Treatment and rehabilitation of narcotic addicts

Sections

THE PROBLEM
FINDINGS
CONCLUSION
FINDINGS
RECOMMENDATIONS

Details

Pages: 3 to 12
Creation Date: 1956/01/01

Treatment and rehabilitation of narcotic addicts

Report of the Committee on the Judiciary of the United States Senate containing the Findings and Recommendations of the Sub-committee on Improvements in the Federal Criminal Code. The two following reports have been transmitted by the representative of the United States of America. They are complementary to the reports already published in Volume VIII, No. 2: "Report of the Interdepartmental Committee on Narcotics to the President of the United States" and "Report of the Committee on the Judiciary of the United States on the Illicit Narcotics Traffic "

By Senate Resolution 67, adopted 18 March 1955, the Senate authorized the first nationwide investigation of the illicit narcotics traffic in the United States. Included in the scope of the inquiry was the direction that

" special attention be given to the extent, cause, and effect of unlawful uses of narcotics and marihuana...and to the additions and changes in the laws... necessary to combat the increasing narcotic addiction in the United States ".

A special aim of the investigation in this area was to find ways and means of bringing about greater success in the treatment and rehabilitation of drug addicts.

THE PROBLEM

While there are fewer drug addicts in the nation today than there were before the Harrison Narcotic Act was passed and before the Federal Bureau of Narcotics was created in 1930, the figure of at least 60,000 addicts today is more than the number reported by any other western nation.[1] In spite of the best efforts of federal agencies with present personnel and procedures, smuggling of illicit narcotics has not been halted. Two recent seizures of heroin and cocaine, valued at more than $10 million, were the largest single seizures of these drugs ever made in the United States. The traffic now costs over $500 million per year, to say nothing of the human lives shortened or destroyed.

Drug addiction and the illicit narcotics traffic, moreover, are responsible for approximately 50% of the total crimes committed in the large metropolitan areas and 20% of all reported crimes in the nation. Drug addiction is contagious. Addicts who are not hospitalized or confined spread the habit with cancerous rapidity to their families and associates. Yet less than 20% are confined. It is inevitable that this contagious problem will increase from year to year unless drug addicts are exposed to an effective treatment and rehabilitation programme, and unless those who fail to respond to treatment are placed in quarantine type confinement or isolation.

With this problem in mind, the sub-committee invited the nation's foremost authorities on drug addiction to attend special hearings held in New York devoted exclusively to an intensive examination of methods and facilities for treating and rehabiliting narcotics addicts. We heard 27 expert witnesses, including leading medical authorities and law-enforcement officers, for a total of 1,058 pages of testimony, and we received more than 2,000 pages of material in the form of supplementary statements and exhibits supporting and describing various alternative approaches to the over-all problem.[2]

The sub-committee has prepared legislation which provides for new and improved laws and enforcement procedures to help stamp out narcotics smuggling and peddling. It is particularly important now to focus attention on the proposals for treatment, rehabilitation, or confinement of narcotics addicts.

I. AN EXAMINATION OF THE SO-CALLED CLINIC PLAN FOR LEGAL DISTRIBUTION OF NARCOTICS TO DRUG ADDICTS

The greater part of the New York hearing was devoted to testimony for and against the recent proposals that the Federal Government establish a chain of "narcotic clinics" across the nation where drug addicts could obtain "shots" at little or no cost on a sustaining basis. The sub-committee considered it imperative that the proposal for "free drugs "--made most recently by the New York Academy of Medicine in its Report on Drug Addiction, dated 7 June 1955--be subjected to an immediate and intensive examination, for not only had it generated a bitter controversy among medical authorities and law-enforcement officials but, even more important, there were indications that the controversy was actually impeding law enforcement and efforts to improve and expand existing programmes for the treatment and rehabilitation of drug addicts.[3]

While the "clinic plan" embodies six major recommendations, the crux of the plan centres on its proposal to set up all over the country a system of dispensary clinics where drug addicts could obtain narcotics free or at a very nominal charge. Provisions would be made for registration, fingerprinting, and photographing to identify the addicts.

