R E P O R T R E SUMES ED 015 125 SE 003.117 ,NARCOTIC . BY- YAHRAES, HERBERT AND OTHERS . PUBLIC HEALTH SERVICE(DREW), BETHESDA, MD. REPORT NUMBER NIMHMOMOGR2 PUB DATE 65 REPORT NUMBERPHS-PUB-1021 EDRS PRICE MF.-$0.25 HC -$1.32 31P.

DESCRIPTORS-. *DRUGADDICTION, *HEALTHEDUCATION, MENTAL HEALTH, *NARCOTICS, ADULT EDUCATION,COLLEGE SCIENCE, ELEMENTARY SCHOOL SCIENCE, HEALTH,PUBLIC HEALTH, 6a0NDARY SCHOOL SCIENCE, UNITED STATES DEPARTMENTOF HEALTH EDUCATION AND WELFARE, PUBLIC HEALTH SERVICE,MENTAL HEALTH MONOGRAPHS,

MUCH HAS-BEEN LEARNEDIN RECENT YEARSABOUT THE NATURE OF DRUG ADDICTION, THE FACTORS WHICHLEAD A PERSON INTO ADDICTION, AND THE EFFECTIVE TREATMENTOF PERSONS WHOHAVE BECOME ADDICTED. THIS PAMPHLET SURVEYSTHE NEW FINDINGS IS INTENDED AND PRIMARILY FOR (1) THOSEWHO IN THE COURSEOF THEIR PROFESSIONAL DUTIES COME IN CONTACTWITH ADDICTED INDIVIDUALS AND DESIRE CURRENT DATA, AND (2)FOR TEACHERS, PARTICULARLY THOSE CHARGED WITH PREPARINGINSTRUCTIONAL MATERIALS. THE PAMPHLET DEALS FOR THE MOSTPART WITH ADDICTION TO NARCOTICS, PRINCIPALLY OPIATESAND SYNTHETIC WITH -LIKE REACTIONS. THEMAJOR AREAS COVERED (1) THE EFFECT ARE OF NARCOTICS, (2)THE PEOPLE WHO TURNTO NARCOTICS, (3) THE DOCTOR AND THEADDICTED PERSON, (4) TREATMENT IN FEDERAL HOSPITALS, (5) AFTERCAREAND OTHER NEW APPROACHES, AND (6) PREVENTING ADDICTION.PROBLEMS WITH OTHER DRUGS SUCH AS MARIHUANA, COCAINE,, BARBITUATES, AND TRANQUILIZERS ARE ALSO BRIEFLYDISCUSSED. SINGLE ARE AVAILABLE COPIES UPON REQUEST FROM THENATIONAL INSTITUTE MENTAL HEALTH, OF BETHESDA 14, MARYLAND.THIS DOCUMENT ISALSO AVAILABLE FOR $0.25 FROM THE SUPERINTENDENTOF DOCUMENTS, U.S. GOVERNMENTPRINTING OFFICE, WASHINGTON, D.C. 20402.(OS) EDUCATION & WELFARE U.S. DEPARTMENT OF HEALTH. OFFICE OF EDUCATION

REPRODUCED EXACTLY AS RECEIVEDFROM THE THIS DOCUMENT HAS SEEN POINTS OF VIEW OR OPINIONS PERSON OR ORGANIZATIONORIGINATING IT. REPRESENT OFFICIAL OFFICE OFEDUCATION STATED DO NOT NECESSARILY POSITION OR POLICY. Ln 01/41 MENTAL HEALTH MONOGRAPH 2 LriN 7.4 cz)

14.1 Narcotic Drug Addiction

0 MENTAL HEALTH MONOGRAPHS

This monograph is one of a series of documents published from timeto time by the Publications and Reports Section of the National Instituteof Mental Health. The reports are issued under the direction of the Editorial Committee of the NIMH, and represent material compiledor edited by members of the staff of this Institute.The series is designed to present comprehensive and specialized reports dealing withaspects of mental health and mental illness which will add to useful knowledge in this field. Single copies of monographs and other publications prepared underthe auspices of this Institute are availableupon request.Quantity copies may be obtained at list prices from the Superintendent of Documents,U.S. Government Printing Office, Washington 25, D.C., witha 25-percent reduction on orders for 100or more. Publications and Reports Section National Institute of Mental Health MENTAL HEALTH MONOGRAPH NO. 2

Narcotic Drug Addiction

U.S. DEPARTMENT OF HEALTH, EDUCATION,AND WELFARE Public Health Service National Institutes of Health National Institute of Mental Health Bethesda 14, Maryland

For sale by the Superintendent of Documents, U.S. Government PrintingOffice Washington 25, D.C.-Price 2S cents

7a, 54,9* Ye' iI

This monographwas written by Herbert Yahraes, in cooperation with an editorial committee of the National Institute of MentalHealth, which in- cluded Carl L. Anderson, Ph. D.,Consultant on Drug Addiction; JosephM. Bobbitt, Ph. D., Associate Directorfor Program Development; JamesW. Osberg, M.D., Director, MentalHealth Study Center; Harris Isbell, M.D., Director, Addiction Research Center;and Stanley F. Yolles, M.D., Associate Director for Extramural Programs. JamesV. Lowry, M.D., Chief, Bureau of Medical Services, Public HealthService; Mabel Ross, M.D., SpeciaLAs- sistant in Mental Health, Bureau ofState Services; andmany other author- ities in the field' of drug addiction alsoprovided substantial help.

PUBLIC HEALTH SERVICEPUBLICATION No. 1021 FOREWORD Since the early 1920's, when a Public Health Service physician, Dr. Lawrence Kolb, conducted the first field studies in narcotic drug addiction in the United States, the Public Health Service has had a major and distinguished role in the field of drug addiction. Dr. Kolb's papers, still regarded as classics in the field, brought a medical viewpoint to bear on the problem of drug addiction. He pointed out, first, that the majority of drug addicts are emotionally unstable individuals, and that drug addiction is largely a psychiatric problem. Second, and contrary to beliefs commonly held in the twenties, he showed that although criminals may use drugs, opiate addiction does not directly lead to crime, except as a means of procuring funds to support addiction. In 1929, acting upon the conviction that drug addiction is primarily a medical and sod: problem and that attempts to treat addiction by im- prisonment are illogical, the U.S. Congress enacted a law calling for the establishment of two medical facilities for the treatment of drug addicts. When the Public Health Service Hospitals at Fort Worth, Tex., and Lexington, Ky., were opened in the 1930's, the program of treatment was based on the premise that addicts were patients, and that the effective treat- ment of drug addiction demanded that attempts be made to rehabilitate the addict, and to assist him in his return to society. The Public Health Service has pioneered in the fields not only of medical care and rehabilitation but also of research.Investigations by PHS person- nel in the Service's Addiction Research Center in Lexington have led to illuminating and highly valuable findings.Most recently, demonstration and pilot projects supported by Public Health Service funds have begun to explore possible ways of controlling drug addiction in the community. Thus the public health approach to the problems of drug addiction involv- ing prevention, treatment, and social rehabilitation is being introduced into our communities.If this approach is to succeed, factual knowledge about the subject of drug addiction must become common knowledge. For this reason, it is my hope that this publication will be widely read, and that the information it transmits will assist in the formation of constructive public attitudes toward the problem of drug addiction. LUTHER L. TERRY, M.D., Surgeon General, Public Health Service. PREFACE If drug addiction is to be controlled in our society, a great deal more biological, clinical, and social research must be done on this problem. There is much we do not know about the nature of addiction. There are many clinical answers to the problem of drug addiction which we do not yet have. There are many so:ial answers to the problem of drug addiction which we do not yet have. Answers to all aspects of the problem must be sought with increasing vigor in the coming years. I believe that some of the missing answers to this grave problem must and will be found and developed within our communities. This can only come about, however, as sound knowledge about drug addiction becomes widespread, and as the effects of the problem of drug addiction on the social, physical, and mental health of a community are honestly faced. I believe this publication will play a significant role in imparting such sound information about drug addiction and the problems addiction creates for the addict, his family, and his community. I further believe that armed with such knowledge, our communities will mobilize existing resources, and develop new ones, to bring the problem of drug addiction under control. ROBERT HAN NA FELIX, M.D., Director, National Institute of Mental Health.

v CONTENTS Page FOREWORD iii PREFACE

NARCOTIC DRUG ADDICTION 1 Scope of Pamphlet 1 Background of Problem.. 1 The Introduction of Heroin 2 Why the Problem is Important 2 THE EFFECT OF NARCOTICS 3 What Happens When Narcoticsare Taken 3 The Withdrawal Sickness 3 The Body's Response to Narcotics 4 THE PEOPLE WHO TURN TO NARCOTICS 4 Why 7)0 People Take Drugs? 4 The Kinds of People Who Become Addicted 5 Backgrounds of Addicted Persons 6 Juvenile Drug-Users 6 The Addict and the Criminal THE DOCTOR AND THE ADDICTED PERSON. 8 Recognizing the Addict 8 Treating the Addict. 8 TREATMENT IN FEDERAL HOSPITALS 9 The Patients at Lexington 10 Treatment of 10 Preparing Patients for Life Outside 11 After They Leave the Hospital 11 Hospital and Posthospital Problems 12 AFTERCARE AND OTHER NEW APPROACHES 13 The New York Demonstration Center 13 Church Mission in East Harlem 14 A Parole Project 14 An Aftercare Program ata Hospital 15 Some State and City Actions 15 Canada's Approach 16 Among Other Efforts 16 A Research Clinic 16 The British Methods 17 The Hope for Safer Drugs 18 PREVENTING ADDICTION 19

vii Page ADDICTION TO OTHERDRUGS Marihuana 19 Cocaine 19 19 The Amphetamines. 19 Tranquilizers 20 20 DRUG ADDICTION:SUMMING UP Some of the Important 20 Things Known 20 Important Points RequiringFurther Research REFERENCES 21 21 lin Arvir-; nits'trr AA; ni-;ins.% (4,1 rkAJ taldr I U.5 10.1A,J11

