would remove so many of the supply system's customers that there would be insufficient volume to justify the costs and risks of the present illegal distribution system (Deininger, 1976). One problem with such an argument is that the economies of scale in heroin supply are simply not that great. It is true that the removal from the illegal market of a substantial percentage of addict customers would at least temporarily depress the amount of heroin sold, which in turn, would depress profits. However, there is no reason to believe that profits would reach such a low level as to prevent the servicing of the sizable illegal market that would remain.

This type of argument, moreover, is really directed at the supply side of the heroin market, not the demand. In fact, of course there very likely would be a destruction of the present supply system-but not because of a contraction in demand. Rather, in all probability, it would simply be the competition from re-sales of prescribed heroin that would put the present system out of business (Smith, 1977).

This, of course, is small cause for comfort, since it says nothing whatever about contracting the market for the drug. We would merely be replacing one distribution system by another, with the newer system able to supply the drug more cheaply and easily than the old one. As a result, we would expect that the demand, at least by those not under maintenance, would go up, rather than down.

Presumably the total demand for illegal heroin will reach some kind of an equilibrium, but we cannot predict where it will lie (Hunt, 1976; Deininger, 1976). In all likelihood, the maintenance system will remove many addicts from the market for illegal heroin. This will depress the demand for the drug and the increase in the number of addicts on maintenance will increase the number of sellers as well. Both of these effects will, of course, tend to lower the market price for heroin. Not only does this lowered price tend to increase the number of users and heroin addicts on the street, but, as the price of heroin falls, it becomes less attractive for them to enter the maintenance system; or, if they do, to sell their supply of the drug. 'Me larger number of addicts on the illegal market would then bid up the price of illegal heroin until an equilibrium is reached. One would expect that the cost of heroin, both in money and in the time, effort and risk involved in securing the drug, would drop sharply. And it takes a great deal of confidence in the other barriers to addiction to believe that this would not result in an unacceptably high addiction rate-even considering what would probably be the lowered social cost of theft per addict.

The "On The Premises" System

The problem of diversion from a prescription system scheme makes one examine more carefully the other major type of heroin maintenance-the on-the-premises system. Here diversion would be minimized by restricting the addict's possession of heroin to the inside of a secure clinic. Requiring the addict to come into the clinic and shoot his heroin on the premises even, with relatively little supervision, would probably be enough to prevent the wholesale diversion that the prescription system might entail (Deininger, 1976). Such a maintenance system, however, would raise other difficulties which are almost equally intractable.

Most of the problems with the "on the premises" system are caused by the brute pharmacological fact that heroin is a short-acting drug, and, hence, the addict would be forced to come in for his dose about every four to six hours (Tinkleberg and Kopell, 1976). The interruptions required by such a schedule would make a normal working life difficult if not impossible, and the inconvenience of so many trips to the clinic might well make this kind of heroin maintenance no more attractive to most addicts than is methadone maintenance today.

Moreover, unless we vastly increase the number of clinics, the addict's problem of going for his heroin three or four times a day would be more than a nuisance-it would be a practical impossibility (Smith, 1977). Addicts often do not have access to automobiles, and public transportation where many of them live is usually very bad. A fair estimate of the average travelling time for addicts to the nearest methadone clinic would be about three-quarters of an hour. It is hard to believe their total business in the clinic could be done in much less than onehalf an hour, leaving an average of about six hours per day spent in the use of the clinic and associated transportation. It is likely that the great majority of heroin addicts, considering the other opportunities open to them, do not want our legal, cheap heroin that much.

Obviously, to make an on-the-premises heroin maintenance system work, we would have to lower the travelling time considerably. To do this, we would need far more clinics to dispense heroin-but here again we run into problems (Smith, 1 977). First of all, there is the problem of diversion. It is true that the diversion by addicts of their allotments can be prevented by an onthe-premises system-but the greater the number of clinics, the greater the security problems of preventing diversion at higher levels. The clinics, the central heroin warehouses, and the vehicles delivering the drug from one place to another, all would be major targets for burglary, robbery, and the like.

