The treatment of opiate addiction, most notably heroin, with fixed daily doses of methadone, termed “methadone maintenance therapy,” was developed in the mid-1960s. Methadone, a long-acting synthetic opiate, can be administered orally, and its onset of action is slower than heroin, avoiding the typical “highs and lows” of heroin injection. Internist Vincent Dole and psychiatrist Marie Nyswander, both at the Rockefeller Institute, worked with addicted individuals treated with various forms of opiates. They found that those who had received methadone behaved in a way that differed significantly from those on short-acting narcotics. In between doses, they were calm and functional and were not consumed by the need to obtain more drugs. This led the researchers to develop a maintenance program, based on the idea that addiction was a metabolic disease, with a physiological need for the narcotic, just as diabetics required insulin. This was in stark contrast to common approaches at the time, which viewed addiction as a moral failing and evidence of personal weakness.Footnote 1 Dole and Nyswander began their first maintenance programs in 1964, with successful results published the following year in the Journal of the American Medical Association.Footnote 2 They particularly noted the “dramatic effect” of the “disappearance of drug hunger,” leading them to the optimistic belief that methadone could “block” the effects of heroin.Footnote 3 Although methadone did not block the pleasurable effects of heroin, it did reduce the craving for the drug, and repeated studies reported that providing oral methadone at fixed doses could maintain addicts and prevent their relapse into addiction.Footnote 4
Dole and Nyswander’s early results gained national awareness while simultaneously inciting controversy as to the advisability of providing addicts with the substance of their addiction. At a time in which abstinence-only programs such as therapeutic communities were popular, emphasizing a triumph of individual willpower over the allure of drugs, many saw methadone maintenance as a cop-out.Footnote 5 For instance, psychiatrist Herbert Kleber recalled a 1966 meeting in which a wary speaker quipped: “I think methadone maintenance is a great idea: we should give money to bank robbers, women to rapists, and methadone to addicts.”Footnote 6 Still, as early results with methadone maintenance aroused public and professional interest, addiction specialists across the nation developed similar programs that involved the use of methadone as a therapeutic measure. Furthermore, there was a dearth of effective treatments for addiction, most of which included a measure of detoxification and counseling, though some therapists attempted psychoanalysis. Most treatment facilities were targeted at individuals already within the justice system, and there were few options available to individuals in the community.Footnote 7 Therapeutic communities, residential programs derived from the twelve-step AA model, which advocated personal growth, responsibility, and group therapy, were the major modality prior to methadone maintenance treatment, and individuals could expect to stay from months up to two years in the program.Footnote 8 Thus methadone maintenance was quickly adopted because it showed potential in addressing the problem of addiction and its social ramifications. The first programs were developed in the mid-1960s in New York City, and were soon followed by programs in Chicago, New Haven, Philadelphia, Washington, D.C., and other major cities across the nation.Footnote 9
In this article, I focus on one D.C. program, begun by psychiatrist Robert DuPont with inmates in D.C. jails, which within a year developed into a large-scale, federally funded program, the Narcotics Treatment Administration (NTA). Due to its unique status, the District was the only local jurisdiction in which federal funding could be made available for municipal crime-reduction programs. Accordingly, the federal government could fund drug addiction treatment programs in D.C., billing these programs as a method of crime control.Footnote 10 Between 1969 and 1973, under DuPont’s leadership, this program expanded to become an influential model for treating addiction, and perhaps more saliently, for combating crime. DuPont published extensively in leading medical journals and gave testimony in multiple federal hearings. His work was closely followed and respected by Nixon’s advisers. In 1973, DuPont was appointed to lead the nation’s antidrug efforts, a position that was colloquially termed the “drug czar,” and officially the director of the National Institute on Drug Abuse (NIDA).
Historians of drug policy and addiction often call attention to the contradictions in the Nixon administration approach to drug abuse.Footnote 11 While Nixon is primarily known for his law-and-order tactics, his rhetoric of being tough on crime and drug abuse, and his emphasis on punitive approaches to drug abuse, he was also a staunch supporter of medical treatment of addiction. In this article, I examine the premises and structure of the NTA methadone maintenance programs. Methadone maintenance programs, alongside other harm-reduction interventions, have been viewed by some scholars as “liberal” interventions.Footnote 12 Here I show that these programs incorporated many aspects of surveillance and regulation, similar to those employed in the prison system, where the NTA was first developed. I argue that methadone maintenance programs, and the later federal regulations of the medical use of methadone, reshaped the roles of physicians and helped form their relationships with those men and women they cared for. These changes, I will contend, helped lay the groundwork for the involvement of physicians in the creation of a punitive approach to drug policy.
I focus on the types of therapy provided in the NTA programs and how they were administered, focusing particularly on the dispensation of methadone and the role of urine tests. I examine how the programs’ outcomes were evaluated by DuPont and his medical colleagues, as well as by policymakers. While the intervention was at the level of the individual—providing methadone for men and women addicted to heroin, the main criteria for success, I show, was social, a reduction in crime. I then follow the development of federal regulations for methadone treatment in the early 1970s. In particular, I examine how the early model of methadone maintenance treatment both incorporated “law-and-order” aspects of drug policy into its own therapeutic framework, and how it helped propagate a body of knowledge that emphasized the criminal behaviors that were the result of addiction. Ultimately, evidence of efficacy in crime reduction helped establish methadone maintenance as an effective treatment in heroin addiction, thus indicating the interrelations between theories of criminality and of mental health, and demonstrating that defining therapeutic success for a certain medical practice relied on criteria removed from the medical realm.
