Dr. Fitzgerald has spent three years in the drug treatment field. He began working with poor, inner city residents with his residencies in emergency medicine and internal medicine in the Bronx. Now he is a staff physician at REACH and the Medical Director at Man Alive. He has also trained in acupuncture and now provides acupuncture for patients in both programs.

You shouldn’t throw someone out of the program because they are using cocaine- you try to address the problem of the cocaine and you move them out of the program if they refuse to participate- if they refuse to do something about it. So we try to find a way to meld these extremes- It’s not that one approach is the right approach and one approach is the wrong approach- they’re different approaches. Different people respond to different approaches.

If you’re coaching or teaching, you have to use different approached for different individuals- some students, some athletes need to be pushed along, or pulled along, they might need a more stern approach, and so forth.

“The problem with Harm Reduction is when it becomes the goal and not the technique.”

It’s different with different individuals. When you are dealing with 600 people, one, you don’t have the time to be so individual with each person, and two, the patients speak to each other so you have to be fairly consistent. The philosophy comes down to treating patients different here from the ones over there. It may not be efficient- some may move around between programs until they land in the one that’s best for them at that time.

I didn’t have a real understanding of Harm Reduction until I came here, and much of what I learned was from the people here. But what’s most important is seeing what works and doing that. Some people are just fuming when they here about a harm reduction approach because they think it is too easy on the people, that the patients don’t move along enough.

The problem with Harm Reduction is when it becomes the goal and not the technique. Like when you get a patient down to cocaine use at just one time a week instead of five or six times a week. That is good, but it can’t be the end point. She needs to do more- get down to just once a month maybe, and then keep going from there.

Anyone who believes that they have the one right way is gravely mistaken, just as some people are appropriately placed in non medication assistance programs and some are not- it’s worth trying a counseling program, but some people don’t work there. I like to emphasize here that this is not a methadone program, this is an addiction treatment program that uses methadone. I think of methadone as treading water- it helps to keep you from going under and that’s very valuable, but it doesn’t get you anywhere, what really helps you go along, to get the tools to go into recovery is what the counselors do- group programs and education services, GED education, job help, psychiatric care and so forth. These things really move a person along. Methadone really just stabilizes the body so the mind can take control. It is very valuable, but can have its downsides, but it works.

It’s valuable, but it’s not the whole treatment. If you don’t get these services and these other things you need to get your life in order- you’ll never get off methadone.

Treatment is more than taking methadone.

“Recovery is more than not using.”

Recovery is more than not using. That’s the problem with just detox- detox and don’t use doesn’t deal with the lifestyle. Addiction is much more complicated than that. Structural changes are needed in life to keep a person from relapse. Some people are okay for a while, but then something goes wrong and it’s all over.

If you have other users in your life- you can’t move down a path with someone who wants to sit on a bench. Either you move down the path or you stand by the bench. And if you stand still in recovery you are going backwards. Methadone is just a tool to get people stabilized. It’s tough to get people to deal with a lot of things. Sometimes you say listen- either deal with these issues or we will have to give your space to someone else that needs to get in recovery.

Not using is not recovery. Not using is a side effect of successful recovery.

Q: What would you change about our approach to treatment?

One of the problems in a city like Baltimore is that there are lots of programs. Baltimore is a pretty good place and quite progressive- it offers a wide array of treatment. But the individual addict finds treatment in a very chaotic way. We have a 180 day detox program.

Someone can only go into methadone maintenance if they have been using heroin for over one year. So if less than a year, you can only put them in detox. But most of the people who would wind up in that program don’t belong in that program.

Essentially, people should be evaluated- some should be put in detox followed by counseling, others maybe 30, 60, or 90 days of medication based treatment with counseling, others in methadone maintenance. If you had this centralized thing you could get a picture of what’s effective. When people are discharged the provider should also write why and what kind of program would work better.

That requires central leadership. But right now, everyone is just trying to keep from losing the funding that they have.

Q: Do you know of that happening anywhere in the country?

No. Not that I know of. It’s just chaos. It makes no sense. Everyone’s just treading water is the problem- there’s so much going on, so much to do, and such limited funding. Baltimore City fights to get more funding that most places, whereas Baltimore County doesn’t do a damn thing. I don’t know if there’s any grant funded slots in the County. Grant funded slots are paid for or heavily subsidized by society. So that you could have a sliding scale- $2-$50 or $70 a month. So the number of people you can take in is limited by the amount of grant funding that you get. But grant funding requires that the government be involved in some way. In Baltimore this is centralized through the Baltimore Substance Abuse Systems. Baltimore city goes down and fights for funding every year. The Baltimore City delegation works with the mayor, the commissioner of health to get an agenda each year for the legislature.

I’ve had people come in from the suburbs for treatment because it’s not available out there. This is an outrage. These towns, the county just denies that there is a problem there and just dumps the load on Baltimore City. All of these surrounding areas of course are more wealthy.

Q: When you look at Baltimore- do you see a city that’s succeeding?