Clinics would be staffed with doctors, employment counsellors, psychiatrists, and others whose task would be to attempt to rehabilitate the addict and to help him find suitable employment. In the course of efforts at rehabilitation, the addict would continue getting a minimum supply of drugs. Eventually, attempts would be made to withdraw drugs gradually. However, if the addict failed to respond to the psychiatric treatment and other rehabilitation efforts of the clinic, he would be given "stabilizing" of "maintenance" doses of narcotic drugs for the rest of his life.

Based on the testimony received during the special hearings in New York and on a mass of other evidence adduced during our investigation, the sub-committee has made the following specific findings.

FINDINGS

THE SO-CALLED CLINIC PLAN FOR LEGAL DISTRIBUTION OF NARCOTICS IS TOTALLY UNWORKABLE, COMPLETELY CONTRARY TO ACCEPTED MEDICAL PRACTICE AND THEORY, AND WOULD AGGRAVATE RATHER THAN SOLVE THE PROBLEM OF DRUG ADDICTION

1. Addicts must be hospitalized, in an atmosphere, free of narcotic drugs, or treatment will fail.

Under the provisions of the proposed "clinic plan ", the drug addict would be given drugs free, or sold drugs at a minimum cost, for the continued support of his addiction. This would be without hospitalization or other confinement. Thus, not only would the drug addict have available his regular supply of drugs at the clinic, but he would have access to additional drugs on the illicit market.

The sub-committee finds that this procedure, as a method of treatment, is almost unanimously rejected by the medical profession, with only the few proponents of the plan claiming that it would work. The Surgeon-General of the United States, Dr. Leonard A. Scheele, spoke for the overwhelming majority of the medical profession when he testified:

"Treatment of drug addiction must take place in a drug-free environment, in an institution with special facilities for gradual withdrawal of the addicting drug.... Our experience leads us to believe that the vast majority of addicts cannot be withdrawn from narcotics with hope for success without institutional treatment."

This opinion, expressed by the head of the Public Health Service, is well established and long-standing among medical authorities. Thirty-five years ago, Dr. Royal Copeland, health commissioner of New York City Health Department, whose department administered similar narcotic clinics in New York during the early 1920's, stated unequivocally that treatment would fail unless conducted in a drug-free environment:

" Without absolute control of the patient and his complete isolation from clandestine sources of supply, there is no hope of cure. Ambulatory treatment is fore-ordained to failure as long as there are secret and illegal methods of obtaining the drug. Under present conditions, it is my belief it will be a very rare instance indeed when a patient is cured outside a hospital, or in the absence of equally well-controlled conditions."

In 1924, the American Medical Association established the following view and policy of the medical profession, and this was reaffirmed before our sub-committee by Dr. Leo H. Bartemeier, chairman, council on mental health, American Medical Association:

" The only proper and scientific method of treating drug addiction is under such conditions of control of both the addict and the drug, that...[there is] no chance of any distribution of the drug of addiction to others, or opportunity for the same person to procure any of the drug from any source other than from the physician directly responsible for the addict's treatment."

2. Ambulatory treatment, where a supply of narcotics is either handed to the drug addict or where he must come to the clinic for "shots ", is totally unsatisfactory.

There are only two alternatives in the proposed plan to treat drug addiction on an ambulatory basis: either the drug addict must be given a supply of narcotic drugs to take with him and administer himself as he desires, or he must be required to report to the "clinic" several times a day to have the "shots" personally administered by medical personnel. Physicians ruled out either procedure as absolutely impractical and were in accord with the long-standing policy of the American Medical Association, that

"... Any method of treatment for narcotic drug addiction, whether private, institutional, official, or governmental, which permits the addicted person to dose himself with the habit-forming drugs placed in his hands for self-administration, is an unsatisfactory treatment of addiction, begets deception, extends the abuse of habit-forming narcotic drugs, and causes an increase in crime."

Dr. Harris Isbell, Director, Addiction Research Center, Public Health Service Hospital, Lexington, Ky., expressed his rejection of the idea in these terms:

"Suppose we did try to set up a narcotic 'bar', and run this service. Certainly, we are not going to give the addicts the drugs to take themselves, for they might sell them. We have to have the drugs and administer them, which means that one of these narcotic bar-rooms will have to be set up at spots around the large cities; they would have to be manned 24 hours a day, 7 days a week. The addict requires drugs 4 or 5 times a day, otherwise he will become ill. Therefore, he is going to spend all of his time waiting in the so-called clinic line-up to get his drugs. In my opinion, it is an utterly unworkable thing."