President Nixon had set forth a law-and-order campaign agenda in the 1968 elections, widely conceived as riding on the backlash against the Great Society interventions of the mid-1960s. In particular, the urban uprisings and civil unrest of the late 1960s, and the subsequent report of the National Advisory Commission on Civil Disorders, known as the Kerner Commission, led to two opposing views of the roots of these violent urban events.Footnote 13 While many liberals attributed the urban unrest to ongoing racial disparities, viewing it as evidence of an urgent need to address structural inequalities, many political and racial conservatives saw these “race riots” as evidence of the failure of liberal policy and a need for harsher law-enforcement intervention.Footnote 14 Nixon’s presidential race highlighted the “wave of crime” in America, dedicating seventeen speeches solely to the topic of law and order.Footnote 15 Even at the time, critics recognized that this “law and order” agenda was a form of racial (and racist) conservatism, as enforcement disproportionately targeted communities of color, and shifted focus from an attention to structural inequalities to a backlash against poverty intervention. This “Southern strategy” helped Nixon secure votes in southern states, particularly competing against the Independent candidate, segregationist George Wallace.Footnote 16 Still, while law and order was a central platform for Nixon’s 1968 election, drugs were not a main focus of concern for the Republican presidential campaign. Yet by 1970, particularly with reports tying criminality to drug use in urban environments, Nixon’s administration turned its focus to drug policy.Footnote 17 Against this backdrop, this article examines the Nixon administration’s response to the rise of methadone maintenance therapy.
Little has been written about the structure of early methadone maintenance treatment in the United States and how it shaped current drug policy. Historian Samuel Roberts has examined the history of methadone maintenance programs in New York City, arguing that they provided a means by which to circumvent addressing structural challenges in minority communities.Footnote 18 James Nolan has written a nuanced exploration of the “therapeutic state,” examining how principles of therapy have become a dominant feature of the American state. He has written compellingly of the rise of drug courts (first established in Florida in 1989), and how a therapeutic discourse pervaded the judicial system, with judges taking on roles of pseudotherapists.Footnote 19 Nolan, who has not studied methadone maintenance, analyzed the emergence of a therapeutic discourse within the judicial system.
Other Foucauldian scholars have focused on the normalizing effects of psychiatric therapy and the implicit discipline and surveillance aspects in different forms of psychiatric intervention.Footnote 20 Some more extreme views, such as those of psychiatrist and well-known critic of psychiatry, Thomas Szasz, have rejected the very notion of addiction. Comparing the medical establishment’s “Holy War on drug abuse” to the Inquisition, Szasz questions distinctions between legal and illegal drugs, and between “accredited and non accredited tempters,” comparing physicians providing methadone to “pushers” who “prostitute themselves as state-salaried addiction mongers.”Footnote 21 These extreme views were not part of the mainstream discourse on methadone maintenance, but they are still informative in mapping the boundaries of contemporary views on methadone.
In his ethnographic studies, Philippe Bourgois has shown how methadone maintenance therapy serves as a disciplinary mechanism to control the “hearts, minds, and bodies of deviants who reject sobriety and economic productivity.”Footnote 22 A similar study of methadone treatment in Australia described it as “disciplining” the addict.Footnote 23 In contrast, my goal in this article is to follow the interrelations between methadone maintenance and its structure of surveillance and the formation of the Nixon administration drug policy. Rather than delving into a Foucauldian analysis of the power structure of the methadone maintenance program, or exposing the normalizing functions of the program’s implicit goals (which I am sure lend themselves well to such an analysis), I am interested in its historical development, and how it interacted with centers of power in the federal government and with policymakers.
The NTA’s Early Years
The origins of the NTA were in a study conducted at a D.C. prison in 1969. Robert DuPont, a promising Harvard-trained psychiatrist, had completed two years working at the National Institutes of Health to fulfill his obligation under the physician’s draft. Unlike most of his peers who then went back to academic medicine or private practice, DuPont sought a different pathway to make a social contribution, accepting his first job as a psychiatrist in the D.C. Department of Corrections in the summer of 1968.Footnote 24
The late 1960s saw an unprecedented rise in narcotic-related arrests in D.C. While much of this may be attributed to a significant increase in heroin use during that decade, other factors came into play. With the 1963 Community Mental Health Centers Act and the ensuing deinstitutionalization of mental health care, many vulnerable individuals, some of whom were already narcotics users, rejoined urban communities.Footnote 25 Many soon found themselves exchanging the mental institution for the prison.Footnote 26 Furthermore, as historian Kathleen Frydl has argued, the D.C. police came under public scrutiny for incidents of racism and excessive force, and for discretionary arrests for “vagrancy,” public drunkenness, and disorderly conduct. Narcotics arrests, previously carried out almost solely by the D.C. narcotics squad, were now under the purview of patrol officers, who received additional training to identify narcotics suspects. Soon these narcotics arrests replaced and significantly outnumbered the contested “discretionary” arrests of previous years.Footnote 27 Thus narcotics arrests multiplied by the late 1960s, leading to a perceived rise in narcotic-related crimes. In addition to the rise in narcotics-related arrests, there was also a steady rise in both property and violent crime in the District.Footnote 28
Prompted by the high number of narcotic offenders in D.C. jails, as well as new statistics pointing to the interrelations between crime and drug abuse, in the summer of 1969, DuPont and his colleagues set to examine the prevalence of heroin use among D.C. inmates. From an estimated 1,000 male offenders incarcerated at a D.C. jail, DuPont and his colleagues interviewed 225 individuals, and collected a total of 129 urine samples from those interviewed. These samples were collected on the basis of availability and did not reflect the responses given to the interview questions. The researchers found that an astounding 45 percent of the inmates studied either reported their addiction to heroin or had positive urine studies, or both. The study also estimated that this habit had cost the inmates, prior to incarceration, approximately $44 a day. DuPont and his colleagues concluded that nearly one out of every two inmates in D.C. was a heroin addict, and that the high cost of the addiction posed a “very real threat to property as well as to person in the community,” as “addicts” turned to crime in order to support their expensive habit.Footnote 29
Ultimately, the study argued, addiction and crime were intrinsically linked, as crime was essential to maintain the cost of addiction. Thus an effective crime prevention program would have to address addiction. Although published only in 1972 in the International Journal of the Addictions, a full description of this report was circulated locally, and it aroused considerable interest among policymakers and corrections professionals.Footnote 30 That addiction often led to crime that previously had been widely accepted, yet the extent and the cost shown by DuPont and his colleagues were striking.Footnote 31 Accordingly, this study was also presented as an appendix for the 1971 House Select Committee on Crime.Footnote 32 The two key findings of this study—the percentage of inmates thought to be addicted to heroin and the daily cost of the addiction—were cited by numerous researchers, despite being based on a small sample in a single intervention, and were cited by DuPont in his subsequent appearances in federal hearings. In June 1971, President Nixon cited similar statistics, although unattributed, estimating the price of addiction between $30 and $100 a day for each individual.Footnote 33