SCOPE OF PAMPHLET was known about the causes of illness, doctors naturally concentrated on the symptomsand Much has been learned in recent years opium could dull the pain and discomfort of about the nature of addiction, the factors almost any disorder. edging a person into addiction, and the effec- For many people, particularly in eastern tive treatment of persons who have become countries, opium had social as well as medici- addicted.Very much more remains to be nal values.They used it for much the same learned.This pamphlet surveying the new reasons that other people have used alcohol. findings is intended primarily for those who, Drug addiction began to be a sizeable prob- in the course of their professional duties, oc- lem in the United States following the Civil casionally come face to face with an addicted War.Three main factors were at work: individual or his family and wonder what can 1. The occurrence of the Civil War just a and should be done.It is intended also for few years after the introduction of the hypo- teachersin particular those charged with dermic syringe, which made it possible to ad- preparing material on health problems.But minister , opium's principal ingredi- it should be of interest to almost anyone look- ent, through the skin and thus relieve pain ing for a short report on our present knowledge more rapidly.Of the wounded soldiers given of the subject. injections of morphine to ease pain, so many The pamphlet deals for the most part with became addicted that their condition was de- addiction to narcoticsprincipally the scribed as "army disease."Many civilian and synthetic drugs with opiate-like reactions. patients, too, given injections for any one of Problems associated with other drugs are, dozens of disorders, found that they had to however, briefly discussed. keep on getting them. 2. The introduction of a great variety of patent medicines containing opium or opiates BACKGROUND OF PROBLEM and sold freely, without prescription, in every Narcotic drugs have been used to relieve drugstore and even intossroads general stores. pain and induce a feeling of well-being as far 3. The introduction of opium smoking by back as man has records, and probably a good the Chinese who had been brought in to help deal farther.Opium is listed on Assyrian build the railroads of the West.Though the medical tablets dating to the 7th century B.C. immigrants themselves were in general an and on an Egyptian list of remedies drawn up orderly crew, the Americans who picked up probably in the16th century B.O.The the opium habit represented the shadier ele- Suinerians had a word for it even earlier ments among the adventurers. As the practice about 6,000 years ago. of opium-smoking spread eastward, after 1870, Until very recent times, opium in one form it appealed mostly to the same elements. or another was mankind's principal medicine By 1900, according to one estimate, the because all through the centuries when little United States had 264,000 narcotic addicts-

764-350 0 - 65 - 2 1 more than 5 times as many as the current Bu- number of addicted persons, which may have reau of Narcotics estimate, though the country reached 60,000 during theearly1950's, then had less than half as many people. dropped during the next decade to about 46,- Many of the addicts were people who had 000.These numbers refer to known addicted taken or been given opiates as a medicine, and persons and are subject to error. On the one most of these were decent, working members hand, not all addicted persons are known to of the community.By and large, however, the Bureau; on the other hand, a person is the opium smokers were not. continued in the files as an addict for 5 years after the last report indicating that addiction THE INTRODUCTION OF is present, and some of the persons who con- HEROIN tinue to be listed are no longer addicted. Some authorities consider the figures too low. Abo at 1900 a drug closely related to mor- In part, the great decline in the number of phine and known chemically as diacetylmor- addicted persons has occurred because medical phinc was developed in Germany and offered knowledge and education have greatly im- under the name of heroin as a safe replace- proved; medical textbooks have been warning ment for its relativeone that could be em- against the indiscriminate use of narcotics ployed, even, to cure addiction to morphine. since the beginning of the present century. Doctors welcomed it, used it enthusiastically, Most importantly it has occurred because a and then discovered that, contrary to the growing worldwide campaign against the originalclaims,itwas highly addicting. opium trade led to the passage in 1914 of the Opium-smokers discovered something else : Harrison Narcotic Act. In the early 1920's, they could get the same effects from snuffing following Supreme Court interpretations of heroin as from smoking several pipes of this law, addicted persons were cut off from opium, and faster, without fuss, and with legal supplies of narcotics. little danger of detection. Measured by its total effect on society, how- Today, heroin is the only opiate available ever, the problem of addiction may have to most addicts.The illicit trade prefers it to grown worse. Today's addict must spend most morphine because, since it is three times as of his time scheming to get his drug and the powerful, a given quantity is worth three times money to pay for it. As the.cost of maintain- as much, and also because heroin can be more ing his "habit" mounts from a few dollars a easily diluted. day to as much as $75, he impoverishes his family and, typically, resorts to crime. In New York City alone, it has been estimated, addicts WHY THE PROBLEM IS must raise between $500,000 and $700,000 IMPORTANT every daymost of it through shoplifting, burglary, forgery, prostitution, and other il- Measured only by the number of addicted legal activities. persons, the problem is co,- iiderably smaller The burden of addiction falls not only on than it was in 1900.Addiction reached an the individual and his family, but also on the alltime low during World War II, when the police and the courts, hospitals, welfare de- underworld found it extremely difficult both partments, and other agencies serving the com- to obtain narcotics abroad and to smuggle munity. Most addictsgoing through t a them in; then addiction increased fora few seemingly endless series of "cures" and re- years and again began declining. lapsesimpose the burden again and again According to the Bureau of Narcotics, the and again.

2 The Effect of Narcotics

WHAT HAPPENS WHEN reason for taking drugs.Long before this NARCOTICS ARE TAKEN point is reached, he has become dependent on the drug. The typical addict prefers to take heroin, Dependenceisboth psychological and morphine, or a similar drug intravenously. A physical. The addictedperson uses drugs to few seconds after the injection, his face flushes, shut out his problems and quiet his anxieties, his pupils constrict, and he feels a tingling sen- and the oftener he turns to them for relief, the sation, particularly in his abdomen.The stronger becomes their hold on him. In this tingling soon gives way to a feeling that every- respect, drug taking is like coffee drinking, thing is fine: as the addict expresses it, he is cigarette smoking, or any other pleasure-giving "fixed." Later he may go "on the nod," drift- habit.Addiction is not just "in the head," ing into somnolence, wakingup, drifting off however; it is a matter also of being physically again, and all the while indulging in day- dependentso dependent that without the dreams. The effects of the drug wear off in drug the user becomes sick 3 or 4 hours. Experiments at the Addiction Research Center of the National Institute of Mental THE WITHDRAWAL SICKNESS Health, the Center is located at the Pub- A few hours after his last dose,an addicted lic Health Service Hospital, Lexington, Ky.) person becomes nervous and anxious and then, showed that drug users appeared uninterested if he can't get more of his drug, develops the in any activity, let their living quarters be- withdrawal sickness or the abstinencesyn- come extremely messy and spent most of their drome.Many of the symptoms resemble time in bed. A drug user "on the nod" could those of severe influenza. The addictedper- be awakened easily and would thenanswer son perspires, has chills, suffers waves of goose- questions accurately.Given a psychological flesh.His eyes water and hisnose runs. test, he would not score quite as high as usual, Either asleep or awake, he tosses restlessly. and given a task he might perform it some- As time goes on, his arms and legs begin what more slowly than usual. He readily to ache and to twitch almost constantly.. He is lapsed back into somnolence. Smokers fre- nauseated, vomits, has diarrhea. quently fell asleep with lighted cigarettes in His nerv- ousness and anxiety increase. He may crawl their mouths. into a corner, cover himself witha blanket Unless he is somnolent, or has taken enough even in the hottest weather, and beg piteously of the drug to make him sick, the person under for a "shot." the influence of an opiatemay not behave If he has been taking heroin, the abstinence abnormally, and there is no easy way to show symptoms reach a peak in 24 hours; ii mor- that he is under the influence. But narcotics phine, in from 36 to 48 hours.In either case, do upset the body's chemistry. Theperson within a week after, he has last had his drug, who regularly takes a drug like heroin or mor- the addict has lived through the worst of the phine soon finds that unless he increases the withdrawal sickness and, in his words, "kicked dose, the drug no longer has thesame degree the habit."He is weak and nervous, but he of effect. He has developed tolerance.As has lost, most of his physical dependenceon the months go by, he has to increase the dose drugs.Complete recovery requires from 2to again and again, and eventually he finds that 6 months. even large doses will no longer bring him the The withdrawal illness is much lesssevere feeling of well-being that was oncea main when the addicted person is withdrawnor

