Dr. Edwin Salsitz is a methadone OG. He was one of a coterie of New York City doctors who pioneered its use to treat opioid use disorder back in the 1980s, including Drs. Vincent Dole, Marie Nyswander and Mary Jeanne Kreek—physicians who researched methadone at Rockefeller University.
Salsitz is an associate clinical professor of psychiatry at Mount Sinai Beth Israel. It was there that he worked with the legendary, fierce methadone advocate Dr. Robert Newman.
“When you work in a place and you have Dr. Newman as the president, most things went pretty smoothly, and if you said something negative about methadone you could kiss your job goodbye. Newman was going to destroy you,” Salsitz told Filter. “He was a charming guy.”
Salsitz is New-York blunt. “A methadone patient is more closely monitored than a paroled murderer,” he told the New York Times decades ago. He has long blasted the methadone clinic system, because of the onerous, invasive regulations and practices that create barriers to a lifesaving medication.
Salsitz never worked at a clinic, or opioid treatment program as they’re known. Instead, he was the director of the medical methadone maintenance program at Beth Israel Medical Center, under what’s known as office-based opioid treatment (OBOT).
“God almighty. So many people could have been saved from HIV if they’d either gotten on methadone or stayed on methadone.”
It started in 1985. He would prescribe in his clinic and patients would pick up a 28-day supply from an on-site pharmacy. It was liberatory not to have to attend a clinic six days a week. To participate, patients had to be “stable,” which meant no positive urine screens usually for a couple of years, be employed and not need counseling. In other words, they had to be, “model methadone patients.” Recruited from clinics around the city and beyond, 70 percent were white and 30 percent were Black or Latino.
A tiny handful of OBOT programs remain around the country, a legacy of a bygone era. To open a new one requires an exemption from the Substance Abuse and Mental Health Services Administration (SAMHSA). Amid the ongoing overdose crisis, it’s urgent to reboot the model that Dr. Salsitz helped pioneer and make the medication available to all who need it.
Salsitz has seen it all. He is the through-line from the early days of life-changing methadone medical maintenance to the HIV/AIDS epidemic to the shutting down of his program in 2020.
He was furious that more people couldn’t get methadone as the HIV crisis peaked in the 1980s and ’90s. “God almighty. So many people could have been saved from HIV if they’d either gotten on methadone or stayed on methadone,” he said. “They all died. Yeah, I often say, what more can you ask from a drug than it prevents a fatal disease in people?”
He also observed that “not much has changed.”
Filter interviewed Dr. Salsitz at his office at the Mount Sinai Behavioral Health Center on the Lower East Side. Our interview has been edited for length and clarity.
Helen Redmond: How did medical methadone maintenance start?
Edwin Salsitz: What happened was Dr. Dole and Dr. Nyswander had a few very stable patients up at Rockefeller University. And Dr. Dole’s dream was not to have this whole clinic system, it was to get methadone into general internal medicine practice.
Dr. Newman was friends and colleagues with Dole and Nyswander, and he had about 20 or 25 patients who were really stable. They didn’t need any counseling, all they needed was the medication. And Dole asked Newman if he would be willing to provide that to them. I was recruited to be a part of this research project at Beth Israel.
I was biased against methadone. I’d never seen patients doing well. They were admitted to the hospital over and over again, and were using a variety of drugs and had behavioral problems. I didn’t know anything about addiction because you don’t learn about it in medical school. So I was a little bit apprehensive about the first four patients that were assigned to me.
The first person that walked in was an administrator in the hospital. That opened up my eyes. Wow, there are people on methadone who work, who are high-functioning and who use methadone the way I use Lipitor.
“When we handed them that bottle of methadone with a label on it, which looked like a drug-store bottle of anything, some of the patients would cry.”
HR: How did the methadone medical maintenance project work?
ES: We recruited patients who no longer needed all the services, and they had to have at least four or five years in the methadone clinic. They would get a month’s worth of medication in the form of diskettes and it came from the hospital pharmacy.
I remember some people when we handed them that bottle of methadone with a label on it, which looked like a drug-store bottle of anything, some of the patients would cry. They couldn’t believe it. In 1985, a week was the most you could get to take home. Most clinics were not even doing that, maybe three times a week. So to go from that to a month just changed people’s lives and made them feel so, so good.
The patients loved sitting in a waiting room where they were anonymous. I mean, nobody knew what they were there for. And so that whole thing about going in and out of the methadone clinic where people know what you’re doing was gone. They were coming into our Union Square Ambulatory Care Center and nobody knew who the hell they were.
And we kept recruiting more patients. Now, the recruitment was not easy either, because we were trying to take the patients from methadone programs who were doing really well. Very often they were reluctant to let them go and sometimes they didn’t want to send in the forms that were required, or they didn’t let the patients know that this was available. We also recruited patients from out of state and they would fly in to get 28 days of medication.
HR: Why didn’t clinics want to let patients go?
ES: I assume because they liked having patients that are so stable and easy to take care of. And also, every clinic patient is revenue.
HR: Why did the project close?