On the basis of this early study, the following month DuPont, in conjunction with the Department of Corrections (DOC), developed his first pilot program with methadone maintenance, called the Narcotic Addict Rehabilitation Corps (later also referred to as Narcotics Addiction Rehabilitation Center).Footnote 34 The NARC program’s original goal was envisioned as reducing “criminal behavior among long-term criminal heroin addicts committed to the D.C. Department of Corrections,” with a secondary goal of researching “the inter-relationships of criminality and heroin addiction and to develop more effective treatment programs.”Footnote 35 The initial participants were volunteers from the Department of Corrections, with priority to those on work release and those who had been paroled and were now again using heroin.Footnote 36
Its goals were threefold: stopping illicit drug abuse, reducing crime, and increasing employment rates.Footnote 37 Initially participants were required to live in a residential program, termed the “NARC Community Correctional Center,” with progression of privileges including working in the community, followed by living at home, and ultimately paroled with the supervision of trained parole officers. Furthermore, all staff members and participants were required to provide regular urine samples for drug monitoring and submit to breath analysis for evaluation of alcohol use.Footnote 38
While clearly relying on methadone maintenance, this program initially incorporated aspects from a different modality common at the time, the therapeutic community, which was also common in prison environments. These communities emphasized personal responsibility and strict discipline in a residential setting, with gradual progression of privileges. Yet therapeutic communities espoused a strict abstinence-only approach, as opposed to the methadone maintenance program, and soon, as historian Claire Clark has shown, these two approaches were seen as diametrically opposed to each other.Footnote 39 Proponents of therapeutic communities emphasized individual transformation and complete abstinence from drugs, viewing methadone as a “crutch” at best and a malignant addiction at worse.Footnote 40
This initial small-scale DOC program served as the impetus for the development of a program for the larger D.C. community. DuPont, together with the district’s Director of Public Health, Murray Grant, submitted in fall of 1969 a proposal for a methadone maintenance program in the nation’s capital. By 1970, the program received federal funding and became the Narcotics Treatment Administration, moving out from the prison and into the community, designed to provide treatment for all addicts in the D.C. area.Footnote 41 While the initial proposal was for a methadone maintenance program, with a plan to experiment in an experimental group with the gradual tapering from methadone, ultimately the NTA was funded as a “multi-modality” treatment program.Footnote 42 Accordingly, three main treatment options were available: abstinence, in which individuals were counseled on maintaining a drug-free life, often within a residential program setting; detoxification, which relied on tapering doses of methadone until it was discontinued; and methadone maintenance, which relied on a daily use of methadone to prevent the use of illicit drugs.Footnote 43
The program expanded as the NTA sought to provide community treatment to addicts throughout D.C., and within three months it was treating 734 adults and 181 youths at four program facilities.Footnote 44 By March 1971, 2,700 adults were in regular treatment by the NTA program in fourteen different facilities.Footnote 45 The program’s population at the time was 95 percent black, 80 percent male, and 60 percent under twenty-six years old. Three-quarters of the patients were voluntary self-referrals, and the remaining were referred from criminal justice agencies, a significant change from the 1969 pilot program, which had targeted released prisoners.Footnote 46
DuPont was quick to publish and present the early results of this program in journals and at conferences. While he invariably published in leading medical journals, the focus of his articles was on the reduction of crime. A few of his 1971 NTA publications included “Development of a Heroin-Addiction Treatment Program: Effect on Urban Crime” in the Journal of the American Medical Association; “Heroin Addiction Treatment and Crime Reduction” in the American Journal of Psychiatry; and “A Profile of a Heroin-Addiction Epidemic,” in the New England Journal of Medicine. These and DuPont’s other early articles included many of the same arguments and graphs concerning crime rates in the nation’s capital. DuPont interpreted the data as follows: D.C. had experienced an abrupt increase in crime between 1964 and 1968, which followed a rise in heroin abuse and addiction. After 1969, there was a significant drop in crime rates in the capital, which DuPont attributed to increased police presence and effectiveness, and to the success of the NTA.Footnote 47
In evaluating the program’s success in treating individuals with drug addiction, DuPont examined the following outcomes: arrest rates, retention in the program, increased employment rates, and abstinence from illicit drug use, as documented by periodic urine drug tests.Footnote 48 Similarly, these data were sought out by politicians and policymakers in order to determine the efficacy of drug-prevention programs. Thus the NTA was particularly influential in comparison to other methadone maintenance programs in major cities by virtue of DuPont’s prolific publications and his activism in engaging with policymakers.
Nixon’s trusted aide, a young lawyer named Egil Krogh, served as liaison to the District of Columbia and was closely involved in attempts to decrease the city’s crime rate. As common wisdom tied crime with narcotics use in the nation’s capital, Krogh soon became the main go-to figure in the District’s attempt to fight what was seen as a “heroin epidemic.”Footnote 49 In July 1970, Krogh prepared a memo for the domestic affairs council staff, expressing satisfaction with the NTA’s achievements, as measured in its success in achieving its three “paramount” goals: stopping illegal drug use, stopping criminal activity, and promoting full-time work or training.Footnote 50 He included a letter from methadone expert Vincent Dole to Maryland senator Joseph Tydings, describing the former’s visit at the NTA in May of that year. Dole was enthusiastic about the NTA, predicting that “as measured by the reduction in total crime and antisocial activity,” the NTA would have the “greatest impact on narcotics addiction of any program in the country.”Footnote 51
In April 1971, DuPont testified before the Congress Select Committee on Crime, a committee headed by Representative (and former Senator) Claude Pepper (D-Fla). DuPont and other experts’ testimony on drug use and treatment demonstrate how closely drug-treatment programs and crime reduction were tied at the time. DuPont was asked to provide information about the NTA program, particularly in light of the committee’s interest in the “efficacy” of methadone maintenance programs and the “decrease in crime rate or illegal activity.”Footnote 52 DuPont provided statistics about the number of individuals currently in treatment in the “multi modality” program and the breakdown by treatment approach. At that time, there were 3,106 individuals in treatment, 1,760 on methadone maintenance, 633 on methadone detoxification, 631 in abstinence programs, and an additional 82 receiving emergency treatment with methadone prior to enrollment in any specific program.