3 detoxifiedthat is, removed from physical at the Addiction Research Center havegiven dependence on drugsunder the medical morphine and allied compoundsover ex- method commonly used today. tended periods to animals in whichthe spinal cord has been severed.At first the drug strongly depresses two of the THE BODY'S RESPONSE TO reflexes in the legs of these animals and stronglystimulates NARCOTICS another. As the animals developtolerance, however, these effects tendto disappear. According to a widely accepted theory, Then when the drug isdiscontinued, some tolerance and the withdrawal sickness are both spectacular changes occurjustopposite to related to the action of forces that try to keep the original effects.The reflex that has been the body's processes funcioning in balance. stimulated disappears;one that had been de- When a person takes a drug like heroin or pressed becomes so active that thelegs are in morphine, this theory explains, his autonomic constant motion. None of these changescan nerve centers try to compensate for its effect, be ascribed to activity in thebrain, because the if which is chiefly depressant. They do this brains in these animals hadbeen severed from through certain changes in the activity of the the legs. central nervous system. But the depressant Other studies indicate thatmorphinepre- effect is what the addicted personcraves, and sumably again through its actionon the nerv- in order to get it he must keep the compensa- ous systemslows the activity both ofthe tory forces in check by taking more and more adrenal glands, whose hormoneshelp the body of the drug. When he stops taking it, the meet stress, and of the sexual glands. compensatory forces are suddenly released and Such experiments and studieshelp.expiain the body has to fight forsome days to return the lessened drive of theaddicted person and to an even keel. his decreased interest insexual activity (con- Medical observationsare in accord with this trary to a fairly common notion, drugslike theory. For instance, morphine constricts the heroin and morphine donot lead to the com- pupils and depresses the respiratory rate; dur- mission of sex crimes; insteadthey tend to put ing the withdrawal sickness, however, the a brake on desire). They also explain the pupils dilate and the breathing becomes ab- symptoms of the withdrawal illness.But normally heavy. answers to how narcotics bring about these Experimentation seems to bear out the effectsthat is, hog they changethe activity theory, too. As a notable example, scientists of the nerve cellsawait furtherresearch.

The People WhoTurn to Narcotics 1

WHY DO PEOPLE TAKE same purpose as another drug, alcohol, DRUGS? serves in the case ofsome other youngsters, whether Studies of juvenile narcoticsusers in New in the New York slumsor the Westchester York Cityand such studiesare important suburbs: it helps theanxious individual feel because today's addictedpersons have gen- at ease, mix more freely, and havea good time. erally begun using drugs in theirteensshow Whatever the occasion,some of those who that a favorite occasion for taking heroinis take a shot of heroinlikesome of those who just before a danceor party.For mar of take a shot of whiskeydoso only for a thrill them, perhaps most, the thugserves much tile or to go along with thegang or to thumb a 4 nose at authority; not all of these will take THE KINDS OF PEOPLE WHO the drug often enough to become addicted. BECOME ADDICTED By and large, the people who become ad- dicts are those for whom drugs serve a special Two psychiatrists who studied addicted per- need, which can be summed up as the relief sons at the Public Health Service Hospital in of pain.Last century the pain that led to Lexington found that they were generally addiction was often physical; today it is mainly noncompetitive individuals who preferred to psychic.Most of today's addicted persons handle their anxieties by avoiding the situa- have discovered, in other words, that opiates tions that provoked them. One principal relieve their anxieties, tensions, feelings of in- source of anxiety related to the expression of sex; drugs reduced their sexual urge. Another adequacy, and other emotional conditions they major source of anxiety related to the expres- cannot bring themselves to cope with in a sion of aggression; drags took the edge off normal way. The relief lasts only a few hours, their aggressiveness. of course, but they tend to seek it again and Before taking drugs, reports another au- again. thority, the addicted person is afraid to attack The user becomes physically addicted his problems; afterward, he knows he could "hooked," he saysafter he has taken drugs solve the problems "but the new-found ease several times a day for about 2 weeks. But and calm are so satisfying that he feels there there is now evidence that the addicting proc- is no necessity to do anything about them." ess begins with the very first dose. Authorities emphasize that no two addicted Perversely, all the work involved in getting persons arealike."Many are far above and paying for the drug gives the addict what average in intelligence," reports a clergyman everybody has to achieve one way or another, who has worked closely with addicted persons a sense of accomplishment, and therefore for a dozen years."Some are extremely dull- strengthens his addiction.Also, once he has witted.Some have worked all their lives and become physically dependent, he has a new have supported their habits with theirearn- biological need to satisfy, and satisfying it ings.Some were leaders of fighting gangs be- fore they becam addicted. like satisfying hungergives him pleasure. There are artists, musicians, and p atential social workersamong The addict leads a wretched existence. He them." He adds that they are "people with- is in trouble with his family and, sooner or out a purpose;" other authorities described later, with the law. He may be sick one day them as "rootless" because he cannot get his drug, and sick the In sum, addicted persons have personality next because, trying for quick relief, he has problemsof many different typesand ad- taken too much of it.He has to raise more diction is a symptom of these problems.But and more money. most people with such problems do not turn Eventually, particularly if he has been ar- to drugs as a way of handling them.This is rested a feW times, the drug user will admit true whether their distress stems from a weak, he has a problem. The problem is "the habit," inadequate personality, or from the anxieties he says; if only he could be cured of it, his or other manifestations of a neurosis, or from other troubles would be nothing. He really a so-called character disorder, manifested by believes this, anddespite the fact that most antisocial activities and an apparent indiffer- addicts, once they have been withdrawn from ence as to what is right and what is wrong. drugs, soon return to themhe may in a sense It takes three things to makean addicta be right.For in order to cure addiction, it psychologically maladjusted individual,an appeals necessary to do something about the available drug, and a mechanism for bringing personality problems that helped bring it on. them together.Contrary to general belief,

5 the bringing-together is largely accidental. Youngsters who experiment with drugs The susceptible person does not, as a rule, start know that what they are doing is both illicit out looking for a shot and he is not, as a rule, and dangerous but have a "delinquent" orien- coaxed into taking one by a "pusher" for the tation toward life.Eighth-grade boys with illegal drug trade.Ordinarily he is intro- a favorable attitude to the use of drugs view duced to drugs by his associates. life with pessimism, unhappiness, and a sense of futility, and they distrust authority. On almost every block in the three de- BACKGROUNDS OF ADDICTED prived areas studied, there are antisocial gangs PERSONS and "respectable" boys. The chance of a boy's becoming exposed to drugs depends, to a large A study in Chicago in the 1930's showed extent, on his association with delinquent that although nine city areas had only 5 per- groups.In spite of great pressure, many of cent of the population, they contained half of the boys do not associate with such groups. the known narcotics users.These areas were By and large, they are the boys who have a the most blighted ones.They suffered from father, a teacher, or a pastor to whom they a wide variety of social problems, andthe peo- can talk about things that bother them. ple in themfrom the social and economic In 14 of the 18 delinquent gangs studied, standpointwere the poorest in the city. the use of heroin and the smoking of mari- The residents tended to be recent migrants huana were more or less common. The gen- foreign-born people finding it hard to get eral attitude was : "It is O.K. to use heroin if ahead. you feel like itas long as you make sure you Later studies in the 1950's showed that drug don't get hooked." users in Chicago were distributed much as they Juvenile addicts in generaleven before had been at the time of the first study.In they take drugsare easily frustrated and many of the areas, however, there had been a made anxious, and they find both states intol- great change: Negroes had replaced the for- erable.They cannot enter into prolonged, eign-born.But the old and new residents of close, friendly relations with others; they have these areas of high drug use had one thing in difficulties assuming a masculine role. Such common: social and economic deprivation. troubles can be traced to their family experi- Similarly, a study in New York City found ences. For example: Relations between par- that three-fourths of they adolescents using ents were often seriously disturbed, as evi- drugs lived in 15 percent of the city's census denced by divorce, separation, hostility; the tracts and that these were the poorest, most parents often gave the children no clear stand- crowded, and most dilapidated areas of the ards of behavior to follow, so the boy who city. eventually took drugs had no strong incentive to suppress impulse and develop discipline; since the father was absent, or cool or hostile, JUVENILE DRUG-USERS the child had relatively little chance to identify The New York study referred to above with and model himself after a male figure; made by the Research Center for Human Re- most of the parents had unrealistically low lations, New York University, and financed by ambitions for their boys, reflecting their own the National Institute of Mental Healthled pessimistic attitude toward life, and they were to a number of significant findings about distrustful of teachers, social workers, and young addicted persons.Here are some of other representatives of society. them, as condensed from a summary by two The activities of the gang offer to mem- of the authors: bers and hangers-on a sense of belonging. But