ES: We did it for 35 years and I stopped because I was getting to be the only physician left doing it and the responsibility was just too much. I was getting older. And buprenorphine came along and I offered it to all the patients who were still on the medical maintenance program. And a whole bunch of people switched, and I still take care of them. When you have somebody on buprenorphine, you can do telehealth. You can just email the prescription and it’s refillable up to five times, so they’ve got a six-month supply of medication. You can’t do that with methadone.
Everyone wasn’t able to switch and [some] had to go back into the clinic system. But by that time, which was 2020, most of the clinics went back to giving a 28-day supply. I would write letters or call the clinic and tell them what was happening, and they were very agreeable to not starting the patients off at stage one because it was a transfer. And so most of the patients wound up in good clinics, getting a supply for a month.
“Methadone is more highly stigmatized than almost anything else in our society, and it is as strong today as it was when it started over 50 years ago.”
HR: Why do you think there is still stigma around methadone? Is it the same, less or more?
ES: The stigma is the same. Methadone is more highly stigmatized than almost anything else in our society, and it is as strong today as it was when it started over 50 years ago. People who are on methadone rarely reveal it to their friends, people at work or even family members.
For example, in the ’80s, when gay rights became an issue, my patients who were gay, they didn’t have any problem marching in the gay pride parade. And then when HIV came along, which was stigmatized initially, they also marched. But methadone is different. They keep it the closest-guarded secret that they have.
In the methadone medical maintenance project, we eventually got up to 347 patients and not one would tell anybody at work or a friend. You get 13 take-home bottles and you go on vacation and your family doesn’t know you take methadone. Now you’re going through security. What are these bottles? Your wife and kids are standing right there. I could have checked my luggage, but what if it got lost? Methadone never leaves your mind. You’re always worried about it. Oh, a snowstorm is coming up on Monday. Christ, that’s my day to go to the clinic. How am I going to get there? Will they be open?
Dr. Herman Joseph [another early methadone champion, who was instrumental in setting up OBOT programs in New York] said methadone permeates every part of a person’s life. It’s really true. All of that is unnecessary if we change the system.
I said this a long, long time ago: Methadone needs to be rebranded. I think the word methadone can’t work anymore. I love methadone, but when people hear the word, there’s such an association with negativity. If it had a different name—I always thought “Norlimb,” short for normalizing the limbic system, could have been a good name to replace methadone.
HR: Talk about the methadone clinic system.
ES: I remember before buprenorphine, I would tell people how great methadone was and how it would help them, and they expected me to take out my prescription pad and give them a prescription. But I said, no, you’re going to have to go to this clinic. And the clinic was in a peculiar part of the city, which it always seems to be, not close to the medical center, always apart. The Mount Sinai clinic was in a parking garage three blocks away, and they closed it around 2008.
I wouldn’t want to live next to a methadone clinic, not because the methadone is dispensed there, but because of what that often brings. People hanging around outside. All my patients would say, if you want to buy drugs it’s all over the methadone clinic. And nobody really wants to be in that environment. That’s one of the problems, and patients who are doing well have to walk through that whole thing, right? Patients complained about that to me all the time.
“I had two patients who became frail and I was making house calls for them. I didn’t mind bringing the medications and giving them out.”
HR: There is a lot of pressure for people to stop taking methadone.
ES: This is the fundamental issue in opiate agonist therapy. And you can ask anybody who’s ever heard me speak that I’m very definite and strong on this. If you have an opioid use disorder, you should stay on methadone or buprenorphine. You shouldn’t think about getting off. You should just find the lowest effective dose that works for you. Because I have hypertension, I’ve been on medication for a long, long time. Never, ever have I thought about getting off of it.
Methadone the way it stands right now is a burden to be on, so I can see why people are always thinking, I’d like to get off of it, so they don’t have to go to the clinic. It was the significant others in my experience who were really pushing the patient to get off, because it’s impacting their lives. My father died, we need to go to Florida. Oh, I can’t go. I have to pick up my methadone tomorrow. So it interferes with people’s lives, and so they have this negative attitude towards it. Get off that shit already, look at what it’s doing to us!
HR: What is the future of treatment for addiction?
ES: I think part of the future is more drugs being developed. I mean, the amount of money put into drug development for addiction is minuscule compared to antidepressants or antibiotics. I think methadone in more of an office-based private practice might be coming along. I know people are advocating for it and working on it again. I think it’s got to be rolled out slowly and well thought out, because of the risk of overdose. And I think that if the clinic stays the clinic, it should not be monolithic. People should graduate at a certain point and be given more take-home methadone.
HR: Do you miss the methadone medical maintenance project?
ES: Yeah. I miss the patients. I thought the whole thing was fun. I liked it. It suited my personality to do that work. I got to be friends with many of the patients and I tried to help them as much as I could. I had two patients who became frail and I was making house calls for them. I didn’t mind bringing the medications from one place to another and then giving them out.
HR: Like DoorDash methadone?
ES: Well, that’s what we sort of had, the early DoorDash, the early UberEats. And I thought when we stopped, that the patients would be okay because of the increased take-homes and also because a lot of them did switch over to buprenorphine.
Photograph of Dr. Salsitz by Helen Redmond
Show Comments