3. The plan fails to consider the "tolerance" factor, which causes the addict to demand ever-increasing doses of narcotic drugs.

Medical authorities agree that the drug addict is dominated by the phenomenon of increasing "tolerance ". In other words, his daily intake of drugs cannot be "stabilized" or "minimized ", but must constantly be increased if he is to obtain an effect equivalent to his first "shot ". For this reason, physicians and law enforcement officials appearing before the sub-committee repeatedly warned that drug addicts could not and would not be satisfied with a minimum dose of narcotics as envisaged in the clinic proposal. They testified that under the clinic plan it would be necessary to provide the chronic addict with an ever-increasing supply of drugs. Otherwise, the drug addict would turn to illicit sources of supply.

4. The illicit market would not be eliminated, as the tolerance factor would drive the addict to supplement his "clinic" supply from peddlers.

The advocates of the clinic plan strongly urge that it would eliminate the illicit narcotics traffic in the United States. Dr. Hubert S. Howe, who testified on behalf of the New York Academy of Medicine, stated:

"We believe very decidedly that if you afforded all the present addicts their drug, that would, to a large extent, destroy the black-market. If you undersell them, if there is no profit at all in narcotic drugs, the black-market cannot live and thrive."

The overwhelming majority of physicians and law-enforcement officers appearing before the sub-committee disagreed with that conclusion.

One of the nation's outstanding law-enforcement officers, Sheriff Owen W. Kilday, of Bexar County, Tex., testified that he, at one time, had strongly approved of the clinics as a possible means of destroying the drug peddler's market and, ultimately, the illicit narcotics traffic. However, owing to an investigation in San Antonio which showed that a peddler had systematically enticed 40 to 50 boys and girls of high-school age to begin using narcotics, he came to the conclusion that

"... If you did away with a market, they would create another one and I am opposed to it all the way. I don't believe there ought to be any clinic whatsoever."

Mr. Malcolm Wilkey, United States district attorney for the Southern District of Texas, summed up the problem this way:

"You will not cut the smuggler and the peddler out because the ration these people get at the clinic must in some way be limited. It cannot be unlimited. If it is limited, these people will go to the free clinic and get their maximum supply, and then they will go out on the black-market and supplement their requirements by illegal purchases. You will still have illegal traffic to supplement the amount that can be obtained at the clinic."

Dr. G. H. Stevenson, director, drug addiction research, Department of Psychiatry, University of British Columbia, Vancouver, Canada; appearing at the special invitation of the sub-committee, testified that in his opinion legalized drugs might even increase black-market sales:

"Unless drugs were to be given to addicts in unlimited quantities to satisfy their wants rather than any need they might have, they would get their surplus from the black-market the same as they do now; and people who were going to start in to drugs, the same as young people get started in drugs now, they could not get it in a legal market, would still get it from the black-market .... I think the black-market would welcome legal sale as a means of increasing their own market."

Dr. Raphael Gamso, medical director of Riverside Hospital in New York, who has had experience treating hundreds of juvenile addicts, stated:

"I do not think it is practicable .... I am afraid that if an addict had access to free drugs he would take that and still want more."

Dr. Harris Isbell, adressing himself to the basic assumption of clinic proponents that addicts simply take drugs to feel normal and forestall withdrawal pains, said:

"The majority of addicts don't want to be normal; they want to be what they call' high '-- they want to be' loaded '. If you provide them with drugs by this single-shot mechanism at five trips a day, that is just enough to keep the addict going and he will go out and get more so that he can get high.

"Not only would the addict fail to maintain his dosage, but his tolerance tendency would go up; indeed, the only limit to tolerance is the amount of skin available to inject, and the time required to take so many injections. Not only would the addict raise his dosage, but he would call for a variety of drugs, and all sorts of abuses would grow up. They would get their maintained doses from the so-called narcotic bars, and then they would go out and buy more on the illicit market. Such systems have been set up in various parts of the world, and it has been found always that the illicit traffic exceeds the legal traffic."

5. The legalized distribution of free drugs would create new addicts and increase the narcotics problem in the United States.