6 as the group grows older, these joint activities ing that the city had25,000 addicts, the Coun- are given up as "kid stuff," and the maturing cil put the total daily'payments for drugsat youngsters develop more individual concerns between $500,000 and $700,000.The addicts about work, future, and a steady girl. Mem- raised this money, the Councilsaid, by com- bers or hangers-on who are too disturbed mitting 50 percent of thecity's crime: emotionally to face the future as adults find On the other hand,persons who are basic- themselves seemingly abandoned bytheir old ally antisocialmay begin taking narcotics cronies and begin to feel increasinglyanxious. king after startingon a criminal career. The psychologically vulnerableyoung- With suchpersons criminal activity isnot ster, experimenting with various drugs, finds caused by a need fordrugs; it is a continuing that heroin is peculiarly effective inrelieving expression of antisocialtendencies. strain.The less 'disturbedyoungsters are In general, the: crimescommitted by ad- satisfied with an occasional shot, butthe un- dicted personsare against property rather than happy, anxious ones turnto it as a means of against persons.In Chicago in 1year, 30 relief from their everyday difficulties.Those percent of the arrestsamong the general pop- ulace were for who are members of delinquentgangs partic- sex offenses or for assault; ipate less and less ingang warfare and sports among narcotics users, however, lessthan 3 percent of the arrests and more and more in gang-organizedrob- were for these types of beries and burglaries. crime.Almost 60 percent ofthe arrests In sum, foran unstable individual who among addicts were for larceny; another25 does not have the kind of guidanceparents percent for robbery and burglary.Those ad- usually try to give, drugs offera solution to the dicted persons who committedserious offenses problem of growingup. against property andpersons were usually individuals who had committedsimilar of- fenses before becoming addicted. THE ADDICT AND THE Over most of the nation, addictedpersons CRIMINAL have been arrested and sentencednot for using drugs but for possessingthem, or for There is no evidence that narcoticsin them- selling themoften to getmoney to buy Some selves turn a person toa life of crime, but they- for themselves. A few Stateshave had laws I do affect individuals inways that allow them making addiction itselfa crime, but a 1962 to violate laws. For example, aperson who Supreme Court decision declaredsuch laws sets fire to a building because hewas smoking unconstitutionalCurrently,the possession while drowsy after taking a drug has broken a of any amount of narcoticsobtained illegally law.So has a physician who failsto provide is a criminal offense. good medical care because he is underthe in- As the result of the rise in additionright fluence of a narcotic.Further, a greatmany after World War II,Congress provided narcotic users do turn to crimeto support their severer penaltiesfor example, a sentence of addiction. from 2 to 10 years fora first offense involving Most of the juvenileusers in the New York possession of narcotics, anda minimum man- City study were spendingat least $40 a week datory sentence of 5years for selling them. on heroin, but eventually addictscome to For subsequent offenses thesentences range spend much more. On theaverage in New from 10 to 40 years.One provision criticized York City, the Mayor's AdvisoryCouncil on by many authorities is the denial of probation, Narcotics Addiction estimated,an addict parole, or suspended sentenceexcept in the spends between $20 and $25a day.Estimat- case of a first offense involving possession.

7 The Doctor and the Addicted Person

The addicted person who turns up in a ess but arrange to have drugs smuggled in, or doctor's office may be someone the doctor (c) may, rarely, have sucha serious physical knows wellanother physician, perhaps, or disease that even diagnostic withdrawal is some member of a family prominent in the unwise. community. More often he will be a stranger The abstinence syndromecanalso be with a plausible story of needing drugs only brought on by injecting N-allylnormorphine, until he can get back to his own physician or a fairly new drug that has proved a highly until his own physician returns.The visitor effective antidote for morphine, heroin, and may tell the doctor frankly he is addicted. similar narcotics.Injected into persons who Or he may say he has angina pectoris, kidney have recently taken sucha drug, it induces colic, migraine, hemorrhoids, or some other signs of the withdrawal illness within 15 min- condition and detailhis symptoms very utes.Several States use or plan touse it to realistically.Other physicians, he is likely to check on addictedpersons who have been say, have found that only narcotics will relieve released on probation or parole.But it has to be used with care. A more accurate test his pain, and he may even produce a drug for drug use is one to demonstrate thepres- label based on a prescription that another doc- ence of an opiate in the urine.It must be tor has given him, he says, and that has performed in a laboratory. proved very effective. What is the physician to do? Whatare his rights and obligations? TREATING THE ADDICT

Federal law does not prohibita physician RECOGNIZING THE ADDICT from treating an addict.It simply says that the physician may prescribeor dispense nar- The addicted person whocomes to the doc- cotics "in the course of his professionalprac- tor's office will probablyappear to be physi- tice only." The Supreme Court has ruled cally and mentally normal.If the doctor that it is not proper professional practiceto suspects addiction, the most important finding dispense narcotics to addicts without attempt- will be the presencear absence of needle ing to cure them, and the American Medical marks on arms, legs, hands, abdomen,or Association has recommended againstany thighs, or signs associated with withdrawal of system of treatment that places drugs in the the narcotic.Another important finding will hands of the addict for self-administration. be the presence or absence of anythingto ex- In sum, a physician may prescribe narcotics plain the symptoms related by thepatient. to anyone, whether or not addicted, if the pur- Often, however, instead of permitting the pose is to treat some painful disease and not physical examinationnecessary to uncover to maintain an addict in the state of addiction these findings, the patient will leave the office. for an extended period.The physician may The only sure way to demonstrate addiction treat addiction itself either in or out ofa is to bring on the withdrawal sickness.This hospital.However, the American Medical can be done by isolating the patient fromnar- Association has taken the position that it is cotics but presentsa problem because the impractical to treat addiction unless the patient (a) may refuse to undergo theprocess, patient's intake of narcotic drugscan be con- (b) may agree togo to a hospital for the proc- trolled by the physician and that such control

8 almostalwaysrequireshospitalization.* be essential to health should be administered ( The prospect of living without drugs arouses either by the physician himself or under his such anxiety that even addicts who voluntarily supervision in a general hospitaland only enter hospitals or private sanitariums often for the shortest period possible.The addict try to bring in a supply of their drug.) should not begivenaprescriptionfor As a practical matter, then, the physician narcotics. with an addict on his hands should either "It may very well be that the regulations treat him himself in a suitable hospital facility concerning dispensing of drugs to addicts have or refer him to a suitable facility for treat- been interpreted and enforced too rigidly," ment.Until recently, virtually the only in- the Council on Mental Health of the Amer- stitutions to which an addicted person could ican Medical Association reported in 1957. be referredunless the patient's family could "A physician who furnished an addict a small affordaprivatesanitariumwerethe quantity of narcotics to tide him over until he Public Health Service Hospitals at Lexington, reaches an institution, or who gives an addict Ky., and Fort Worth, Tex. Now an increas- narcotics so he can arrange his affairs prior ing number of municipal and State hospitals to entering a hospital for treatment is in have facilities for addicts: information about danger of being charged with a violation of them can be obtained from local and State the law despite the fact that he may be acting health departments and State departments of in what he regards as the best interest of his mental hygiene. patient.The Council...feelsthat the If there is a waiting period, drugs that may regulations should be altered to cover situ- ations of this sort." *For detailed information on the withdrawal of narcotics, as the first step in treatment, see, among Must the physician report cases of addic- other works: Isbell, Harris, "Opium Poisoning," tion?That depends on the State law; there in Cecil and Loeb, "A Textbook of Medicine," is no Federal requirement that he do so. W. B. Saunders Co., 1 1 th ed., 1959, p. 1637. Treatment in Federal Hospitals

