It was bad enough that Michelle had to pee in front of strangers in the Orange County jail cell. The Miami woman couldn't get ahold of the narcotic she had used daily for nearly fifteen years, and she suffered severe withdrawal symptoms. To rise out of bed without putting pressure on her throbbing lower back, she gripped with both hands the pipe that connected the top and bottom bunks, swung her legs around, and rested her feet on the cold concrete floor. The smell of disinfectant, deodorant, and dust that hung in the air nauseated her. Once standing, she trudged to the toilet, where she struggled with stiff fingers to unsnap her regulation blue uniform.
Turned out it didn't matter about peeing in front of strangers anyway. All the other women in the cellblock were asleep; the rows of bunks -- occupied by nearly identical lumps of human flesh covered by gray blankets -- gave the impression of being empty in the dim light. Michelle shivered. If only she could have rested for a while. Just shut her eyes for more than a few minutes.
That was in August 1996, her second jail stint. Thirteen years earlier the cops busted her when she was mainlining Dilaudid, a synthetic morphine compound. Back then, she explains now, her supplier had stolen a car, and she was charged as an accessory to grand theft. An Orange County judge later dismissed the charge after she had been in jail for 21 days.
Then in July 1996 Michelle and her husband were watching television at their North Dade home when Metro-Dade police officers knocked on the door. They informed her that they were arresting her on a fugitive warrant in connection with the 1983 accessory charge. The police weren't swayed by her arguments that the case had been tossed out. So she wound up back in jail, this time for two months, charged again as an accessory to grand theft.
But she refused to complain to the guards because she knew she had to seem tough. She just wanted out of that cell. Just wanted her drug. To warm herself, Michelle (she declines to use her full name for this article) placed her hands in her armpits and curled up on her stiff bunk, where she tried to nap. But sleep seldom came. "Withdrawal symptoms hit you heavy, like all the flu symptoms at the same time: backache, sweatin', freezin', diarrhea, throwing up -- all those," Michelle relates. "And no sleep, no sleep at all, hardly ever."
During the two months of mid-1996 that Michelle remained in that cell, she was wracked by bouts of insomnia, nausea, cramps, and cold sweats; they surged and abated in her body like rip tides. For 48-hour stretches she shook with uncontrollable seizures. Nightmares haunted her fitful sleep. "You think you are going to die," she recounts. "After three weeks you think it's over: 'I'm finally coming back to myself. I'm finally feeling normal.' But no, no. There's a second- and a third-stage detox. You're back. You're worse than you were at first."
A central Florida judge -- the same one who adjudicated the 1983 case -- finally determined that the fugitive warrant was a mistake and released her. Back on the outside she remained substance-free for about 40 days. Then, trembling with paranoia and anxiety, Michelle caved in to her desire for a drug many consider more addictive than opium, heroin, or morphine: methadone. "I was both coming off the drug and I was high-strung, nervous," Michelle recalls. "I had been used to being in jail with people watching you, saying, 'Do this, do that,' watching your most private functions. All of a sudden I had all this freedom. I was scared. Then there was the weakness of knowing what I would go through. Would I go back to using? Would I have seizures that would put me in the hospital?"
Her fears were understandable: Off and on for seventeen years, Michelle, now 35 years old, has been tethered to her regular dose of methadone, a legal, synthetic opium-based medication that two New York City physicians in the Sixties discovered could help wean addicts from heroin. But long-term addiction to opiates alters the brain's structure and creates a physical dependency that methadone neither cures nor curbs. It merely satisfies an opiate user's craving for about 24 hours, forcing him or her to re-dose -- often at a for-profit methadone clinic -- almost daily. Such a treatment regimen, known as methadone maintenance, can last a lifetime for some former heroin addicts.
These days when Michelle wakes up, her forehead beads with sweat and her hands turn cold as if she's undergoing withdrawal. Still, when she gazes in the mirror she can't help thinking how much she's improved in the five years since she stopped using Dilaudid, morphine, heroin, cocaine, and other addictive drugs.
She's put more than 25 pounds on her once spindly five-foot, nine-inch frame. Her highlighted brown hair is always clean. A fastidious dresser, she carefully applies makeup, checks the lines of her tweezered brows, and examines her manicured fingernails. She puts her hair into a neat high ponytail and slides antique gold rings onto her fingers. Quietly, alone in her bathroom, she exults in the self-esteem she's methodically built up. Then a twinge in her gut reminds her: She must take her methadone. "The good things about [methadone maintenance] is that you can get on your feet, you can save your money -- it helps you grow," she notes. "The only bad part is the shame: In your own heart you always feel like a weakling."
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."