The stated aim of the proponents of the "clinic plan" is to eradicate narcotic addiction. As Dr. Hubert S. Howe testified:

"The objective is to stamp out drug addiction as completely as possible. The crux of these objectives is to diminish the number of individuals becoming newly addicted. The natural decrease with time in the number of existing addicts must not be over-balanced by the formation of new addicts at a more rapid rate. Indeed, if the objective of little or no addiction is to be achieved, there must be little or no formation of new addicts."

However, this suggestion that the "clinic plan" would be helpful in reducing narcotic addiction has been met with the vehement opposition of many of the nation's acknowledged experts on the treatment of drug addiction. Three of these, Dr. Victor Vogel, Dr. Harris Isbell, and Dr. Kenneth Chapman, all with first-hand experience treating thousands of drug addicts at Lexington and Fort Worth, wrote earlier:

"The proponents of this plan believe that addiction is incurable or that treatment is inhumane and that if addicts are given the minimum amounts of drugs necessary to maintain their addiction, lawlessness attendant on contraband traffic in narcotic drugs would be eliminated. This reasoning is unrealistic, as has been shown by several attempts in this country and abroad that have failed. Addicts on such 'rations' connive to get more than their allotted amount of drugs, so that they can increase their dosage and continue to obtain a euphoric effect. They may sell or give away part of the extra supply so obtained to persons who are not addicted. This creates new addicts who are potential customers for the contraband market, and thus increases the problem which the ration plan is supposed to abolish. Furthermore, many addicts can be treated and learn to live a useful, effective life instead of one of personal neglect, indolence, and semi-somnolence which is so typical of the addict. Addiction is infectious and treatment, rather than support of addiction, is necessary to minimize its spread."

Dr. A. M. MacLeod, director, John Howard Society of Montreal, experienced in the treatment of addicts both in Canada and in England, testified that drug addiction is not spread primarily for profits, as the advocates of the clinic plan claim, but that it has the contagious qualities of a social disease. He stated:

"Without exception, every addict whom I had in treatment either attempted to give expression to or fought against a clearly recognized desire to involve non-addicts.

"Although it would be logical to assume that the reason for such proselytism is the desire to render surer a source of supply of the drug, it was my opinion that this activity was the outcome of some deeper psychological conflict, and indicated a perverse inner need of the addict to turn his self-destruction drives against those around him as well as against himself.

"Drug addicts are predominantly sociable people, and they cannot stand any degree of social isolation for very long without attempting to find a suitable companion. As a matter of medical interest, I found this desire to make converts much more pronounced in the male addicts than in the female addicts."

The sub-committee is convinced that the conclusion advanced by Dr. MacLeod is correct, for more than 95% of the addicts who appeared before the sub-committee stated that the person who first introduced them to drugs (1) gave them the drugs free of charge, and (2) never tried to sell them drugs at any subsequent time. They all claimed that they were addicted through personal contact with "friends" or "associates".

It is apparent, therefore, that inherent in the plan for "free drugs" is the idea that the Federal Government would be maintaining in society the agent of the contagion-the drug addict himself.

6. Successful rehabilitation of drug addicts cannot be accomplished under the "clinic plan".

While existing treatment programmes insist upon confining the addict in the drug-free environment of a hospital for withdrawal of the drug prior to any efforts to rehabilitate him in the community, the "clinic" proposals call for keeping the addict on drugs while trying to rehabilitate him.

(a) Rehabilitation will fail if the addict is still using drugs

The sub-committee finds from the overwhelming weight of authority in the field that social rehabilitation of the addict cannot succeed while he is using narcotic drugs due, in large measure, to the effect of the drug upon the individual. Testifying on this point, Dr. Robert H. Felix, Director, National Institute of Mental Health, emphasized that

". . . It would be much more difficult to rehabilitate a person on narcotics than off. . . Because the addict, when he is on drugs, has certainly retreated from the province of reality. I feel from what I have seen over the years that this would be doomed to failure."

Dr. Stevenson told the sub-committee that, in his opinion, an individual under the influence of drugs was not a good subject for social guidance or psychiatric treatment, because

"When a person has drugs in his system, drugs are the only thing he is interested in; that is the only thing he wants. It solves all his problems, it removes his ambition, and reduces his inhibitions and moral tendencies . . . they are not as good people physically and mentally and socially when they are on drugs as when they are off drugs.

"They need increasing amounts; their mind is completely preoccupied with getting drugs when they are on drugs, and their work is, in my opinion, never as of good quality when they are using drugs as when they are not using drugs.