Under legislation passed in 1929, the Pub- Almost half of the 2,770 patients admitted lic Health Service was authorized to establish during 1961 at Lexington-44 percentcame hospitals where Federal prisoners who were from New York.Illinois was second, with narcotic drug addicts could be treated.It 13 percent, Ohio third, with 4 percent. At was also authorized to accept voluntary pa- Fort Worth there were 661 addict admissions, tients if beds were available. The result was with 29 percent from Texas, 26 percent from the establishment in the mid-1930's of the California, and 9 percent from Louisiana. During the firstyears, virtually all the Public Health Service hospitals at Lexington, patients were addicts who had been convicted Ky., and Fort Worth, Tex. of some Federal offense and sent to the hos- The hospital at Lexington, which receives pitals by the Federal Bureau of Prisons. male addict patients from east of the Missis- Now, however, a great many are individuals sippi River and female addict patients from who have entered voluntarily.In fact, at the entire country, has accommodations for Lexington, 75 percent of the admissions are about 1,000 patients.The hospital at Fort now of voluntary patients, though these come Worth has 800 beds, half of which are used and go at such a rate that at any given time for male addict patients from west of the they constitute only about 50 percent of the Mississippi. total. 9 Some of the voluntary patients come be- narcotics, and the firststepcalled with- cause they genuinely want to stop takingnar- drawal or, insome other hospitals, detoxifi- cotics; others, because theyhave been threat- cation is to treat his physical ened with arrest unless dependence on treated; others, be- drugs.This is accomplished by cause their supply of drugs has been substituting cut off; for heroinorwhatever Other others, because theywant to lose an expensive narcotic he has been usingandthen gradu- "habit" and thengo back and get the same ally reducing the dosage of thesubstitute drug. kick for lessmoney. Methadone is a synthetic drug,discovered Generally there isa short waiting period, in Germany just before but the hospitals or during World War try to take first-time patients II, with onlya very slight chemical relation- at once.Application for admission can be ship to morphine andthe other opiates. made by a letter to themedical officer in Until 1945, when the charge of the appropriate Addiction Research institution.Vol- Center tested methadone, Lexington untary patients who can afford had been to pay are withdrawing addicts by giving charged $9.50a day. them injections of morphine in graduallydecreasing amounts. The new drug provedto have two great ad- THE PATENTS ATLEXINGTON vantages: it was very effective whengiven by mouth, whichmeant that the nursing staff About three-fourths of thepatients ad- could lay aside the hypodermicsyringes, and mitted during 1961were men, and 60 percent its action lasted longer,which meant that the were white. The whitegroup included staff could cut downon the number of doses. Puerto Ricans, who madeup 10 percent of When morphinewas the withdrawal drug, the the total admissions.Only 2 percent of the addicted person received itin a ward he patients admittedwere less than 20 years old; called "the shooting gallery;"now, drinking 74 percent were between 20 and 39.About reddish-colored methadone froma little glass, one-third were married. he calls the ward "thecocktail lounge." Fifty-three percent of the newly admitted For the heavily addictedperson, the acute patients claimed to havebeen unemployed; phase of the withdrawal 20 percent admitted they period may last 10 had been working or 12 days, but for the usual addict, who at illegal occupations. has been taking a highly adulterated Sixty-eight percent had drug, it is not finished high over much soonerin about 4 days. school.Eighty-five percent During were in the this period he is sick, but the lowest of five socioeconomiclevels, and most decreasing doses of methadone flatten had a background ofsevere emotional and out the peaks of the ill- ness and make it endurable. At the social deprivation.(But some of thepersons end he is admitted were doctors andnurses; every year transferred to the OrientationWard for a Lexington takes in about 60 ofthese.) convalescence period lastingabout 2 weeks. About 90 percent of thepatients were He regains his appetite andstrength during classified by Lexington doctorsas easily frus- this time but shows irritabilityand restlessness, trated, impulsive, unstable,and unable to symptoms that may last for severalmore plan ahead; in the hospitalthey were often months. childishly demanding andstubborn. In the Orientation Ward,the patient is in- terviewed by members ofthe vocational, TREATMENTOF PHYSICAL correctional, social service,and psychiatric DEPENDENCE staffs and acourse of treatment is then out- linedby his administrativephysician, a The treatment program aims to prepare a psychiatric resident whosupervises hispro- patient to return home andlive without using gram until the patient is discharged. 10 PREPARING PATIENTS FOR The patient may attendchurch services and LIFE OUTSIDE consult a chaplain of hisown faith. He may join Narcotics Anonymous,known also as Ad- Fewer than a fourth of the patients get any dicts Anonymous.His vocational supervisor, formal psychotherapy, partly because the staff the psychiatric aides inhis dormitory, his is too small and partly becausemany patients physician, and social serviceworkers all stand resist it or are judged incapable of being bene- ready to listen and,where advisable, offer fited by it.However, all activities of the help. hospital are designedto have therapeutic Lexington believes that ifa person is to value for people who, by and large, have completely recover fromphysical addiction never quite grown up, distrust everybody in and start anew pattern of lifein which authority (and virtually everybody else) ,and drugs are not used, eitherto produce pleasure have substituted drug-taking for practically or banish distresshe ought tostay in a drug- everything that occupies other people. free environment for 4months after receiving All physically able patients are assigned to his last narcotic drugs.More than one-third jobsin the kitchen, the butcher shop,or the of the voluntary patients, bakery; as a waiter however, leave or as an attendant; in within 2 weeks--assoon as they have gone maintenance and engineering; painting and through the withdrawalperiod, or shortly glazing, woodcrafts, needle trades, printing,or afterward. By the end ofthe first month, agriculture; as a laboratory assistant,an auto more than half have gone.Less thanone- mechanic, an electrician, a typist, or a variety third stay as longas the doctors would like. of other occupations. For almost all types of All the othersare discharged AMAagainst work there is a trainingprogram that helps medical advice. prepare the patient to get and hold a job when he is discharged.The primary purpose of the vocationalprogram, however, is not to AFTER THEY LEAVETHE get patients on payrolls but to help themes- HOSPITAL tablish work habits and learnto work with other people.This means that they have to Lexington records show that ofsome 35,000 learn to put some controlson themselves and patients since 1935 fewerthan half havere- also to accept authority. turned (but of thesemany have been back 5 "Immature adults, like normal children,"a or more times). What happened to those former medical officer in chargeat Lexington who did not return? HoAr many stayed free points out, "resist and reject authoritybecause of drugs and howmany merely avoidedor it limits their freedom of action. To many were deniedthe opportunity togo back? of our patients authority is regardedin terms What about those who did of their past experience with their return: why did parents and they relapse? societyas hostile, punitive, and Unfortunately, nobody knows rejecting. the answers.The best information Constructive, consistent relations with author- now available on what happens ity figures of a differenttype may permit a to Lexington pa- modification of previous reaction patterns." tients is provided bya followup study of some At Lexington the patient also hasan oppor- 1,900 residents of New York Citywho were tunity to participate in softball,basketball, discharged between July 1952 andDecember boxing, and other sports,go bowling, watch 1955.More than 90 percent of them be- TV and movies, play inan orchestra, take came readdictedgenerally within 6 months. part in a show, help get out The Blue Grass A similarly high readdictionrate prevails Times (a Ilvelynewspaper, by and for the among persons treated at New York City's patients, 10,4aringa column, "The Talk of Riverside Hospital.This is a joint hospital Nar-Towne" ), and useone of several libraries. and school facility, witha capacity of 140

11 patients, set up in 1952 to care for drug users 2. Readdiction rateswere lower for those under 21 years of age. who had gone to the hospitalas prisoners than Does this mean that treatmentof the for those who hadgone voluntarily.One ex- physical addiction is only successful in about planation, presumably, is that the prisoners 10 percent?Hardly.Any patient who stays had to stay longer, thoughstays beyond .$0 for more than 2 weeks isover the acute illness days apparently broughtno improvement in phase.One Lexington medical officer points readdiction rates.Another likely reason: the out that 4f they were then killed in an acci- involuntary patients often hadsomeone to re- dent, they could be recordedas persons who port to regularly upon releasea paroleor had recovered.Instead of beingkilled, probation officer. though, thetypical addictat least,the typical New York City addictgoes back to his same old associations and hissame old HOSPITAL AND POSTHOSPITAL troubles and eventually turns to drugs again PROBLEMS for relief.He does well in a sheltered, drug- free environment, but away from it he finds Hospital authorities would liketo have some his world too painful and himself too weak. means of keeping voluntary patients under Doctors at Lexington can tell of patients treatment as long as the doctors in charge of who have stayed free of drugs foryears and the treatment thinknecessary.They are par- apparently will continue to stay free.One ticularly concerned about the patientwho has has become an official ofhis'home town. withdrawn from treatment severaltimes Another---who telephones greetingsyear after against medical advice and then appliesagain year on Christmas Eveowns a little business for admission, with nothingto indicate that on the West Coast. And one founded Nar- he will stay beyond the timenecessary for cotics Anonymous after he had been to Lex- withdrawal.The answer may lie in- legisla- ington eight times. tion enablinga hospital staff to seek civil Doctors can also cite illuminating cases of commitmentin the courts of theStates readdictiona woman free of drugs 15 years, where the hospital is locatedforindividuals whose marriage broke up; a lonely, rootless who in the judgment of the staffrequire it. man who finally found a sweetheart and lived From the viewpoint of the PublicHealth happily for the first time, till thewoman sud- Service, the long-termanswer to this and denly died. other problems presented by voluntarypatients Physicians now look on addictionas a lies in the establishment of State andmunici- chronic disease, with relapses to be expected. pal facilities sufficient tocare for all the But they believe, too, that the periods of addicted persons whonow apply to Federal abstinence can be lengthened andin many hospitals.Such facilities, too, ofcourse, will cases, at leastperhaps extended indefinitely if need ways to keep their patients longenough. only the right measures can be found andap- No matter wherean addicted person is plied.The Lexington fcllowup study gives treated, however, hospitalization is onlythe some reason for optimism because it shows first step; posthospital supervision,or what is that: commonly known as aftercare, is usually just 1. Readdiction rates were lower forpersons as essential.Among five measures to which over 30 than under it.The implication (sup- the American Medical Association and the ported by other evidence) : As addictedper- National Research Council of the National sons grow older,there is some tendency Academy of Sciences gave their support, ina toward giving up drugs, presumably because joint statement in 1962on narcotic addiction, some of these persons are becoming emotion- the first three were listed as "1, after complete ally more mature. withdrawal, followup treatment for addicts,

12 including that available at rehabilitation cen- commitment."( The other measures were ters,2, measures designed to permit the "4, the development of research designed to compulsory civil commitment of drug addicts gain new knowledge about the prevention of for treatment in a drug-free environment, 3, drug addiction and the treatment of addicted the advancement of methods towards rehabili- persons, and 5, the dissemination of factual tation of the addict under continuing civil information on narcotic addiction.")

A pir,:me, " E-10%ckci Af, tv-...,,e'are and Other New13.. vakanda

Since hospitalization by itself has proved Lexington patients ranging in age from 16 to insufficient,a number ofadditional ap- 72.It was a frustrating and educational ex- proaches have been tried or suggested. Most perience.The addicts were neat, undemand- of them have to do with aftercare, where the ing, not difficult to deal with.Most of them problems include what services should be seemed genuinely eager for help in overcom- offered, what organizations should offer them, ing their addiction, and they said they wanted and how the addicted person can be induced jobs.But they were also hypersensitive and to accept them. suspiciousquite naturally, perhaps, in view This section notes some of the new ap- of their backgrounds and the fact that this was proaches. a government project.They wanted their problems solved in a hurry, and most of them could not admit that they had any problems THE NEW YORK except the immediate oneslike mcney or DEMONSTRATION CENTER a place to live.They seemed puzzled over what to do with freedom, yet often they could It seemed reasonable to suppose at one not bring themselves to keep appointments time that the problems of the addicted person whether with the Center itself or with cooper- might be solved, once he had been discharged ating agencies. Many of them were placed from Lexington or some other hospital treat- on jobs, but most of these soon relapsed to ing addiction, if only all the resources of the using drugs and left. community could be brought to bear on them. On the other hand, a number did work out To test this hypothesis, and to assist cooperat- better ways of dealing with strains in their ing agencies to extend theirservices to family and social relationships and stayed addicted persons, the National Institute of away from drugs longer than ever before. Mental Health in 1957 set up a Demonstration Once more those under probation or parole Center in New York City staffed by eight tended to do better than the others. social workers and a psychiatric consultant. This lesson emerged clearly :for the ad- Selected patients returning to New York from dicted person coming out of the hospital, a Lexington were advised to go to the Center guidance center is not enough: he must also if they needed help. A social worker would listen to an individual's problems and then have some resourcean agency or an indi- enlist the services of any community group vidualto provide constant step-by-step sup- such as the city welfare department, the port of his efforts. State employment service, and counseling In 1962 a new demonstration began in the agenciesthatcouldhelp solve these Washington Heights area of New York City. problems. One of its objectives is to explore the potential During its 5-year life, the Demonstration role of a local public health agency in working Center worked with more than 900 recent with some portions of the narcotic addict