Unlike methadone, heroin carries with it a range of other dangers -- deadly cardiovascular diseases, and the risk of hepatitis and HIV infection from dirty needles. Yet Vocci and an official who supervises drug and alcohol treatment for the state Department of Children and Families in Tallahassee acknowledge that the main hazards of heroin stem not from its chemical and physical effects but from its handling. Because heroin is sold illegally, its exact dosage and purity are always undetermined. But methadone is highly regulated and controlled by the state and federal governments, and therefore does not pose the same risks.
Ruiz argues that methadone allows users to 24 hours of relative normality so they can hold a steady job. On the other hand, he claims, heroin users lose their equilibrium because they move from illness to euphoria to lethargy several times a day, rendering them unable to function in a career. But neither Michelle, Gissen, nor Baumel would draw such clear distinctions between methadone and other opiates. "People can and do work while under the influence of heroin," Baumel observes. "Most of our patients are professionals. Some are surgeons. It's a little frightening. You never know who could be mainlining."
Michelle was waiting tables at a Chinese restaurant in Fort Lauderdale when she first injected herself with Dilaudid. The year was 1979; she was seventeen. She had fled from a violent broken home in New England, where her parents divorced after her father attacked her mother. Michelle sought refuge in Fort Lauderdale.
A casual marijuana and alcohol user, she came home from work one day and surprised her live-in boyfriend in their bathroom. "He was sitting on the toilet, one leg crossed over the other, one arm hanging down with a belt around it," Michelle remembers. "His mouth just dropped open, and the syringe was in his arm."
Though he tried to dissuade her from using Dilaudid, he ultimately provided Michelle with the tiny yellow tablets, which they mixed with hot water before sucking the substance into a syringe and injecting it. Michelle vomited the first time she used the drug; then the skin on her face became itchy and she felt drowsy. Euphoria came only after subsequent doses. Before a year was up both Michelle and her boyfriend had $100-a-day habits. She left the restaurant for more lucrative work as a topless dancer in North Miami.
She graduated from Dilaudid to heroin and cocaine within three years, and finally landed at Ruiz's NW 183rd Street clinic in 1981. But she didn't stop using illegal drugs for another seven years, drugs that showed up in her monthly urine tests at the clinic. "I didn't care if my urines came out dirty," she admits. "I didn't care if I had to go to counseling seven days a week. I didn't care about any punishment."
Michelle's work as a dancer continued throughout her consumption of narcotics. Patrons of the club helped support her habit by lavishing her with dope; they also bought her drinks and dinner. She didn't want to stop using the drugs, she explains now, because she wanted to stay thin. In 1983, after her boyfriend left Florida, she eventually took up with a small-time dealer who, over the course of their relationship, gave Michelle the necessary drugs for her to continue her habit for the next two years. "I know it's sickening to admit, but I was using around $400 in drugs a day," she recounts. "I didn't have to pay for it, but you pay for it one way or another. At the end of the day I paid for what I did. I don't just mean the sexual stuff. I'd clean his house. I'd accompany him if he wanted me to go to restaurants -- he wanted to go out and show me off. He was like a middle guy -- a handler and a user -- and he tried to make himself bigger and more of a honcho than he was."
But Michelle had become frighteningly thin -- she dropped to slightly more than 100 pounds -- and a family friend flew Michelle's mother, who worked as a nurse in New England, to Florida just to observe her daughter's condition and to see the dangers Michelle faced. Michelle didn't even bother to wash her scraggly hair on the day she met her mother in a Miami Beach hotel room -- but she remembers her mother's immaculate appearance. "That's the point I started to grow up," she says tearfully. "I saw my mother weeping and weeping when she saw me. She was wearing a gray wool dress and she had her hair done and everything. When I saw her face, it was like a precious Chinese vase shattering in slow motion before my eyes. She hugged me. She said, 'Honey, oh, honey, it's okay, don't worry, honey, it's going to be okay.'"
Her mother's visit hounded Michelle's conscience, but it would be several more years before she could surrender the daily high of her drug cocktails. Her first jail stint in 1986 made no impression on her. One time, after her release, she injected heroin cut with meat tenderizer; it caused a burning sensation in her veins and left a star-shaped scar on her hand. She was rushed to the emergency room. But the incident changed nothing. Her family friend began to telephone Michelle each morning to make certain she hadn't overdosed the previous night.
Michelle's mother and sister also called frequently, and her mother mailed her scientific studies detailing the dangers of the drugs she was using. In 1985 Michelle broke up with her dealer boyfriend, and her use declined from a $400 daily habit to what she could afford on her own: 100 milligrams of Dilaudid, which cost $100. She finally stopped using illegal opiates in 1989. She had been high on Dilaudid, cocaine, or heroin nearly every day for the previous decade. Finding money for her next injection had preoccupied her life. "You go for years and you're doing something illegal and addictive and kind of immoral," she muses. "You lose your self-respect, you lose your dignity. It would have ended up with death for me. There wasn't any jail or any institution about it. It would have been death.