More important, even, would be the problems of diversion by those employees of the system corrupted by the high profits to be made in selling heroin (Deininger, 1976). Sale of heroin legitimately coming into police possession has been a nagging problem of heroin enforcement; dealers arrested for selling heroin have been given back the drug supply seized from them and permitted to continue their business-with policemen as senior partners. And we even know of cases where sizable amounts of confiscated heroin have found their way from guarded police property-rooms onto the street.

There is certainly no reason to think that the profits of heroin dealing would prove less tempting to those working for the maintenance system; and the problems of designing a security system would be far greater. The police, at least, are not expected to distribute heroin at all.

Once one allows distribution on any scale, diversion becomes much easier. It becomes possible to keep non-existent addicts on the rolls, diverting their allotment of heroin to the illegal market, or to shortweigh the dosage addicts receive, and sell the difference. And, of course, "unexplained inventory shrinkages" can result from simple, crude theft.

It is no doubt possible to design methods of combatting each of these problems. The difficulty is that as the number of clinics goes up, the cost of supervision, the likelihood of corruption somewhere in the system, and the difficulty of simply keeping track of both heroin and addicts goes up as well, and probably much faster.

There is, of course, one way of solving a considerable number of the transportation problems caused by heroin maintenance though frankly, it smacks more of Swift's modest proposal than of Dole and Nyswander's. We might simply make our on-the-premise system a mobile one. A large armored car would cruise around areas of heroin use. In the car would be technicians, injection devices, and a supply of heroin, together with identification systems which could recognize a card, and perhaps even a fingerprint pattern, of a certified addict. As the car moved slowly through the ghetto, the addict would walk along close beside it, put his arm into a hole in the side of the car for a moment, have his identity and dosage checked and receive a heroin injection (most likely intramuscular rather than intravenous, but probably enough to be satisfying) and then simply go about his business until the next time the "Kaplan Wagon" went by. The advantage of such an arrangement over the immobile on-the-premises system are obvious-but those who would argue that there are only a few public relations problems to be ironed out may, unfortunately, be wildly optimistic.

It is true that in any on-the-premises system-whether mobile or stationary-the total amount of diversion would probably be considerably less than the hemorrhaging to be expected from a prescription system. As a result, the price of the drug on the street, both in informational and financial terms, is likely to be much higher, and the control of supply to the illegal market far more complete than in a prescription system.

On the other hand, the on-the-premises system does not promise nearly as much of a reduction in the demand for heroin by those who presently are addicted. The problem is that the on-the-premises system would be much less attractive to the addict. He would have to contend with all the inconvenience of travelling; he could not shoot up in his pleasant home surroundings or, presumably, with his friends, but rather in an institutional setting; and, even more than in the prescription system, he would be denied many of the exciting satisfactions of the addict's life style.

To the extent that the price of heroin remains high, but more addicts stay out of maintenance, the situation looks more like that under our present heroin prohibition. The fact that some addicts would be attracted into the system might lower the social costs their addiction imposes upon society-but this comes at the price of adding those others who become addicted through diversion from the maintenance system.

In addition, the great increases in the number of clinics would cause problems of a political nature. The presence of the addicts it attracts would make each clinic the focus for a local drug culture. The location of methadone clinics has caused considerable opposition from the surrounding neighborhoods, and heroin dispensaries would be likely to generate much stronger resentment. The amount of traffic per addict to a heroin clinic would be considerably greater than to a methadone program because of the larger number of visits necessary, and the short time between injections would tend to induce those addicts who had nothing else to do to congregate in the area, either nodding from their last shot or waiting around for the next.

This would raise community objections on a host of grounds; many would protest on the ground that the congregation of addicts near the clinic might become a magnet to the youth of the area, and because, if past experience is any guide, the areas where addicts gather soon will become prolific sources of both petty crime and unsightly litter.

Moreover, the small area served by each on-the-premise heroin clinic caused by the necessity of minimizing travelling time, would increase the difficulty of locating them outside of residential areas. Indeed, many of them would have to be located inside the ghetto rather than on its edges, a matter which would increase the political opposition to the clinics, and exacerbate their abrasions of the surrounding community.