13 population and their families.The demon- same time give sufficient attention to the indi- stratica is a cooperative project involving the vidual. And it emphasized that only by form- New York City Department of Health, the ing continuing relationships with the addicted New York City Community Mental Health person himself could a staff member "begin to Board, and the National Institute of Mental help him reshape his lifepattern along lines Health. more compatible with society's." Of those the committee has worked within CHURCH MISSION IN an intensive way in an effort to help themrec- EAST HARLEM ognize and do something about theiremo- tional problems, the number whoare free Since 1956 a church mission in New York from narcotics atany one time remains con- Citythe East Harlem Protestant Parish Nar- stantly between 20 and 22percent. This is a cotics Committeehas been demonstrating relatively high percentage. the value of direct, personal support. A crudely painted insigne over the door to its headquP rters, a converted store inan area A PAROLE PROJECT containing several hundred known addicted persons within a radius of four blocks, de- Late in 1956 the New York State Division picts a cross bearing down and smashinga of Parole establisheda special narcotic project hypodermic syringe, but the religionprac- under which four parole officerstrained so- ticed within is simply that of the Golden Rule cial workerswere each assigned 30 addicted and of the admonition to forgive,even up persons newly paroled from reformatories and to seventy times seven. Stateprisons. Because thecaseload was The EHPP Narcotics Committee, which is lighter than theone usually carried, each offi- staffed by two ministers, a sociologist, anda cer could see his parolees frequently and visit secretary,helps theaddicted person go their famnif s, too. Many of the addictedper- through the routine of enteringa hospital, sons seemed to look forward to their sessions generally one in New York City, and visits and with the officer: they hadno one else to turn counsels him.If he has been arrested, it visits to for advice. And many of the families him in prison.It visits and counsels his fam- proved to be just as much in need of counsel- ily. When he is free, it helps him finda job ing as the narolees and eventuallycame to re- and food and lodging, too, ifnecessary.Its gard the visitor as a friend rather than doors are open for a whileevery morning so a law enforcement agent. that persons with emergenciescan be helped, Over a 3-year period, the special project and they are open again all afternoon andcer- tain evenings. supervised approximately 350 parolees, and of Until 1962, staff memberssaw between 15 these 42 percentan unusually highpropor- and 20 persons a day at headquarters. Then, tiondid not return to theuse of drugs. as the committee's work became more widely In reporting on the project, the supervising parole officer wrote: known and as New York City providedmore beds for addicted persons, the number of visi- A discharged patient who hasno one to help him tors began rising and on some days reachedas get a job, who is confronted with the same family tensions, who has no vocational many as 70. or academic skills to prepare him for life, who is shunned by employers At this point the committee, asking for city and legitimate members of his community,is or Federal funds to increase its staff, pointed doomed to failure before hr leaves thehospital. out that it could no longer take care of the Unless someone is there to extenda firm but helping hand, another incurable case will be enteredon the needs of everyone asking for help andat the records.

14 z

AN AFTERCARE PROGRAM AT to treatment in the California Rehabilitation A HOSPITAL Center, a hospital expectedto have room for 1,800 narcotic addicts.Once admitted, he Mainly as a laboratory for study andre- has to stay at least 6 months, andeven if he search, a narcotic addiction treatment unit came in voluntarily he may have to stayas was established in 1959 at Metropolitan Hos- long as 5 years.Prisoner or volunteer, he is pital, which is a municipal general hospital released on parole, andto win discharge from in East Harlem associated with New York this he must remain drug-freeat least 3 con- Medical College. All patientscome in volun- secutive years.Eventually patients released tarily and are housed in a locked ward. Asat from the hospitalmay spend some time in a Lexington, they are withdrawn from heroin halfway house as further preparationfor re- by the methadone-substitution method, but suming life in the outside world.Making the withdrawal period lasts 2or 3 weeks, and addiction itself a crime is unconstitutional, they are eligible for discharge about a week said a 1962 Supreme Courtdecision. It later. They undergo psychotherapy during stated also that in the interest of thegeneral their hospital stay and are urged to continue health and welfarea State might establish a treatment as outpatients. program of compulsory treatment of those Metropolitan's program emphasizes after- addicted. care. In addition to continued psychother- Under a New York law passed in 1962,ad- apy, it offers a number of services, including dicted persons whoare arrested may request help with financial, family, and housing prob- treatment in a State hospital havinga special lems, vocational counseling, legal advice,a narcotics unit. New units will givethe State clubroom where anyone who has been treated a total of 555 beds for such persons. Patients may spend his free time, and arts, crafts, must stay in the hospital as longas the doctors games, sports. parties, shows, and other recrea. think necessary. They will remainunder su- tional activities. pervision of the Commissioner of MentalHy- During the first 2 years of the program, the giene, inside and outside the hospital(after majority of the patients did not continue release they must report regularlyto an after- treatment. The ideal center for rehabilita- care facility) for a period of up to 36 months. tion of the addicted person,say the psychia- Commitments will not be made whenthe trists ; barge of Metropolitan's program, court considers them contrary to the interest wou. a day-night hospital, where persons of justice or when space isnot available. The who been treated would spend half of State's programs in narcotics researchand each 24 hours."A full range of services aftercare as well as in treatmentare growing; would be provided," they suggest, "including they are directed bya central office in the De- a street-work staff reaching out into the neigh- partment of Mental Hygiene. borhood and the precinct home, pychother- A pilot project in Marylandat the Spring apy, drug therapy, vocational counseling, Grove State Hospital, Catonsvilleempha- educational rehabilitation, selected vocational sizes the need to buildup an addicted person's placement, sheltered workshop, familycoun- esteem. Upon his release from a closed ward, seling, and recreational therapy.It is this after a month or two, he is assignedto a job kind of broad effort thatseems necessary for in the hospital, and later is given ground attacking the problem." privileges.Later, if he shows responsible be- havior, he is given weekend paroles.Five SOME STATE AND CITY days a week he goes out from the hospitalto ACTIONS learn a trade or a skill, returningat night. Upon his discharge, he returnsto the outpa- Under a California law passed in 1961any tient clinic once a week for counseling and addicted person may volunteer or be sentenced other help.

15 New York City's master plan for narcotics other authority writes: "It is too bad that con'-ol, which is under the direction of a Nar- Narcotics Anonymous has had so little en- cotics Coordinator appointed in 1960, calls couragement and backing from community for hospitalization in community institutions leaders that it must struggle along with insuf- (which in 1962 had several hundred beds for ficient funds.The by-passing of this group is addicted persons and planned additional in all probability due to the deeply ingrained ones) and then for aftercare to be supplied by and widely held belief that drug addicts cannot neighborhood groups, outpatient departments get together for any constructive purposes." of mu; licipal hospitals, health department In the Los Angeles area an organization clinics, halfway houses (to ease the return to called Synanon has enabled a number of ad- the community) and work camps (for long- dicted persons to cure themselves for saeable term rehabilitation, vocational guidance, and periods.It is a residential organization. An eventual job placement). The program also addicted person is accepted only if heagrees to calls for educational and preventive activi- kick his habit "cold turkey"that is, without ties and for research and evaluation. the use of methadone or any other drugand to remain at Synanon a considerable time. During the first 6 months or longer, he lives CANADA'S APPROACH and works within the building. Then he gets Under the new Canadian Narcotic Control a job on the outside but continues to live at Act, passed in 1961, the criminal ackactthat Synanon, contributing most of his earnings to is, the addicted person who has been ar- the community.Eventually he moves to a restedis to be treated in a Federal rehabilita- place of his own but continues to visit Syna- tion center and, when released, is to be sub- non frequently and take part in group sessions. ject to the supervision of the Parole Board. In 1962 the organization reported that more This supervision lasts indefinitely. The Fed- than 100 of its addicted personsmost of eral Government offered to treat all addicts in them still residentshad been free of drugs for the same centers, but whether or not it will do as long as 4 years. Residents stress the fact of so depends upon whether or not the provin- motivation. As they progress they can become cial governments will provide for the commit- responsible for part of the program: they tal of addicted persons who are not charged may even become members of the board of with any criminal offense. directors. Another important feature of the act is that Canadian physicians now may prescribe drugs A RESEARCH CLINIC for the state of addiction as well as for disease. The Narcotic Control Division keeps a watch- In the early 1920's, following a Supreme ful eye upon such cases to make sure the Court decision holding it illegal for a physician treatment is in good faith. to prescribe drugs to an addicted person merely to gratify his addiction, States and AMONG OTHER EFFORTS municipalities opened some 40 so-callednar- cotic clinics.Most of them were simply dis- Alcoholics Anonymous, founded to help pensaries set up to provide persons with drugs people addicted to alcohol, often works also in order to prevent exploitation by drug ped- with people addicted to other drugs.Pat- dlers.They were all closed by 1924. There terned on it is Narcotics Anonymous, which is no clear record of their accomplishments, some authorities on addiction report has been for good or evil. troubled by a tendency on the part of the Some authorities have argued that if an ad- police to note who attends the meetings.An- dicted person could get his drug legally,