"The drug is an intoxicant, and it seems to me it is foolish to think that a person who is intoxicated, even in a mild degree, is as capable a person or as well adjusted a person as a person who is free from an intoxication."

Addicts who testified before the sub-committee, or who were interviewed, repeatedly emphasized that the only way to be cured of narcotic addiction is absolutely to forgo the continued use of drugs. They even scoffed at the idea that the addict could be "weaned away ", saying that "it is a matter of the addict making up his mind, once and for all". While this is undoubtedly an over-simplification on the part of the addict, it demonstrates that even from his point of view, the first step in treatment is to give up drugs, or for them to be made unavailable through law enforcement.

(b) Employers would not hire drug addicts as envisaged under the clinic plan

An essential element in the plan to rehabilitate drug addicts while they are getting drugs from the clinic would be the finding of suitable regular employment. Evidence adduced during our investigation shows that one of the most difficult tasks confronting the drug addict who has returned to his home community from a federal narcotics hospital is to find an employer who will hire him, even though he has ceased using drugs and has undergone extensive treatment. It is unreasonable to expect that the long-standing distrust of addicts will change and that employers will be more inclined to hire addicts actively using drugs than at present.

As already stated, an addict should never be given a supply of drugs to carry. Therefore, it would be necessary for him to leave his job and report to the clinic 4 or 5 times a day to receive his "shots". The employers, moreover, would undoubtedly be influenced by the fear that the addict would infect others with his drug habit and that some employees might resign their jobs and others suffer a lowering of morale.

Employment opportunities would be further limited by the fact that, as medical authorities stated, addicts co-ordinate less well and are less reliable when actively using drugs. Dr. Robett H. Felix, commenting on this point, said:

"An individual who is taking drugs is less accurate in many kinds of operations. He co-ordinates less well, without knowledge of this, for he feels that he is even more acute than he really is. So this would be another argument for me to keep the person away from drugs."

7. "Clinics" would maintain drug addiction, as the addict who failed to respond to rehabilitation would be given "sustaining" doses for life.

The "clinic" plan provides that the drug addict who fails to respond to rehabilitation efforts should be given, on a permanent basis, so-called "sustaining" or "maintenance" doses of narcotic drugs. This proposal for thus maintaining narcotic addiction has met with the vigorous and virtually unanimous disapproval of the medical profession. Dr. James V. Lowry, Medical Director, Public Health Service Hospital, Lexington, Ky., emphasizing that the drug addict should be treated and not kept in a state of narcotic semi-somnolence, testified:

"I think my function as a physician is to treat people, not to maintain them in a state of disease, and I think in administering narcotic drugs to a person, we cannot forget what happens to that person. It is important, particularly in people who are married, that one of the things wives tell us about the addicted man is that he is sexually impotent and he, therefore, loses his function as a male.

"Let us take the woman. If she is addicted and physically dependent, she becomes sterile and unable to have any children. This sometimes has great significance to the husband.

"We see coming into our hospitals many addicts in whom, after they have been hospitalized a while and taken off drugs, it becomes apparent that they have such illnesses as gastric ulcers that they have not been aware of because their whole situation has been disguised by the narcotic drugs which they have been taking.

"Ishould also like to point out that if a person receives narcotic drugs he has every need satisfied in terms of blotting out reality. His worries are gone; his cares are gone; his responsibilities are gone.

"Now, what you are asking me as a physician is whether I want to perpetuate a condition of this kind; and I say, no. I am more interested in treating the basic condition of the individual, to restore him to health, and so my position is perfectly clear."

Each of Dr. Lowry's colleagues in the Public Health Service -and each with many years' experience in treating drug addicts-who appeared before us in New York strongly upheld the view that as doctors they could not condone dispensing drugs for the purpose merely of supporting addiction.

Dr. Robert H. Felix amplified his view in these words:

"I would not administer narcotics for the maintenance of addiction to an individual under any other circumstances except in case of painful illness for which there was no other relief.

"An addict is truly not normal without drugs. He is not normal on drugs. He is a disordered personality in either circumstance, and I have not in the years that I have worked with these people felt that the administration of narcotics to the individual improved him in any particular, as far as psychological and physical health was concerned."

