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needles, visiting shooting galleries and practicing unsafe sex at
significantly higher rates than those in treatment. Clinics are currently
a major point of intervention to teach risk reduction techniques and
expedite referral to treatment for the HIV virus.

The influence of a public health perspective has not only helped to
reduce the stigma, it has opened the possibility of new ways of
thinking about treatment goals. HIV service providers quickly pointed
out that many drug users had little or no commitment to stop their drug
use. Extensive studies on interventions to reduce the spread of the
HIV virus demonstrated that harm reduction approaches were
effective. Methadone treatment providers have always struggled with
meeting the needs of patients with very different goals. Some were
committed to complete abstinence from illicit drugs and alcohol;
others merely wanted to reduce the hassle associated with using. The
harm reduction framework allows programs to work with those who
are not committed to abstinence within a model that does not define
their efforts as failure if the patient does not abstain. This improved
the morale of the treatment providers, and allowed them to maintain a
positive relationship with their patients. It also produced demonstrable
benefits in public health.

The hepatitis C virus (HCV) is more highly transmissible, and many
patients are HCV positive upon entry into treatment. Among injection
drug users in California, rates run 85%-90%. Recent efforts to treat
HCV have been successful in methadone patients, even if they still use
some drugs, so long as they are not engaged in daily use (Sylvestre,
Litwin, Clements, & Gourevitch, 2005). Many methadone patients are
still not aware that treatment can be effective, and avoid getting initial
testing or completing an appropriate workup. Peer based education
(using videos) and psychoeducational support groups are under
investigation as key elements in engaging patients and supporting
them through the ordeal of treating their HCV.

It is generally agreed that partly due to the aging of the population in
treatment, patients today are far more medically ill and require more
resources than before. Cutbacks in resources for medical care have a