DuPont also addressed the retention rate in the program and the strong correlation he found with methadone maintenance treatment and even with the dosage of methadone given. Patients in abstinence programs had high dropout rates, whereas patients dosed with 60 or more milligrams of methadone had an 86 percent retention rate.Footnote 53 Thus, providing methadone at higher dosing facilitated retention—one of the program’s main goals.
DuPont then confidently addressed the interrelations between drug use and arrest rates. Based on information provided from the Department of Corrections, DuPont found lower arrest rates among program participants overall, in comparison to re-arrests among released narcotics-involved offenders prior to the establishment of the NTA. Furthermore, the longer individuals stayed in the program, the lower their arrest rates. However, for reasons of privacy, data regarding arrests that did not lead to incarceration were not released to the program. Undeterred by this setback in obtaining such confidential data, DuPont noted that he and the NTA were actively attempting to access this privileged information from enforcement agencies.Footnote 54 In terms of the kinds of crimes narcotic users were likely to be involved in, DuPont cautioned that “anybody who is reassured by thinking that heroin-addiction-related crime is confined to shoplifting, prostitution, and drug sales is sadly mistaken.” Nearly half of “criminal homicides” in D.C., he warned, were committed by addicts.Footnote 55 Answering Chairman Pepper’s specific question as to the relationship between addiction and crime, DuPont noted that addiction “absolutely” was linked to crime, including crimes against persons, and not simply property crime. Again relying on the figure of approximately $40 a day to support a heroin addiction, DuPont addressed questions of the extent of criminal activity needed to support this habit, concluding that in D.C. alone $200 million a year of criminal activity was probably “a low estimate.”Footnote 56 Of note, the focus was on individual criminality, rather than on networks of illegal activity, or on the spread of what DuPont had repeatedly termed an “epidemic.”Footnote 57 This was a highly individualized view of both the cause and treatment of addiction, and accordingly, the proposed solution of methadone maintenance was focused at the individual level.
Urine Testing
Urine testing played a pivotal role in the practice of methadone maintenance programs. Although the advent of widespread urine tests to evaluate for the use of drugs is often tied to 1970s programs targeting returning soldiers from Vietnam, its history in fact begins earlier. In the early 1960s, publications on the commercial use of urine-testing techniques to identify illicit drugs began appearing in the medical literature. A year after his first article was published on the use of methadone maintenance, in 1966 Vincent Dole published a new technique to evaluate urine samples for evidence of narcotic use, specifically designed to evaluate large numbers of samples “to meet the needs of a large-scale treatment program.” The tone of the article is noticeable for its reliance on nonmedical terminology and concepts. For instance, the requirements of the testing technique included “being dependable enough to exclude false-positive reports that would tend to incriminate innocent patients.” Although not explicitly stated, clearly the urine tests were designed to identify noninnocent, and thus “guilty,” individuals, highlighting the role that concepts of criminality played in the development of these programs.
From their inception, methadone maintenance programs relied on the use of urine tests to determine whether the individual initially presenting for treatment was in fact addicted to heroin by identifying metabolites in their urine. Urine tests were subsequently used to follow whether he or she was using heroin or other illicit drugs.Footnote 58 The technology and utilization of urine testing, which historian Nancy Campbell has described as a “technology of suspicion,” were described in detail in subsequent publications by researchers and practitioners at methadone clinics.Footnote 59 For instance, a 1970 article addressing the appropriate schedule of urine testing argued that it was necessary to insist on having urine samples produced under observation of a staff member, as it was “just as reasonable to accept the addict’s assertion that he has taken no opiate the previous day, as to accept his assertion that a given urine specimen is his own.” Urine tests, the authors argued, had to be random and unexpected, observed, and sensitive in order to be useful in the setting of large-scale methadone programs.
The use of urine testing also appeared in the 1971 AMA guidelines for methadone maintenance programs. While at first there was some debate as to the significance of positive urine samples—meaning urine samples that showed evidence of illicit drug use—in the early 1970s programs began translating these findings into action. For instance, a 1972 article in the International Journal of the Addictions addressed the “clinical implications” of urine testing. All methadone maintenance programs rely on “urine surveillance,” the authors argued, in order to better treat individual patients, but also to provide evidence of efficacy “to supporting agencies and the public.” The article described changes made in their methadone maintenance program, designed to translate the findings of these urine tests into clinical intervention. Over a course of eight months, the program underwent changes in structure, defined in time blocks as preprobation, probation, and postprobation months, which allowed for the development and enforcement of new rules regarding both individual behavior and the repercussions of urine positivity. Two positive urines in the probation and postprobation months led to “discharge of violators” or “termination” from the program. Of note, older age and black race were cited as being statistically correlated with urine positivity. The nonmedical terminology resonating in law-enforcement discourse is no accident; the authors describe how their approach to urine positivity changed from “permissive” to “punitive.” However, they cautioned that the urine positivity ideally should be used to identify individuals who needed closer attention, and not to determine who would be forced to leave the program.Footnote 60 Although this was the authors’ recommendation, this was not the approach in the NTA, nor was it that adopted by policymakers.
In D.C., the NTA relied heavily on urine testing to evaluate the program’s outcomes and success, and it had been part of its structure from its first implementation in the DOC. As the NTA began working with computerized systems in the early 1970s, data on urine testing were analyzed and reported through the NTA’s new Bureau of Computer Systems. This system provided reports including data of all urine tests of patients at a certain treatment center by week and created individual patient profiles, including the percentage of “dirty urine tests” and a “urine and counseling summary” report, which provided information on a monthly basis as to how many patients provided urine specimens, as well as how many patients received counseling and the total number of counseling sessions.Footnote 61 This terminology was also adopted by patients, as they referred to their own urine tests as clean or dirty. One former heroin user in New York noted proudly, “I got on methadone, and I’ve never had a dirty urine.”Footnote 62
Elsewhere, DuPont referred to the twice-weekly urine testing as part of the “routine NTA data collection system.”Footnote 63 In fact, by 1972 the NTA offered a separate service of urine surveillance, offered for patients “needing to demonstrate they can remain drug free” such as those “awaiting court action” or required to prove abstinence for a motor-vehicle license.Footnote 64 The urine testing in the NTA, however, did not serve to tailor different therapy or refer patients to more intensive intervention, but rather was a sign of program adherence or lack thereof.