This is not merely a public relations difficulty. The opposition of the clinics' neighbors would most likely be based on a genuine lowering of the quality of their lives-and one which would be differentially imposed on those least able to afford it.

As if this were not enough, we must consider the problem of the automobile. Although, perhaps in the crowded inner cities, most addicts do not drive cars, there are a larger number, perhaps a majority-in places like California-who do.

The difficulty here is that most addicts on heroin are simply not in good enough condition to drive, especially not just before and just after their injection. Heroin in this respect is quite unlike methadone where the longer-acting nature of the drug, plus the fact that it is taken orally, make its onset far more gentle. Even those addicts who are taking stable doses of heroin will not be in good enough condition to drive just after their injection, and should they be delayed in traffic on the way to the clinic, they may become a danger then. Entirely apart from any legal liability the clinic may incur, there is the simple fact of risk to those on the streets, and this danger will be most concentrated nearest the clinic.

The more one thinks about this problem, the more intractable it becomes. The clinic, in theory, could bar its patients from coming by car-but this would be unenforceable since they could simply park nearby and fie about their transportation. Moreover, as a practical matter, this might be the only way the addicts could arrive. We could, of course, simply provide taxi service or require that the addicts be chauffered by their friends. The costs and inconvenience of this kind of service, however, may simply price the whole program out of the market.

Indeed, it is the simple financial cost of the program that would probably raise the most serious obstacle to an on-the-premises heroin maintenance system. For a host of reasons on the-premises heroin maintenance is considerably more expensive than methadone maintenance. It is likely that an on-the-premises heroin maintenance system would cost some $15,000 per addict (Judson, 1975:116-117). perhaps this would still fall short of the total social costs per addict of heroin prohibition, but we must consider as well the serious problems of diversion and the many other costs which such a system would also add.

The General Costs of Heroin Maintenance

In addition to the particular costs raised by the nature of a prescription or an on-the-premises system, there are certain other difficulties inherent in every heroin maintenance scheme. First of all, we must remember that the very nature of heroin maintenance involves giving heroin to addicts. Indeed, that is their whole point. The problem is that, in the long term, heroin use, especially through intravenous injection, is not good for the addict's health (Platt & Labate, 1976:80). Heroin addicts, even the British addicts on legal heroin, have a far higher death rate than does their age group in the general population. So long as addicts continue intravenous administration, they will risk collapsed veins hepatitis , and a whole series of physical ailments. Moreoever, even though heroin seems relatively non-toxic, at least as compared to alcohol, the long-term effects of heroin addiction, even on a stabilized dosage and apart from the method of administration, are simply not known-and there is reason to believe they will prove adverse.

In addition, the fact is that many of those maintained on heroin will not be able to stabilize their doses. As a result, a sizable number of addicts may be left suffering from a virtually constant heroin euphoria as their tolerance develops and they receive increasing amounts of the drug.

The situation may even be more complex than this. A number of America's leading experimentalists in the opiate area have pointed out that gradually escalating heroin dosages do not continue to produce euphoria and that in the higher dose ranges, tolerance to euphoria develops more quickly than tolerance to certain unpleasant effects. As a result, in the place of euphoria "come negative mood changes such as irritability, suspiciousness, hostility [and that] ... sooner or later a state is reached at which disphoria predominates, [and] the interval between doses are more marked by withdrawal type discomfort." (Lindesmith, 1968). In either case, the effect of heroin upon the addict's ability to hold employment and psychological adjustment will put considerable strain on the physicians running the programs.

Presumably, they will attempt to stabilize the addict's dosage at not too great a level, despite the high likelihood of complaints that the dosage is not high enough. In England, when the clinics were prescribing heroin, the amount of the drug prescribed was a matter of negotiation, often adversarial, between the staff and the addict (Stimson, 1977). The staff was reacting not only to the social control aspects of their position, but also to the therapeutic undesirability of giving ever-increasing doses to addicts. At the very least, the constant tension between the physician's ideal of helping his patient and the desires of the heroin addict will result in serious staffing and administrative problems in any heroin maintenance program run under our medical model. And, at worst, stabilization can be achieved only at the cost of meeting so few of the addicts' wants, that they drop out of the entire program.