The final, and perhaps most effective argument against supplying drug addicts with narcotics on a "maintenance" basis was made not by an opponent of the plan, but by one of its vigorous advocates, Dr. Herbert Berger, vice-president, New York State Medical Society, when he stated:

"A problem put off with narcotics remains unsolved. It is still there tomorrow or the next day, requiring larger and larger doses of narcotics to control. Whatever strength of character the addict may have once possessed he loses as he everlastingly retreats from the making of decisions."

8 . The"clinic" proposal would necessitate United States withdrawal from international treaties, as well as major changes in federal and state laws.

Commissioner Harry J. Anslinger, of the Federal Bureau of Narcotics, testified that the adoption of the "clinic plan" would not only undermine enforcement and spread addiction, but would also be in absolute contradiction to responsibilities and obligations assumed by the United States in international treaties. It would, moreover, be contrary to our present leading role on the United Nations Commission on Narcotic Drugs which is designed to curb narcotic addiction and to prevent the international traffic in narcotic drugs.

In addition, the laws of all the 48 States would have to be changed accordingly if the Federal Government were to adopt the programme envisaged under the "clinic plan".

It would, therefore, be a complete turnabout in our present policies and programmes which are aimed at reducing narcotic addiction in this country to "an irreducible minimum" and, also, to stamp out the vicious narcotics traffic in this country and abroad.

9. Experiments with similar "narcotic clinics" in the 1920's showed their abject failure.

The sub-committee gave extensive study to the experience with somewhat similar "narcotic clinics" which were established on an experimental basis in the early 'twenties in some 44 cities in the United States. We have concluded that the clinics, as they operated at that time, were little more than "filling stations "for drug addicts, with little if any emphasis on treatment and ultimate rehabilitation.

Though drugs were sold at clinics for as little as two cents a "shot", the problems arising from addiction did not cease. The addicts soon built up a tolerance for the amount of drugs supplied them at the clinics and resorted to fraud and trickery to secure larger doses. When addicts could not satisfy their cravings with the clinic shots, they turned to illicit sources again. Commissioner Anslinger told the subcommittee that records indicate that the illicit traffic increased after the opening of the clinics. For instance, in one year during such period, enforcement officials seized 75,000 ounces of narcotic drugs. Today, they seize about 6,000 ounces annually. On the basis of this experience, he predicted that smuggling of narcotics would triple if a clinic system were established.

The material available to the sub-committee indicates that the "clinics" attracted criminals and drug addicts from areas where no clinics existed, increasing the number of idle, delinquent, and maladjusted individuals in the cities where" clinics" were situated, and these concentrations inevitably resulted in crime waves. Prostitution and other crimes flourished in the areas immediately surrounding the clinics.

As a result of these conditions, the Committee on Narcotic Drugs of the American Medical Association wrote in their 1921 report:

We have given the "clinic" a careful, thorough, as well as lengthy trial, and we honestly believe it is unwise to maintain it any longer.

In 1924, the house of delegates of the American Medical Association unanimously adopted the following recommendation fried by its committee on narcotic drugs:

Your committee recommends that the American Medical Association urge both Federal and State Governments to exert their full powers and authority to put end to all manner of such so-called ambulatory methods of treatment of narcotic drug addiction, whether practiced by the private physician or by "narcotic clinic" or dispensary.

By 1925, all the clinics were dosed, and the experiment had proved to be a complete failure.

It should be noted that the same failure has been experienced in all other countries which have tried the dispensing of free or cheap narcotics to addicts.

10. The "clinic plan" undermines efforts to prevent drug addiction and raises a grave moral issue.

Two important points remain to be considered in an evaluation of the "clinic plan". They are: (1) whether governmental sanction of a narcotic clinic would provide drug addiction with a source of official respectability, and (2) whether, even if the plan were entirely workable, it is morally desirable to maintain individuals on drugs in a perpetual state of disease.

With regard to the first of these points, the sub-committee is much impressed with the arguments of citizens' groups and law-enforcement officers to the effect that federal or state sponsorship of such a plan would inevitably provide narcotic addiction with a pseudo respectability which ultimately would tend to increase drug addiction in the United States. This point was forcefully presented to the sub-committee by Mr. Malcolm Wilkey, who spent more than a year studying the "clinic" proposal:

"Initially, I was considerably impressed. The scheme has a plausibility about it that is somewhat misleading. But the more I studied it and the more I looked into the results of the plan where they have tried it, the more convinced I have become that such a step would be a step backward as far as the suppression of narcotics is concerned.