In fact, urine testing at methadone clinics was one of the earliest instances of routine reliance on observed urine samples to screen for illicit substances, well before this practice became commonplace in other fields, such as competitive sports.Footnote 65 Urine surveillance later became widespread, as President Reagan enacted Executive Order No. 12564 in 1986 requiring federal workplaces to screen for drugs, to ensure a “drug-free work place,” a practice now familiar to us from large private-sector organizations, schools, and medical organizations.Footnote 66
Methadone, the NTA, and a New Drug Policy
Jeffrey Donfeld, a young lawyer and domestic policy staffer, was a staunch conservative and deeply committed to countering drug abuse, even before it became a battle cry for the Nixon administration.Footnote 67 Donfeld worked closely with Krogh on drug treatment in D.C. In June 1970, Donfeld set out to evaluate five different narcotic treatment programs in New York and Chicago and interview experts, including psychiatrist Jerome Jaffe, head of the drug-abuse program in the Illinois State Department of Mental Health. Jaffe headed a multimodality addiction rehabilitation program in Chicago, which incorporated methadone maintenance therapy.Footnote 68 On his return, Donfeld submitted a report he titled “Different Strokes for Different Folkes [sic].” He praised Jaffe’s program, and noted he was particularly taken by Jaffe, who “was not a dogmatist, he thinks in broad management terms, is politically sensitive and recognizes that modalities must be meticulously evaluated in order to empirically determine success.” Jaffe’s program’s goals, according to Donfeld, were threefold: “a) prevent crime, b) develop productive, tax-paying people, and c) stop the use of illicit drugs.” Donfeld was especially impressed by Jaffe’s managerial capabilities and political savviness, noting that Jaffe always “made sure he could deliver more than he promised.” In particular, Donfeld noted that the “different strokes” idea, which was how he colloquially referred to Jaffe’s multimodality approach, was politically prescient. Jaffe was quoted as cautioning Donfeld that “the political price of methadone will be escalated by the blacks who will argue that you are trying to addict them.” Thus Donfeld observed, “Jaffe sells his mixed modality approach though he believes that 90 percent of the addicts will require methadone.” Ultimately, Donfeld concluded, the mixed modality approach was “political protection.”Footnote 69
As both heroin use and crime increasingly became racialized in the late 1960s and early 1970s, methadone maintenance was seen as targeting particularly urban black communities, with the goal of reducing crime.Footnote 70 African American activists and journalists warned against becoming dependent on a drug provided by the government, in the form of federally funded methadone programs. Black activists warned against what they perceived as a “genocide” and form of enslavement, by means of a new addiction.Footnote 71 In 1971, future Pulitzer Prize–winning journalist William Raspberry cautioned that methadone maintenance could become “a device for rendering our angry young people docile and harmless to society at large.”Footnote 72 Thus Jaffe’s “political protection,” according to Donfeld, was particularly valuable at the time.
Donfeld’s praise for Jaffe’s program resonated amongst D.C. policymakers, and in late October 1970, Jaffe was brought to D.C. to head a committee of nongovernmental experts to provide recommendations on treatment and rehabilitation of individuals addicted to heroin.Footnote 73 The resulting Jaffe Committee Report highlighted the role of methadone as the basis of a federal program for drug rehabilitation. The experts warned, however, against presenting methadone as an “addiction panacea.” Rather, it noted that a decline in arrest and imprisonment rates were a “major justification for Federal funding” of methadone-based treatment programs, suggesting that the provision of fixed doses of methadone be presented as an effective intervention to minimize “(1) the crimes committed by addicts to get money for heroin, and (2) the profits of the heroin pushers and high-ups.” Furthermore, methadone could help the addicted individual “become a productive and self-respecting member of the community,” since the report that the cost of creating a “job holder” in a methadone maintenance program was lower than in competing programs of the time. Still, Jaffe’s report warned that methadone was not a solution to “the many economic, psychological, social and criminological symptoms of heroin addiction,” but noted that the goal of treatment should be “socially acceptable” behavior. Significantly, the report cautioned against simply distributing methadone and highlighted the need for a comprehensive, “multi-modality” approach that would encourage social rehabilitation. Although these services would certainly increase the program’s cost, they would have the additional benefit of dispelling criticism and suspicion of a federal program in which methadone would be dispensed regularly.Footnote 74
Bertram Brown of the National Institute of Mental Health (NIMH) headed a committee of experts that prepared a report on drug treatment. In contrast to the Jaffe Committee Report, the NIMH report was cautious, warning of a lack of data and evidence concerning drug-abuse treatment, and highlighted the need for further research.Footnote 75 The report cautioned against large-scale projects of unclear efficacy and offered modest goals of “minimizing” drug abuse, in contrast to the ambitious language of the time, which relied on both medical and military metaphors, waging “war” on drugs and curbing “abuse epidemics.”Footnote 76
Thus the NIMH report was largely ignored, while the Jaffe Committee Report was enthusiastically adopted. The latter provided the basis for Donfeld and his colleagues on the Domestic Council staff, who prepared a series of reports on drug policy options. Agreeing with the Jaffe report, the Domestic Council staff reviewed parameters including arrest rates, employment rates, and decreased daily use of heroin and annual costs per individual and concluded that “the federal government has only one economical and effective technique for reducing crime on the streets—methadone maintenance.”Footnote 77 Thus methadone maintenance was seen as a powerful tool to advance the Nixon administration’s law-and-order agenda. Accordingly, the Nixon administration embraced methadone maintenance as a main component of its approach to drug addiction. Shortly thereafter, Egil Krogh proposed the creation of a Special Action Office for Drug Abuse Prevention (SAODAP), which would be headed by Jaffe and would coordinate the federal government’s antidrug efforts. Treatment and, notably, methadone maintenance, would be a significant part of the SAODAP’s agenda.