Another problem inherent in evaluating the desirability of any heroin maintenance program is the decision as to the addict's alternative. If the only alternative to being maintained on legal, cheap and pure heroin were the life of the junkie, we could probably agree that those on heroin maintenance would be better off. The choice, however, in many cases, will be between heroin maintenance and no addiction at all. Despite the once-an-addict, always-an-addict myth, we know that many addicts give up addiction after relatively short periods and before they have built up too great a habit. Usually they do this because they fear the disastrous consequences of continued addiction, because of the problem of locating and affording a supply, and because the heroin scene is too much of a "hassle" for them. Moreover, even among long-term addicts, perhaps a majority, "mature out" and give up addiction after the age of about 35 (Platt and Labate, 1976:193). If heroin maintenance is attractive and easy enough to attract addicts into the treatment, it is quite likely to attract them to stay, and, hence, to put a great deal more truth in the once-an-addict, always-an -addict myth.

In addition, heroin maintenance of any kind is likely to put more truth into the myth that every heroin user is likely to become addicted. The most obvious reason for this is that the heroin user may simply prefer life in even an inconvenient on-the-premises system to his present drug use pattern. One reason is that he may enjoy the drug and find it easier to secure through the maintenance system. Another is that certified heroin addiction may be regarded by welfare authorities as tantamount to an inability to work. We know that even membership in a methadone program has been so considered in some areas, and there is certainly no reason to assume that heroin maintenance will attract fewer seekers of welfare payments. Moreover, with respect to them, it may be more correct to conclude that their addiction is incompatible with productive work (Moore, 1977:89-98; Caplovitz, 1976:64-81; Kopell & Tinklenberg, 1978; Platt and Labate, 1976:251).

It is true that a maintenance program could be run with considerable care to deny almost all but the most clever and determined non-addicts' access to legal, low-cost heroin. It turns out, however, that it is by no means easy to determine who is and who is not an addict. Urine tests can tell whether a person has used heroin within 48-72 hours, but not whether he is addicted (Kaistha, 1977). Although we tend to use the term addiction as if it were a precise, either-or condition, the fact is that it is a very imprecise term. Often the question of addiction will turn out to be a question of degree-and even then one dependent upon the expectations of the user. Moreover, though there are certain tests, such as injecting an opiate antagonist, which will, for the most part, throw an addict, but not a mere user, into withdrawal, there are disadvantages in this somewhat drastic method of screening. First of all, it requires considerable care and skill, and second, it is likely, at the least, to make signing up for the maintenance program considerably less attractive to those who are addicted.

One of the great problems with methadone maintenance is that the programs are very rarely as well run as, in some ideal sense, they should be (Epstein, 1974; Moffett, 1974; Vorenberg & Lokoff, 1973; Maddax & Bowden, 1972; Inciardi, 1977). Indeed, this is true of the criminal law-and just about every other social institution one might name. Bureaucratic problems always develop; empire building by individuals within the organization always requires that the component parts try to expand and negate the restraints upon their growth often until their budgets are cut; whereupon they economize where we can least afford it. Even on the individual level, people are not always as intelligent, well-motivated, hard-working and honest as we would like. There is certainly no reason to believe that heroin maintenance programs would be an exception to these iron laws.

As a result, we must be careful to do more than merely consider how heroin maintenance would work in a perfect world. After all, in a perfect world we would probably not have heroin addiction to begin with. Rather, we must consider how heroin maintenance would work with the imperfect human beings and institutions that would, in fact, run it.

