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The man who sells methadone to Michelle violates no laws. He has no criminal record. He carries no beeper, no two-way radio. He owns a handgun but uses it only to protect himself during his trips to and from the sometimes dangerous neighborhoods in which he works.
Dr. Roberto Ruiz is a healer, not a dealer. But he enjoys a respectable profit anyway, providing approximately 500 South Floridians with their daily methadone dose at a rate of five to ten dollars. Four clinics operating under the name Comprehensive Psychiatric Centers (CPC) -- of which Ruiz is owner and president -- serve patients from Key Largo to the Broward County line. The largest of these is located on NW 183rd Street in North Dade, where two of his five children and stepchildren work. (The other Miami clinics can be found on NW 54th Street in the city and NW Second Avenue in North Dade. A fourth is in Monroe County.) Based on estimates and patient information supplied by Ruiz's staff, annual CPC revenues from selling methadone approach $1.5 million. Those earnings are expected to increase during the next five years as an expanding heroin epidemic drives more addicts to treatment.
The genial doctor downplays the profit-making side of his business, pointing out that he employs eighteen people, including an administrator, counselors, licensed practical nurses, and receptionists. And yet Ruiz, whose patients sometimes affectionately describe him as "the methadone king," owns a one-story bungalow in Gables by the Sea, a gated South Dade community. He drives a sleek, late-model black Mercedes.
This mixing of profits and healing irks some members of the local drug-treatment community who operate abstinence-based programs. It especially irks Matthew Gissen, executive director of the Village, a substance-abuse treatment center just north of downtown Miami. "What happens if you don't pay?" Gissen asks rhetorically. "You don't get it. What happens then? You go into withdrawal. In my estimation methadone is a good business -- as long as I have someone on methadone, they are going to keep paying the bill."
The problem, Gissen insists, is that methadone maintenance simply replaces one addiction with another. "It should be the last alternative after everything has been tried," Gissen argues. "It doesn't prevent drug use and it doesn't allow [users] to function at a high level. Instead we've given up and given them a sentence for life."
Gissen also questions the quality of the various services Ruiz's clinics provide. Under state law, for example, all drug-treatment programs are required to offer counseling. But while Ruiz's counselors provide patients with encouragement and advice, they do not give what the CPC owner calls "deep therapy" to help addicts change the behaviors or thought patterns that may have led them to abuse drugs in the first place. In contrast, residential programs such as the Village base their treatment on showing addicts how to reorganize their lives and their thinking so they will not need drugs.
Ruiz does not dispute Gissen's contention that addicts should learn to stop using all drugs, including methadone. But he asserts such a goal is unrealistic for some patients because addiction is a chronic disease. Not all patients can afford -- nor do they have the insurance -- to pay for long-term residential treatment, adds Ruiz, and not all addicts are good candidates for methadone. "We have refused people to be treated, because I don't think it's best for them," he explains. "For example a young person who says, 'I've been using heroin for about a year,' [that person] would benefit from an abstinence type of program."
According to Ruiz, the ideal methadone patient is one who has tried and failed to stop using heroin or other opiates on his or her own. "What about this guy who's a diabetic -- would you send him home without insulin?" Ruiz queries. "What about the guy who has depression -- do you send him home without Prozac? In medicine what do we cure?"
Debra Baumel administers CITA Americas, Inc., a for-profit treatment program for opiate addicts based at Mount Sinai Medical Center in Miami Beach. Using a relatively new medication called naltroxene, which curbs the craving for an opiate, CITA attempts to detoxify patients rapidly and to helps them stop using narcotics within six months. As Baumel explains it, methadone patients are the most resistant to detoxification and the most likely to relapse. She suggests that Ruiz's staff subtly encourages CITA's clients to return to methadone -- an allegation he denies.
Gissen's and Baumel's arguments sound all too familiar to Ruiz, who first treated heroin addicts with methadone at Jackson Memorial Hospital in the late Sixties; he later operated publicly financed maintenance programs in the Seventies, and opened his first for-profit methadone clinic in 1981. In the beginning, Ruiz points out, many in the treatment community believed, as Gissen does, that methadone should be used for short-term treatment. "We had unrealistic goals and expectations," Ruiz reflects. "We thought of putting people on methadone for three or four months and detoxifying them. We thought it was a magic cure, but that didn't happen."
Scientists have since discovered why methadone is so hard to kick: Unlike heroin, it binds with fat cells in the body. So while the worst symptoms of heroin withdrawal last only about three days, methadone withdrawal can last several weeks, even as long as several months in long-term users. "It's like having a tub full of water," says Dr. Frank Vocci, director of the medications division at the National Institute of Drug Abuse, located just outside Washington, D.C. "With heroin you pull the plug and it leaks out quickly. With methadone it's slower draining."