"A free clinic plan would remove a very important psychological and practical deterrent to drug addiction. As conditions are now, public opinion scorns drug addicts. The average normal citizen has no contact with either drug addicts or a source of drug supply. If the average citizen suddenly decided to acquire narcotic drugs, unless he were a physician or nurse or in some way in contact with a legal supply, he would not know where to turn for an illegal source. Once we legitimize distribution of drugs to satisfy a craving for narcotics, then we will have given a stamp of legitimacy to the heinous habit. Apparently respectable citizens who are the victims of the habit now find it advisable to conceal it from their most intimate friends. If satisfying a craving for drug addiction becomes legal, becomes a topic of conversation in normal human intercourse, then many persons who have never knowingly come in contact with drug addicts would do so, and might be induced to become addicts simply by contact and example.

"I do not mean that perfectly normal human beings are likely to become drug addicts. But those human beings suffering from psychological deficiencies do frequently seek drugs to compensate for their psychological deficiencies. If these people, who can develop a psychological craving for drugs, are forced to go down in the gutter, to consort with criminals, shady characters, in disreputable portions of the city, they will be much more reluctant to initiate the drug habit than if they have the assurance that after all they can get it legally, cheaply, through a government-sponsored clinic."

The crux of the "clinic" proposal ultimately rests, not upon its practical workability, but upon the fundamental moral issue involved. The sub-committee has found that narcotic drug addiction is like a communicable disease; it has found that the use of narcotic drugs blots out reality, ambition, responsibility, reduces inhibitions and moral tendencies, and contributes to much of the nation's crime; it has found, as one of the advocates of the "clinic plan" stated, that "whatever strength of character the addict may have once possessed he loses, as he everlastingly retreats from the making of decisions"; finally, it has found that drug addiction causes men to be physically impotent and women to be sterile.

Therefore, the sub-committee believes that it would be absolutely immoral to give in to drug addiction and help perpetuate such pitiful conditions for the individual human being. We subscribe wholly to the belief that we should do everything possible to treat and rehabilitate narcotic addicts and that we should not adopt any programme to give the drug addict "sustaining" doses of narcotics which would maintain him in a state of disease.

CONCLUSION

The sub-committee is unalterably opposed to and rejects the "clinic plan" proposal for supplying narcotic addicts with free or low-cost narcotic drugs. We are opposed to all types of so-called ambulatory treatment. We believe that initial treatment must take place within a special institution, and that rehabilitation of a drug addict should not begin until after the withdrawal of narcotic drugs and he has undergone extensive physical and psychiatric treatment within an institution. We believe that attempts to reduce narcotic addiction and to destroy the illicit narcotics traffic by giving "free drugs" to narcotic addicts would be an abject failure and, more important, that it would maintain and tend to increase the present problem of drug addiction in the United States. Finally, we believe the thought of permanently maintaining drug addiction with "sustaining" doses of narcotic drugs to the addict to be utterly repugnant to the moral principles inherent in our laws and the character of our people.

The sub-committee is supported in its conclusions and policy by other groups which have given intensive study to this particular problem. Among them are:

(a) The Canadian Senate's Special Narcotics Investigating Committee, which reported on 20 June 1955, as follows : 4

The committee heard considerable evidence with respect to narcotics clinics and ambulatory treatment. The vast preponderance of responsible evidence on this subject, both oral and written, leads the committee to conclude that the establishment of such clinics or the provision of any other legalized supply of drugs for the purpose merely of supporting addiction would be a retrograde step. The committee is therefore strongly of the opinion that the narcotic drug problem cannot be solved by the creation of Government clinics where addicts could obtain their supplies.

"The committee unanimously rejects any proposal designed to provide legal supplies of drugs to criminal addicts."

(b) The Commission on Narcotic Drugs of the United Nations, which reported at its 10th session that in the treatment of drug addiction methods of ambulatory treatment and open clinics were not advisable.

(c) The Committee on Drug Addiction and Narcotics of the National Academy of Sciences-National Research Council, which adopted the following policy at its 14th meeting, 1-2 October 1954:

The committee disapproves a policy of legalization of administration of narcotics to addicts by established clinics or suitably designated physicians because:

1. It is impossible to maintain addicts on a uniform level of dosage;

2. Ambulatory treatment of addiction is impossible and has been so judged by the American Medical Association and other informed groups;

See Bulletin on Narcotics, Vol. VIII, No. 2.