16 through his physician or a carefully supervised THE BRITISH METHODS clinic, he would not have to buy it from crimi- nals and he would not have to turn to criminal Under certain circumstances, in Britainas activities himself. Therefore, the profit would in the United States,a doctor may legitimately go out of drug-smuggling, the relation between administer drugs to addictedpersons. In Brit- addiction and crime would be broken, and the ain these circumstances,as defined in 1926 by addicted person could become self-supporting. the Departmental Committeeon Morphine Further, this argument goes, in order to ob- and Heroin Addiction, have included "per- tain their drugs legally, addicted persons could sons for whom, after every effort has been be required to undergo treatment intended to made for the cure of addiction, the drugcan- help them understand themselves; eventually not be completely withdrawn, either because: many of these might drop drugs entirely. 1. Complete withdrawal produces serious (Some of the addicted persons treated as out- symptoms which cannot be satisfactorily treated patients by a group of New York psychothera- under the ordinary conditions of privateprac- pists began within 2 months after starting tice; or 2. The patient, while capable of leadinga treatment to consider dropping drugs.) useful and fairly normal lifeso long as he takes Many other authorities, however, have ar- a certainnonprogressivequantity, usually gued to the contrary.For physical reasons, small, of the drug of addiction,ceases to be able to do so when the regular allowance is with- because of the development of tolerance, they drawn. say, the addicted person.must continue to in- In 1960 a second groupthe Interdepart- crease his dose in order to get the desired ef- mental Committee on Drug Addiction, fect.If he could not obtain as much of the ap- pointed 2 years earlier by the Minister of drug from his physician or clinic as he wanted, Healthconcluded its study of,among other he would go back to the illegal market. He questions, whether or not therewere still cir- might continue to patronize the drug peddler cumstances in which the continued adminis- in any event, giving or selling to friends any- tration of drugs could be justified. thing beyond his own needs. Great Britain, this committeereports, has In a joint statement in 1962, the American only a very small addiction problem-454 Medical Association and the National Re- known addicts in 1960, out ofa population of search Council of the National Academy of more than 50 million.Furthermore, the il- Sciences declared that "the maintenance of licit trade in morphine, heroin, and drugs of stable dosage levels in individuals addicted to similar effect is "so smallas to be almost narcotics is generally inadequate and medi- negligible." cally unsound and ambulatory clinic plans for As for point 1, given above, thenew com- the withdrawal of narcotics from addictsare mittee finds that only institutional treatment likewise generally inadequate and medically is likely to be satisfactory but that, since there unsound." are so few addicts, it would be impracticable To bring scientific evidence to bear on the to establish treatment centers exclusively for problem, a number ofindividualsand addicted persons.Initial treatment is best groupsincluding the Joint American Bar undertaken in the psychiatric ward ofa gen- Association and the American Medical Asso- eral hospital, it advises, and long-termsuper- ciation Committee on Narcotic Drugsrec- vision "would best be undertaken at selected ommended "an experimental facility for the centers." Compulsory commitment toan in- outpatient treatment of drug addicts toex- stitution "is not desirable." plore the possibilities of dealing with at least With point 2 the committee agrees butem- some types of addicted persons in the com- phasizes that "the continued provision of sup- munity rather than in institutions." plies to patient addicts depends solely on the

17 individual decision made by the medicalprac- migration, or migration, of greatly underpriv- titioner professionally responsible for each ileged people. case." Contrary to a widespread impression, Along with law enforcement, thecause of in Britain an addicted person is not automati- the almost negligible traffic in illicitdrugs, cally entitled to receive drugs and there isno says the British committee, "seems to lie official system for allocating him regular largely in social attitudes to the observance of supplies. the law in general and to the taking of danger- From time to time, the committee reports, ous drugs in particular." "there have been doctors who were prepared to issue prescriptions to addicts without pro- viding adequate medical supervision, without THE HOPE FOR SAFER DRUGS making any determined effort at withdrawal, and, notably, without seeking another medical Comp 3unds developedas possible substi- opinion. Such action cannot be too strongly tutes for morphine, codeine, and other opiates, condeMned." But no such doctor is known at are submitted for testing to the Committeeon present, and in 20years there have been only Drug Addiction and Narcotics of the National two hapitual offenders. Research Council. If theyappear to be non- Under present regulations, the Government addicting in animals, the committeerecom- may withdraw from an offending doctor his mends a test with human volunteersat the authority to possess and prescribe dangerous Addiction Research Center, Lexington.In drugsprovided he has been convicted ofan recent years these tests have shown thata offense against laws relating to these drugs. number of new drugs are justas effective as The committee considereda proposal to estab- codeine in suppressing coughs but, in spite of lish special medical tribunals that would ad- the fact that they are closely relatedto codeine, vise the government whetheror not in particu- are not addicting. In other words, chemists lar cases there were sufficient medical grounds have succeeded in splitting off the cough-re- for administering drugs by the doctorcon- lieving elements ofan addicting drug, ants cerned, either to a patientor himself.If a there is hope that they will be ableto do the tribunal decided therewere not, the Govern- same thing with pain-relieving elements. ment could act without a previous conviction In preliminary tests in 1962one compound in the courts. induced much the same effectsas morphine The committee opposes such tribunals. "Ir- but, when withdrawn, only minor signs of ab- regularities in prescribing of dangerous drugs," stinence.If further testing bears out these it concludes, "are infrequent and wouldnot findings, the new compoundmay come to re- justify further statutory controls." place methadone in treating physical depend- Both British and United States law limits ence. dispensing or administering narcotic drugs by Another promising compound provedas ef- physicians to bona fide professional practice. fective in early tests as morphine in relieving However, authorities feel that thereare differ- pain but to be no substitute for morphineor ences between them in the interpretation of methadone in treating the withdrawal illness; what is bona fide professional practice.In hence there was hope that it wouldprove to addition, the vast difference between thetwo be non-addicting. But the scientists in charge countries both in the size of the problem and of the tests recall that thesame hope existed the extent of the underworld's connection for every °pie-7 or opiate-like drug introduced with it appears to stem primarily from differ- since 1900, and they are determined to letno ences in culture and history.As a notable new compounds come into use under false example, Britain has not experiencedmass ink. colors.

18 Preventing Addiction

With any disease or disorder, it is better to tion, the treatment and rehabilitation of ad- prevent than to treat, and this is particularly dicted persons will help prevent the spread of true when treatment is long and difficult. addiction.But such treatment, ofcourse, is Programs directed toward improvingmen- difficult and costly. tal health and eventually reducing the number Addiction can also be fought by reducing of susceptible individuals are needed, but the availability of illegal drugs. A substantial these call for a long-term effort.In blighted reduction in the supply of such drugs in the areas, improving the environment will reduce 1 United States has been accomplished at rela- the number of individuals who woulduse tively little expense, and aloig with this de- drugs if they were available, but this,too, is a cline has come a substantial decrease in the long-term effort. 1:, number of addicted persons.Reducing the Since most addictedpersons have been in- supply of narcotic drugs is probably themost troduced to narcotic drugs bysomeone who is readily available means of preventing narcotic himself addicted, or is heading toward addle- drug addiction. I Addiction To OtherDrugs 1

When physicians and law enforcement offi- COCAINE cers talk about addiction, they almost always 1 mean addiction to morphine, heroin, and This drug, which comes from the leaves of other opiates or opiate-type drugs. Buttwo the coca plant and was widely usedas an anes- entirely different drugs, marihuana andco- thetic until chemists replaced it withnovo- caine, are associated in the public mind with caine, today has relatively fewusers. But it is "the drug menace" and are under Federal responsible for the common misconception control, and a third class of drugs, the bar- that all drag takers are "dope fiends." Taken biturates, presents a greater problem than by injection, cocaine confersa feeling of tre- either of these. mendous power, and when thissoon dies, the user tries to recapture it by taking more, and then more. Eventually he develops danger- MARIHUANA ous hallucinations and may assault people in the belief that they are persecuting him In this country, marihuana, prepared from the leaves of the hemp plant, is generally Tolerance does not develop, and abstinence symptoms do not occur. smoked as a cigarette; in eastern countries, preparations of the same drug, known thereas , are chewed, smoked,or drunk. THE AMPHETAMINES Smokers generally use the drug at social gath- erings and become mildly intoxicated; they do Like cocaine, the amphetamines powerfully not develop tolerance and do not become stimulate the central nervous system.These physically dependent. However, certainun- are the so-called "pep pills." They have me- stable ones may become psychotic, and smok- dicinal uses but when taken inexcessas they ing marihuana has been formany juveniles a often are by mixed-up persons seekinga thrill step to taking heroin. or an escapethey bring on a number of toxic