The SAODOP and Methadone Treatment
Announced in June 1971, Nixon emphasized that the SAODAP would prioritize drug-abuse prevention and rehabilitation and would not be concerned with “the law enforcement aspects of drug abuse control.”Footnote 78 Jaffe would head the SAODAP, reporting directly to the president, becoming the foremost expert on drug abuse and prevention, a position that would later be described as the “drug czar.” As many historians have noted, a main impetus for this new interest in drug treatment was concern over drug use among soldiers in Vietnam, and the concern that they would return to U.S. cities with a newly acquired heroin addiction, made all the more dangerous by their military training. Although this did not prove to be the case, and the extent of drug addiction (rather than occasional use) among returning soldiers and veterans did not come close to the epidemic proportions predicted, this concern helped fuel interest in therapeutic approaches to drug use.Footnote 79
In March 1972, the SAODOP and its treatment-based approach were institutionalized by law with the Drug Abuse Office and Treatment Act of 1972, which provided for the creation of the SAODAP office. Curiously, this bill also had an expiration date, ultimately set for June 1975, after which the office would be dismantled, during Nixon’s predicted second term. The president had envisioned this office to be an “emergency response” to the national problem of drug abuse, and he promised a swift solution.Footnote 80 The law simultaneously created the National Institute on Drug Abuse (NIDA), which would be under the auspices of the Department of Health, Education and Welfare, and was planned to begin its work in December 1974, allowing for a short overlap.Footnote 81
The SAODAP’s main goals were to rapidly expand treatment available, and Jaffe specifically noted that one of the office’s main goals would be to make treatment “available that no addict could say he committed a crime because he couldn’t get treatment.”Footnote 82 The SAODAP developed a “capitated treatment system,” in which the government paid a certain sum for each year of treatment for an individual patient, in a variety of programs and approaches.Footnote 83 Although not openly endorsing one form of treatment over others, methadone maintenance programs expanded the most during this period, and the SAODAP worked to increase the number of such programs available nationwide, but also to institute regulations as to the proper use of methadone.Footnote 84
The early 1970s were a period of intense investment in federal measures to combat drug addiction. While both enforcement and drug treatment and prevention programs benefited from this additional support, the funding for therapeutic programs increased from $33.5 million in 1970 to $350.3 million in 1973, a tenfold increase, while the funding for enforcement programs increased from $8.5 million in 1970 to $45.7 million in 1973, a fivefold increase. By October 1973, more than seventy thousand individuals were enrolled in methadone maintenance programs nationwide, many of which were federally funded.Footnote 85 This was, as Egil Krogh would later recall, the “Camelot” period in drug policy.Footnote 86 Many heroin users were also satisfied with the availability of methadone programs and their effectiveness. One New York couple recalled, “It got so bad for me . . . I used to go to these stores to steal meat . . . me and the wife, and sell it so we could buy junk . . . once I got into the methadone program, I stopped everything. I was living again; I got back to my old self. . . . Methadone saved the whole situation.”Footnote 87
Looking back, historian Edward Jay Epstein has compelling argued that this approach was fueled by the Nixon’s administrations urgent need to reduce crime statistics, if not actual crime, prior to the 1972 Presidential elections. As most arrests were caused by narcotic violations, by providing methadone maintenance, narcotic violations in major cities would be reduced, resulting in a rapid decrease in crime statistics.Footnote 88 As historian David Musto has noted, by 1972 public interest in drug abuse and policy declined. This was also reflected within the Nixon administration as structural reorganization de-emphasized drug policy and treatment, favoring enforcement instead.
In 1972, Nixon established the Office of Drug Abuse and Enforcement (ODALE), which effectively waged the domestic war on drugs. Its officials, unfettered by state laws, could carry out warrantless raids, tap wires, and conduct “no-knock” searches, and zealously hunted down drug dealers. The ODALE faced significant public controversy as, armed with these far-reaching capabilities, it terrorized innocent individuals in their homes with their paramilitary tactics, including two infamous cases of mistaken identity. The ODALE was dismantled in 1973, subsumed into the DEA.Footnote 89
Thus in September 1973, when Nixon announced that “we have turned the corner on drug addiction in the United States,” his statement reflected an ongoing process designed to marginalize what had been a central platform of his reelection campaign.Footnote 90 Citing success in international efforts against trafficking, increase in street prices, the expansion of treatment facilities, and a perceived reduction in heroin-related crimes and arrests, the Nixon administration announced a victory. This provided the grounds for an early dismantling of the SAODAP and a significant decline in the visibility of drug policy issues. Furthermore, during this period the SAODAP became involved in the development of a series of restrictions and regulations of methadone treatment. Ultimately, much of SAODAP’s legacy would be the strict restriction of methadone maintenance treatment, rather than the expansion of its availability.
Methadone Regulations
Methadone was a highly controversial form of treatment, and reports of diversion, methadone-related deaths, and abuse were common in the popular media and helped fuel concerns over the legitimacy of this form of treatment. The media was particularly concerned about the deaths of children who accidently ingested methadone, and with the deaths of adolescents, who experimented with the drug, without a history of previous opiate addiction.Footnote 91 The District’s first methadone maintenance opened in late 1969; in January 1970, the first methadone-related fatality was reported.Footnote 92 In 1971, a two-year-old died after drinking a bottle of methadone prescribed for her mother, leading the NTA to institute stricter safety measures, including take-home pills rather than liquid, and ensuring that all patients received metal strongboxes to store the drug safely.Footnote 93
According to a later analysis by DuPont and his colleagues, approximately one-fourth of methadone-related deaths occurred in individuals who had no evidence of previous addiction to opiates, and 46 percent were not known to be addicted at the time of their death. In order to prevent these deaths, emphasis was placed on preventing the diversion of methadone from addicted individuals in methadone treatment programs, to individuals seeking the drug on the black market, for its euphoric effects. As methadone-related deaths rose in early 1972, there was an intense backlash for further regulation of the drug and scrutiny of questionable prescription habits among private-practice physicians.Footnote 94 Thus debates over regulation of methadone were not disconnected from the dangers intrinsic in the use of this medication and the possible public health hazards of it leaking into broader circulation.
The period between 1970 and 1974 saw the development of a strict new set of regulations for the use of methadone, reflecting cooperation between the SAODAP, the Food and Drug Administration (the FDA), and the Bureau of Narcotics and Dangerous Drugs (BNDD), which in 1973 became part of the newly created DEA.