In terms of addictions, Baltimore is trying- more than others I’ve seen. I grew up in Omaha, Nebraska. Omaha is not a city that is trying to do anything. The counties around here are not doing anything. So I wouldn’t say it’s succeeding, but it’s trying. It’s like addiction- it’s not, “Are they succeeding,” but, “Are they trying?”

Q: Why do you think treatment programs are often restricted by local governments?

Why do we have restrictions? They are in ignorance, fear, lack of knowledge. We are involved here with a study done in the prisons. We are establishing this current program in the state prison. There was a good deal of resistance, but as soon as I explained the idea of addiction- recovery is more than treatment, how does addiction work, the reward system in the brain-

The reward system in the brain- to eat, drink, be warm, be with other people- these things are fundamental for survival. So the system in your brain is there for survival. The drugs of addiction hijack this system. This system becomes wired as if the drugs of addiction are necessary for survival- that is why cravings for drugs can be so strong even for years out. It’s like if you are thirsty. If you are very, very thirsty, you would search out water. The brain can always heal in this regard, but there’s an imprint. As other things may be going on- like depression, stress, negative situations- you fall back to this imprint of drug addiction- that’s why relapse happens. There are actually physiological changes in the way your brain responds under stress. When you start to explain this stuff to people, they say, “Oh, that makes sense” and their attitude can start to change.

For instance, they said someone on home release couldn’t be on methadone, because then they couldn’t test them for drugs. Well, that’s a flat out misunderstanding of the tests- but you can’t fault some guy trained as a corrections officer. I have seen highly skilled emergency physicians get confused about this. Throughout medical school, five years of residency, even the Board exams, nothing really explained addiction. There is shockingly little education about addiction.

They were afraid we would disagree with their approach of referring inmates to counselors if they get positives. But we agree with that- it works with our system. Telling someone to do something about- with more restrictions put on them. We thought that was a great thing. If a methadone patient showed up with cocaine in their system we would do something like that.

By the end of a couple meetings, the director of home detention for Baltimore City was enthusiastically looking forward to working with us. So a lot of it has to do with understanding what’s going on. What’s going on in the brain, what methadone does.

So why do other states set limits on this? It’s out of fear of the unknown. It’s unknown because they don’t know it. But it’s not unknown- they just don’t know.

“You don’t lock someone up for having high blood sugars.”

In addition though, in addition, there is the crime versus medicine approach. If you look upon this as disease- you don’t lock people up for having high blood sugars. Even if they know that they have diabetes and there are some things they should or shouldn’t do. You can’t lock someone up for having a disease.

Sometimes it is also a fundamental refusal to believe it is anything but a lack of will.

Q: But someone didn’t break the law to get diabetes, where an addiction is the result of criminal behavior.

Addiction is the result of using heroin- I don’t know if that is criminal behavior. It may be against the law- I think killing people in cold blood is criminal behavior. Slavery was criminal behavior but was the law. “Criminal behavior” is a term that has a lot attached to it- it isn’t just two words. It says a lot about the people- that they are evil or bad, that they’re different from us. But they aren’t different from us. That’s another aspect- addicts are all over. That’s why Baltimore County won’t do anything about it, because they won’t admit that they have addicts out there.

Step one is very hard for someone used to controlling other people. Putting the blame on people- where does that get you? That is the past. They are paying a price- they are addicts! What addiction kills the most people? It kills more than cocaine and heroin and alcohol and car crashes and AIDS and murder and suicide- combined. That’s not criminal behavior? Putting cigarettes on the market and putting things into them to make them more addictive- that’s not criminal behavior?

The teenage brain is still developing- not new cells, but new connections. When you bring in a chemical like cigarettes, and introduce it while the connections are still being made, it is much harder to get off the cigarettes later- that’s why they aim for teenagers. That’s true for these other chemicals, too.

You don’t speak of criminal behavior when someone runs a red light. That’s because it’s too close to home. A term like criminal behavior is about making it the “other” - and then you can do something to them because they’re not like us. But you have to understand that they are like us and we just don’t know it.

A lot of people who have diabetes or who are obese are in part responsible for it- isn’t it a matter of choice what we eat? You are somewhat responsible for where you’ve gotten yourself- but then what do you do? They’re there.

There are also biochemical reasons for why someone does not have as much control- such as susceptibility. Only about 12% of people who use heroin become addicted to it I saw one study said. There are biochemical reasons that some people are more susceptible. You’ll hear that some people have an “addictive personality.” It’s not personality except that personality does reflect some biochemical aspects of a person. Some of it is genetics as well. But blaming people isn’t what it’s about. Someone has Lung Cancer, do you just tell them because they were a smoker that it’s their fault? That they get no treatment? You have Skin Cancer- it’s you fault because you went to the beach too much right?

If it is someone who is close to you, then you begin to have a different feeling towards it. But these folks are close to us- even if you don’t know it- maybe some of them you haven’t even gotten to know yet.