19 symptoms including heightened bloodpres- Sudden, complete withdrawal ofbarbitu- sure, rapid pulse, sweating, tremors, spasms, rates from an addicted person usually results in and sometimes a psychosis. convulsions and oftena temporary psychosis resembling delirium tremens. Deathmay fol- BARBITURATES low.So the drug must be withdrawn under medical supervisionover a relatively long With the exception of the opiates and alco- period.* ho!, the chief addicting drugs inuse today are Among the patients at Lexington,roughly the sedatives knownas barbituratesin par- 20 percent have been addictedto both bar- ticular, the more potent, quick-actingones biturates and narcotics, and for thesethe with- such as , , andamo- drawal period usuallyruns from 10 to 14 days. barbital. Taken in small amounts and under In some cases of addictionto barbiturates, the direction of a physician, these depressants however, withdrawalmay take as long as 2 of the central nervous system dono harm; months. taken in uncontrolled quantities at frequent The barbiturates donot come under the intervals, they are as truly addictingas heroin narcotic laws and nobody knowshow many or morphine and give the individual and his persons are affected; however, the number ap- physician an even greater problem. Hence in pears to be many thousands and to havegrown prescribing barbiturates the physician should greatly over the last decadeor more. Persons use the same care as in prescribing narcotics. addicted to barbiturates aloneare not legally Like alcohol, the barbituratesare intoxicat- eligible for treatment at the Public Health ing. Addicted personswho suffer from the Service hospitals. same type of personality disorders as those who become addicted to opiatesuse them for TRANQUILIZERS short sprees or long debauches,or even to keep more or less continuously intoxicated. The Tranquilizers of the meprobamategroup person intoxicated with barbiturates is drowsy have also been shown to be addicting if taken and confused, unable to think clearly, andun- in falrly large dailyamounts over a period of able to coordinate muscular action when he months. stands or walks. He is depressed, irritable, morose, And quarrelsome. He shows poor *For more detailed information,see, among judgment, and finds it difficult to perfornf other works: Isbell, Harris, " Poison- ing," p. 1631, "A Textbook of Medicine"by Cecil simple tasks or take simple psychologicaltests. and Loeb, W. B. Saunders Co.

Drug Addiction: SummingUp

SOME OF THE IMPORTANT addictedis both physical and psychological. THINGS KNOWN 2. Curing an acAticted person's physicalde- pendence on drugscan now be accomplished 1. Addiction is usuallya symptom of a per- humanely and quickly.Curing his psycho- sonality maladjustment, thoughno typical ad- logical dependence,or his tendency to use dict personality has been identified. Inrecent drugs to solve his problems,may take years times in this country addiction has beenmost so far as we knowbecause it is rooted in his prevalent among deprivedgroups in large maladjustment. cities.The illness itselfthat is, the compul- 3. Many addictedpersons relapse frequently sion to take drugsonce one has become after treatment;some, not at all.It seems 20 reasonable to view addictionas a chronic ill- 2. How do drugs workon the cells of the ness, with relapses to be expected but with the brain and the body? Arecertain people more hope that the periods of abstinence willgrow likely than others, biochemically,to become longer. addicted? 4. Hospitalization is not enough because, 3. What are the most effectivetypes of hos- upon discharge, the patient often finds himself pital and aftercare programs?And where, in in the same painful environment that helped relation to the addictedperson's community, lead to his addiction. Thereturn of a treated should they be located? addict to an environment where drugs are 4. Why dosome addicted persons seek out available is almost a certain return to addic- and accept help while othersdo not? tion.Some type of aftercare program ex- 5. Whatmeasures are needed to keepan tending for a long period, and perhapsin- addicted person ina hospital long enough for definitely, seems needed to strengthenand him to get the maximum benefit?And how train the addictedperson for normal living. long is that ? Also, whatare the most effective One problem: typically the addictedperson ways of exposing an addictedperson to an has been treated as an outcast and even a aftercare program, and keepinghim exposed? criminal and he feels he will continueto be 6. Are certain addicts incurable,on the treated that way. basis of everythingwe now know? If they are, 5. The addicted person does best when he can they be maintained as useful membersof has some type of authority to bolster him; like societyand the profit takenout of the illicit an adolescent, he wants limits set on him. marketby some arrangements forsupplying Possibly this authoritycan be effectively ex- drugs legally? erted by an experienced worker in thefield of 7. What happensto addicted persons over addictionphysician, pastor, social worker a period of years?In the case of those who who is genuinely interested inthe addicted relapse, whatare the factors involved? What person, has time and patience to help him, and factors enable the othersto remain abstinent? wins his respect.Possibly it must have the force of the law behind it for best results. 6. Addiction can be prevented (a) through REFERENCES mental healthprograms to reduce the number AMA Restates Positionon Ambulatory Clinics for of susceptible persons; (b) throughcontinued Addicts.Journal of the American MedicalAs- efforts reduce the availability of illegal sociation.Vol. 182, 30.Oct. 13, 1962. Brill, Leon. drugs; (c) through treatment that reduces Preliminary Experiences ofa Pilot the Project in Drug Addiction.Social Casework. number of addictedpersons, since these bring January 1961. the drug and the susceptibleperson together; Chapman, Kenneth W. Managementand Treat- (d) by improving the conditions inthe de- ment of Drug Addiction.Journal of Chronic Diseases, vol. 9 (3), 315.1959. prived neighborhoods where addiction is most Chapman, Kenneth W. NarcoticAddiction. Mod- common. ern Medicine. Oct. 15, 1957. Chein, Isidor, and Rosenfeld,Eva.Juvenile Nar- cotics Use. Law and ContemporaryProblems, IMPORTANT POINTS vol. 22(1), 57.1957. REQUIRING FURTHER Clausen, John A.Social and Psychological Factors in Drug Addiction.Law and Contemporary RESEARCH Problems, vol. 22 (1), 34. 1957. Comment, Narcotic Drug Addiction. 1. Why do some individuals witha person- ,,tri...-rican Journal of Psychiatry, vol. 119(8),7! &.`..bru- alitymaladjustment become addictedto ary 1963. drugs, the opiates in particular, while others Council on Mental Health, AmericanMatical As- even some of those who experiment with sociation, Reporton Narcotic AdO'clion, Journal of the American Medical Assoc drugs----C1 not? .. don, vol. 165 (Nov. 30, Dec. 7, Dec. 14).1957.

21 Diskind, Meyer H. New Horizons in the Treatment Kolb, Lawrence. Drug Addictionin Its Relation to of Narcotic Addiction. Federal Probation Quar- Crime.Mental Hygiene, vol. 9(1), 74.1925. terly. December 1960. Lowry, James V.Hospital Therapy of Narcotic Eddy, Norman C. Different Approaches to Drug Addicts.Modern Medicine.Oct. 15, 1957. Addiction: The Clergyman's Viewpoint.Pre- Lowry, James V.Hospital Treatment of theNar- pared for Institute in Pastoral Psychology: Prob- cotic Addict.Federal Probation Quarterly.De- lems in Addiction, Fordham University.1959. cember 1956. Finestone, Harold.Narcotics and Criminality. Nyswander, Marie.The Drug Addictas a Pa- Law and Contemporary Problems, vol. 22(1), tient. Grune and Stratton, New 69.1957. York.1956. Nyswander, Marie, and others. Freedman, Alfred M., and others.Response of The Treatment of Drug Addicts as Voluntary Outpatients:A Prog- Adult Heroin Addicts to a Total Therapeutic ress Report. Program.Presented before the American Ortho- American Journal of Orthopsy- chiatry, vol. 28. psychiatric Association. March 1962. October 1958. Hunt, G. Halsey, and Odoroff, Maurice E. Follow- Report to the Councilon Pharmacy and Chemistry. up Study of Narcotic Drug Addicts After Hos- What to Do with a Drug Addict.Journal of the pitalization.Public Health Reports, vol. 77(1), American Medical Association, vol.149, 1220. 41. January 1962. July 25, 1952. Interdepartmental Committee on Drug Addiction. Report of the Mayor's AdvisoryCouncil on Nar- Drug Addiction, Her Majesty's Stationery Office, cotic Addiction. Quoted in the New YorkWorld- London, England. 1961. Telegram, Apr. 25, 1962. Isbell, Harris.Historical Development of Attitudes Terry, Charles E., and Pellens,Mildred.The Toward Opiate Addiction in the United States. Opium Problem.For the Committeeon Drug A manuscript. Addiction in collaboration with theBureau of Isbell, Harris. Trends in Research on Opiate Ad- Social Hygiene, Inc., New York.1928. diction.Transactions & Studies of the College U.S. Treasury Department, Bureauof Narcotics. of Physicians of Philadelphia, vol. 24(1 ). 1956. Prevention and Control of Narcotic Isbell, Harris. What to Know about Drug Addic- Addiction. Undated. ticn.Public Health Service Publication No. 94, revised. May 1958. Wilder, Abraham. Drug Addiction.From Tice's Joint Committee of the American Bar Association Practice of Medicine. Vol. VIII. W. F.Pryor and the American Medical Associationon Nar- Co., Hagerstown.1953. cotic Drugs, Drug Addiction: Crimeor Disease. Wilder, Abraham. On the Nature of Addictionand Interim and Final Reports.Indiana University Habituation.British Journal of Addiction, vol. Press, Bloomington, 1961. 57(2), 73. 1961. Kolb, Lawrence.Drug Addiction as a Public Wilder, Abraham, and Rasor, Robert W.Psychi- Health Problem.The Scientific Monthly, vol. atric Aspects of Drug Addiction. TheAmerican 48,391. 1939. Journal of Medicine, vol. 14(5), 556.1953.

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22 U. S. GOVERNMENT PRINTING OFFICE: 1965 0 - 764-350