"I just kept thinking, 'What do I have that's so bad in life?' and I started counting the good things, and the good outweighed the bad, and I was like, 'Why do I want to continue on like that?'"
Ruiz's NW 183rd Street clinic occupies a portion of an unprepossessing one-story office building. No external sign indicates its presence. The interior is drab and virtually windowless. A dull brown rug covers the waiting room floor; a row of plastic chairs lines the walls. Patients rarely dawdle here. It smells of dust and disinfectant. This is where Michelle comes six days a week (no Sundays) to get her methadone.
According to Dave Delesdernier, a former addict who used to be a client at the Comprehensive Psychiatric Center but is now under treatment at the Village, Ruiz discourages patients from lingering anywhere near the clinic, his reasoning being that it can be a magnet for the sale of illegal drugs. "You can score anything in the parking lot," Delesdernier contends.
A receptionist sits at a desk behind bulletproof Plexiglas near the entrance. She determines if Michelle has paid her current bill (it costs her ten dollars per day). Signs on the walls of all Ruiz's clinics issue the stern warning "Clients Behind in Their Payments Will Be Detoxed." Other signs provide a schedule for gradual weaning from the drug. If Michelle doesn't owe any money -- and today she doesn't -- the receptionist hands her a tiny paper ticket stamped with a number.
Michelle waits for a buzzer that unlocks the door to the treatment area. Once inside she makes her way down a hallway to a room where a nurse breaks three methadone tablets into a small paper cup and places it on a counter. (Michelle started her treatment taking 30 milligrams per day and is now up to 70.) The nurse pours hot water over the methadone. Michelle stirs the mixture and downs the sweet liquid in one gulp. She must speak to the nurse to show that she actually swallowed her "medicine." For the past three years, Michelle's urine tests have been clean, which means she can take her weekend doses home if she wishes. (State law requires that the clinic test a client's urine for six substances: tranquilizers, barbiturates, amphetamines, cocaine, heroin, and methadone. Tests for marijuana, hallucinogens, and Rohypnol -- the latter a sedative commonly mixed with alcohol -- are not required. A positive test for any of the six above-mentioned substances -- with the exception of methadone, of course -- does not result in a penalty. It means only that CPC clients are not allowed to take their weekend methadone doses home.)
Methadone sells for a dollar a milligram on the streets. Delesdernier says that while he was a patient at Ruiz's clinic he used to earn money to supplement his heroin habit by selling his weekend methadone supply. "Ruiz is easy, very easy," Delesdernier relates. "You can write your own ticket. You get take-home on the weekend -- for every month you have clean urine, they'll give you a day's take-home. After two months I had two bottles. By five months you have a five-day supply. I could sell [the bottles] for $45 each as soon as I walked out the door." (Ruiz says that he has no control over what happens outside his clinics.)
After taking her medication, Michelle heads out for some breakfast; she isn't allowed to eat until after she doses. Over the years a half-dozen of Ruiz's patients, including Michelle, have routinely congregated at a cafeteria in a North Miami strip mall on U.S. 441. There she chain-smokes, sips Cuban coffee, and catches up. Just as her life once gathered its force and purpose from illegal drugs, it now centers on this affable group of users and ex-users who have come to represent a family of sorts. One of them, a stocky man in his forties, often gives her money for the medication and buys her breakfast. Usually she repays him right away.
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They gather at the restaurant because Ruiz has forbidden them to chat in the clinic's waiting room or hanging around the parking lot. Michelle won't violate the rules. In fact, during the course of her methadone-maintenance treatment she has acquired an almost religious reverence for the clinic owner and his staff. She consults Ruiz about financial and personal problems and bares her troubles to CPC counselors each week.
Two years ago she quit her job as a topless dancer and married a man who loads freight for a living. Now that she can see past her next injection, she has begun to make plans for the rest of her life. Between jobs, she wants to return to school to develop a skill -- preferably working with computers. She also wants to have at least two children. A voracious reader who dabbles with writing, she dreams of publishing her autobiography.
But above and beyond these goals, Michelle yearns to end her dependency on methadone. "Even though you are an addict in recovery and you may not have touched anything for ten or more years -- you could be an office professional, a bus driver, a lawyer -- you are still drinking that little cup of juice that attaches a stigma to you," she laments. "It is a constant reminder of the past, when you were doing something really wrong.