While methadone had been approved as an analgesic and antitussive drug in 1947, its use for treating heroin dependence remained investigational until the early 1970s. Most clinicians and researchers providing methadone submitted an Investigational New Drug (IND) application to the FDA to use methadone for a new indication (addiction treatment) in order to provide the medication experimentally.Footnote 95 By 1970, more than three hundred INDs had been granted for methadone treatment, thus becoming a way to allow clinicians to provide methadone. As these INDs multiplied, and it became clear that it was being used for treatment rather than research, in 1971 the FDA established strict guidelines for these INDs, which included monitoring of arrest records, alcohol and other substance abuse, weekly urinalyses, and low initial dosages.Footnote 96 These restrictive guidelines discouraged further applications for INDs and were supplanted in 1972 by newer FDA guidelines, which provide the basis for methadone guidelines to this day. The SAODAP did not yet exist in 1971, when the initial guidelines were developed, but Jaffe and his staff were closely involved in the development of the final 1972 restrictions and their translation into law in 1974.
The 1972 FDA requirements were twofold: physician registration and the provision of services and oversight for the patients. Any methadone maintenance program had to provide comprehensive services, including counseling, rehabilitation, and additional social support. Inpatient and outpatient hospital care were to be available, and so programs had to have some agreement or affiliation with nearby hospitals. There were restrictions on the doses used to treat, as well as criteria for admission to maintenance programs, including at least two years of documented addiction.Footnote 97 Criteria for taking home doses versus observed therapy were established, and all patients had to come in six days a week for their observed doses, for at least three months, before take-home doses might be considered.Footnote 98 Methadone designed for maintenance could only be distributed at a maintenance program and could not be obtained from a pharmacy.Footnote 99
In 1974, the Narcotic Addict Treatment Act, driven by concerns over methadone diversion and unscrupulous physicians who wrote prescriptions indiscriminately, presumably for financial gain, set these and additional restrictions of methadone treatment into law. Physicians who prescribed methadone would need to register annually with the DEA, and this registration could be revoked with any evidence of noncompliance with the federal restrictions on methadone prescription.Footnote 100
In fact, these strict federal restrictions and subsequent legislation did not differ significantly from the professional recommendations of the medical community. In 1971, the AMA published its guidelines on the use and treatment of narcotics in JAMA. This report was prepared by the AMA Council on Mental Health and the National Academy of Sciences’ Research Council Committee on Problems of Drug Dependence. In assessing methadone maintenance practice, the report made a number of restrictive recommendations, including repeat urine testing, access to hospital facilities as needed, and “rigid controls of methods of dispensing methadone to prevent diversion to illicit sale or to possible intravenous use.” Furthermore, the report specifically stated that “methadone maintenance is not feasible in the office practice of private physicians,” who neither could provide the “therapeutic needs” of the patient nor assure “control against redistribution of the drug into illicit channels.”Footnote 101 Thus, the AMA viewed the prevention of methadone diversion as both a responsibility and a goal of the individual physicians who prescribed it, and discouraged the use of methadone in settings in which diversion could not controlled. The report further suggested that “responsible medical bodies should be developed in each state to promote coordination between law enforcement and medical treatment” to ensure that physicians were prescribing and administering controlled drugs in accordance with regulations.Footnote 102
Thus while methadone programs were expanding in the early 1970s, they were faced with increasing regulations and restrictions as to who and how to provide methadone to clients. The net effect was the development of a close regulatory mechanism, which served to undermine the therapeutic endeavor it ostensibly was designed to promote. While methadone also assisted many individuals who struggled with heroin addiction, its punitive overtones were not lost on the users. Philippe Bourgois and Jeff Schonberg’s ethnographic study of heroin injectors, conducted between 1994 and 2006, reflected this aptly. Methadone maintenance, according to one of the individuals interviewed in the study, was “like being in prison. I can’t stand that. . . . They threaten you: ‘Do this, and ‘Do that.’ You know, fuckin’ following rules.”Footnote 103 Thus the harsh framework in administrating the treatment may have served as a deterrent for addicted individuals who would have wanted to seek care.
While methadone remained an effective medical treatment for the management of heroin addiction, it was never developed into a coherent national response to what was seen at the time as an American crisis. Rather, bureaucracy and restrictions limited the programs’ scope and appeal, ultimately reaching fewer than one-fourth of America’s heroin addicts. Furthermore, as historian David Courtwright has argued, the strict regulations on methadone set precedence for other statutory interventions to curtail diversion of additional drugs, such as steroids and methaqualone.Footnote 104
The End of an Era?
In June 1973, Jerome Jaffe resigned from his position as head of the SAODAP. Some historians attribute this to his frustration with the White House’s distancing itself from the SAODAP, which was moved into the Department of Health, Education and Welfare, and merged into the NIDA, a year earlier than had been planned.Footnote 105 However, the main rift between Jaffe and the administration concerned minimum mandatory sentences for drug charges. Nixon, not to be outdone by New York governor Rockefeller’s harsh drug laws, prepared a new set of drug penalties with a mandatory minimum of five years for sale of up to four ounces of heroin. Jaffe prepared a memo expressing his reservations, which was later leaked to the press. The administration was livid. Although Jaffe’s initial offer to resign was declined, his standing in the White House was irreversibly damaged, and within a month Jaffe submitted a new letter of resignation, making no mention of this episode. The president accepted his resignation, and in June of 1973, two years after the creation of SAODAP, Jaffe stepped down.Footnote 106
DuPont was appointed as his successor, and then went on to head the NIDA, which would replace the SAODAP as the foremost authority on drug addiction research and treatment. Although this reflected the perceived success of the NTA and acceptance of DuPont’s methods, it was a great loss for the NTA, which lost a dynamic and enthusiastic leader. It subsequently suffered a series of significant setbacks. Budget cuts led to staff downsizing, and the NTA ultimately had to close clinics that were understaffed and undermonitored, and therefore not complying with FDA requirements. By the mid-1970s, the NTA was on its decline.Footnote 107
From 1973 to 1978, DuPont served as “drug czar” in the Nixon and then Ford administrations. While the SAODAP had worked closely with the president in its early years, and maintained a powerful presence in the administration, NIDA was based in Rockville, Maryland, disconnected from major spheres of influence and with limited coordinating powers, as much of the legal authority granted to the SAODAP was not transferred to NIDA.Footnote 108 The treatment and rehabilitation budget for 1975 was $33 million less than in the previous fiscal year, signifying further the de-emphasis on treatment programs.