Even where the non-addict wishing to join a maintenance system cannot convincingly feign addiction, the staff may be too busy or burdened to notice this. And, if our experience with methadone maintenance is any guide, it is likely that patients and staff will often collude (Fleetwood, 1977). The prospective patients, as we have seen, may counterfeit addiction for various reasons while the staff ignores the safeguards meant to bar non-addicts, both because the support for such clinics is based on a per-patient payment and because they are sympathetic with the -reasons the non-addict wants to join. If, in practice, this and more can go wrong with maintenance on methadone, a much less troublesome and less attractive drug than heroin, we would have to expect that considerably more would go wrong with any heroin maintenance system.

Another cost which must be allocated to any heroin maintenance system is its adverse effect upon those already in methadone maintenance. It seems quite clear that the great majority of those in methadone maintenance would prefer heroin-if they could get it without too much difficulty. Nonetheless, there are large numbers of addicts who have adjusted to methadone and seem to be leading productive, non-criminal lives. The institution of heroin maintenance, whatever good it would do for those who have refused our present treatments, would be very likely to undermine the advantages of methadone, even to those who could, in fact, adjust to that more convenient and more therapeutic drug.

It is likely that any clinic offering a choice between methadone and heroin maintenance would find its methadone rolls considerably undersubscribed. Nor could it insist as a condition of receiving heroin that addicts try methadone first. The preliminary period on methadone before switching to heroin might make that so lessen the attractiveness of the entire program that it would lose much of its appeal to street addicts. And, unless the heroin maintenance scheme was very extremely inconvenient, the addict would have an enormous incentive to fail during the trial period on methadone.

A more problematic effect of heroin maintenance is perhaps even more worrisome. The cultural constraints against heroin addiction, and even against simple use, are probably a major factor in keeping down the present number of addicts. It is true that maintenance, with its implication that heroin addiction is a sickness, would probably not cause so great a change in our cultural view of heroin addiction. Nonetheless, certain facts about heroin maintenance would tend to lower the cultural aversion to use of the drug. The mere fact of large scale legal supply of the drug by the government and by the medical profession might broadcast the message that heroin is not that bad. And the very fact that addiction would be less threatening where the addict could be maintained without great difficulty on the very drug which had caused his problem might weaken the simple fear that many have of initially trying the drug and the social disapproval with which they regard anyone who does try it.

On the other hand, this is by no means obvious and it is possible that the greatest benefit of heroin maintenance would be that it might change our cultural view of the drug. Oscar Wilde once wrote, "as long as war is regarded as wicked, it will always have its fascination; when it is looked upon as vulgar, it will cease to be popular." 'Me same may be true of heroin addiction. It can be argued that the more we treat addiction as a sickness, the less glamorous and attractive it might become. And, if heroin maintenance were easily available to addicts, risking addiction would become much less reckless and dangerous and therefore less productive of status among one's peers. Finally, even if the cultural controls on heroin use and addiction might temporarily be weakened, both the "demystification" of the drug and the increased experience with it which heroin maintenance might bring, could speed the development of cultural controls which may be the best safeguard against the social damage caused by uncontrolled addiction.

Even when this somewhat problematic advantage of heroin maintenance is added to the more obvious benefits involving those present addicts who would fare best on legal heroin, it would seem that the balance tilts fairly heavily against both the prescription and the on-the-premises systems. It is possible, of course, that some yet unthought of method will produce better results; but, it must be acknowledged that no one so far has come up with a specific plan that seems much better than either of the extremes we have discussed. And, if the more general comments on heroin maintenance are correct, it is not very likely that they will be able to do well enough.

It is common in discussions of heroin maintenance to suggest, at this point, that we mount a small scale experiment to find out something that may help us (Platt & Labate, 1974:255; Waldorf & Reinarman, 1974; Fink, 1977). Typically, this would take place in some area that doesn't have a serious heroin problem. It is very difficult on principle to oppose an experiment, but it is hard to see what such an experiment could prove. Presumably, where heroin is not a problem, heroin maintenance will not be much of a problem either-at least in the short run; and, if we demand the same kind of rigor in addressing the cost and benefits from such a proposed experiment as we would from a proposed program, the case even for a limited, controlled, isolated, small scale, or what-have-you experiment with any form of heroin maintenance has not been made either.

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