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."