DuPont was briefly a vocal proponent of decriminalization of marijuana in the mid-1970s.Footnote 109 However, by the late 1970s, he became involved with what would become known as the “Parents Movement,” an organization consisting mainly of educated, middle-class white parents who were concerned about the detrimental effects of marijuana use among teenagers in suburban America.Footnote 110 He soon became a crusader against marijuana and warned clinicians and parents of the risks of “gateway” drugs.Footnote 111 In the private sector, DuPont established the Institute for Behavior and Health in 1978, a nonprofit organization designed to reduce drug use, and in 1982 he cofounded the company Bensinger, DuPont and Associates (BDA), which describes its mission as “promoting healthy outcomes for the workplace, employees, individuals and their families.”Footnote 112 DuPont himself has become an expert on the science of workplace drug screening, and one of the major services the BDA provides is the management of drug-screening tests, including urine tests, for companies to administer to their employees. In 1996, he wrote a critique of harm-reduction approaches and noted that personally he was “less attracted to permissive methadone treatment, and more attracted to a stricter standard for program participation, including tests to detect use of other drugs and sanctions for failure to meet program goals, including cessation of nonmedical drug use and criminal behavior and promotion of gainful employment.”Footnote 113 DuPont’s own declaration is telling of the trajectory of methadone maintenance programs, as they gradually became a locus for strict behavioral control to advance the perceived benefit of society at large.
Conclusion
Drug historians often identify a perceived shift from therapeutic to punitive approaches in drug policy, citing 1973 as the turning point in Nixon’s policy. Budget cuts from treatment and prevention programs, combined with increased investment in enforcement programs, set the stage for the modern War on Drugs and its punitive policies.Footnote 114 As the SAODAP closed and NIDA adopted a more research-based agenda, community-based treatment programs were seen as a relic of the 1960s and soon disappeared. Overtones of the “Great Society” programs, which Jaffe later described as having characterized the early therapeutic attempts, were no longer evident.Footnote 115 Strict federal regulations of methadone further served to curtail the availability of large-scale treatment programs, as had been envisioned in the late 1960s and early 1970s.
Punitive approaches and strict enforcement emerged as the legacy of Nixon’s drug policy from the 1970s and onward. I have argued that the development of federally funded methadone maintenance programs in the 1970s helped shape this legacy. Initially developed in a D.C. prison, the NTA helped inform a policy that relied on strict behavioral control and surveillance of individuals addicted to heroin. Rather than having therapeutic ideals serve to inform and reform drug policy, an emphasis on criminality, surveillance, and mistrust pervaded therapeutic programs from the outset. This emphasis shaped new forms of interaction between health-care providers and the individuals who sought treatment. In effect, the therapeutic programs designed to treat addiction became an additional site of surveillance and management of individuals addicted to heroin and enabled close cooperation with law enforcement. While striving to provide individual patients with an answer to their struggle with addiction, these programs were caught up in the political climate of the time. Furthermore, while surely some health-care providers were solely dedicated to patient care, the fact that leaders in methadone maintenance treatment participated in and provided key testimony for Nixon administration policymakers demonstrates the active role health-care professionals took in bringing their expertise to shape drug policy. Thus methadone maintenance treatment moved from the D.C. prison to the community and into the federal government.
While conceived of as a treatment modality, the main goal of methadone maintenance programs was crime reduction, and the methods these programs developed were distinctly nonmedical. Individuals treated in methadone clinics were subject to regular and observed urine testing, were disciplined if there was evidence of ongoing substance abuse, and complied with strict regulations designed to prevent methadone diversion, including the requirement of consuming the drug on the premises. Physicians who administered these programs were concerned with outcomes such as rates of urine positivity, arrest rates and employment statistics, and were committed to preventing misuse and diversion of the medication they were providing. In fact, apart from the setup, in which a medication was dispensed and laboratory tests were followed, the therapeutic aspect of the interaction was quite minimal. Nurses who provided the methadone expressed their frustration, as their role was limited to simply dispensing methadone in a cup. “It could have been plain orange juice and it wouldn’t have made any difference to the work I was doing,” one nurse explained.Footnote 116
Historian Kevin Yuill has provocatively described Nixon as the “first therapeutic president.” He argues that Nixon relied on therapeutic interventions, designed to replace complicated political relationships with marginalized groups, as a way to establish social control. Concentrating on a perceived “epidemic” of drug use in inner cities, Yuill argues, helped transform the relationship between the federal government and the ghettoes, depoliticizing drug abuse and crime. Yuill argues that by focusing on the pathology of drug abuse, “the angry man with the Molotov cocktail in his hand became instead a pathetic figure with a syringe,” who required treatment and rehabilitation, provided by the federal government.Footnote 117 While I find Yuill’s interpretation compelling, I believe there is a flip side to this argument. Nixon’s presidency incorporated therapy, and in particularly, the methadone maintenance model, into its drug policy approach, and in doing so, helped redefine the meaning of treatment of addiction. The success of methadone maintenance treatment was measured by parameters such as crime reduction and employment rates, and was implemented based on concepts of large-scale close surveillance, thus lending itself easily to incorporation into Nixon’s law and order agenda. While Nolan argues that the rise of drug courts in the 1990s helped define intrapsychic measures of success that replaced judicial measures such as recidivism, in this case, social and legal measures of success helped redefine the goals of treating addiction.Footnote 118
As individual doctors were discouraged from providing methadone therapy in an outpatient setting, methadone maintenance became entangled in an unwieldy bureaucratic system that hampered access to services for both patients and providers, a challenge still evident today in providing care for individuals addicted to opiates. Furthermore, the therapeutic relationship was replaced by an approach that was based on distrust and surveillance, which informed and still informs the clinical encounter between providers and those seeking care for their addiction. Methadone maintenance treatment thus redefined the meaning of therapy, with the main beneficiary seen as society, rather than individuals seeking treatment.