3. The clinics would facilitate the production of new addicts by increasing drug availability; and

4. The policy is contrary to international conventions and national legislation.

II. AN APPRAISAL OF THE EXISTING TREATMENT AND REHABILITATION PROGRAMME

The Federal Government operates two world-famed narcotics hospitals-the Public Health Service hospitals at Lexington, Ky., and Fort Worth, Tex. The land, plant, and equipment of these two institutions represent a total original investment of $10,500,000, covering more than 2,000 acres. Estimated operating costs for fiscal 1957 are $5,328,100. Men and women are treated at Lexington, and men only are admitted to the Fort Worth hospital.

Many of the physicians and scientists assigned to the hospitals are internationally known, and they work with the benefit of the finest research facilities. The hospitals have pioneered in the development of methods of treatment. Here are conducted studies dealing with the nature of drug addiction and the abusive use of narcotic drugs, while other research aims at finding improved methods of treatment and rehabilitation of persons addicted to narcotic drugs. These hospitals have beds for 2,313 patients, and 1,574 are now reserved for narcotic addicts.During 1955, there were 3,638 addict-admissions, and during the 20 years the hospitals have been in operation more than 35,000 addict-patients have been admitted for treatment and psychiatric care, for a total of almost 54,000 separate admissions.

These Public Health Service hospitals, despite a shortage of psychiatrists and other professional help, are doing highly creditablejobs. They withdraw the addicts from drugs; they restore them to health physically; and they teach the addicts good work habits and train them to be self-supporting. However, if we measure success in terms of the number of permanent "cures", these two important institutions, for reasons we discuss below, are failing to accomplish their full mission.

FINDINGS

EXISTING PROCEDURES AND FACILITIES FOR THE TREATMENT AND REHABILITATION OF DRUG ADDICTS ARE INADEQUATE AND REQUIRE SUBSTANTIAL IMPROVEMENTS.

1. Less than 15% of the victims of drug addiction are being successfully cured today.

Less than 15% of the thousands of addict-patients who have been treated at federal narcotics hospitals have remained free of the drugs thereafter. One out of every three addicts treated comes back for another "cure". In fact, 40% of the admissions to Lexington and Fort Worth are repeaters. This rate of relapse is one of the most discouraging aspects of treatment. Addict after addict testified before our subcommittee that they had returned to the use of drugs within a month or even the day after their release from Lexington and Fort Worth, although they spoke highly of the method of treatment at the hospitals. Even federal officials in charge of the hospitals agree that cures, in the strict medical sense, are presently impossible for the vast majority of drug addicts. With young people this is especially tragic, for it means a lifetime of slavish addiction to drugs, criminal activities to support themselves and their habit, and spreading their addiction to others. This failure cannot be attributed to the treatment methods within the institution. Rather, it is the result of two main weaknesses : first, poor admission procedure, which permit voluntary patients to come and go at will, and second, the utter lack of community follow-through programmes to receive the addict patient upon this discharge.

2. 75% of the drug addicts who volunteer for treatment in federal narcotics hospitals demand to leave before they fully benefit from medical and psychiatric treatment.

Voluntary patients account for two-thirds of the admissions to federal narcotics hospitals. Only 25% of these remain for the recommended minimum period of 4? months. Of the 75% who do not stay for the minimum period of treatment, 50% leave in less than 30 days. Only the one-third admitted under court orders are required to remain the full time prescribed by the hospital staffs.

Commenting on this abnormally high rate of turnover, Dr. Harris Isbell, Director of Research, Public Health Service Hospital, Lexington, Ky., testified:

"Drug addicts frequently come to the hospital for a very superficial reason. Some of them may come there because they are mad at a peddler who suddenly raised his prices; that is their only reason for coming. Others may come simply to get the degree of addiction reduced to where their habits [do not cost so much.] Many of them come under pressure from their families, not really of their own will, their own wish, and accord.

"Addicts are a group who, even in treatment, will vacillate. They are very changeable and immature people. One day they may be really desiring to get away from addiction. This frame of mind may last for a matter of clays or weeks, then they will have a change of mind."

Many addicts have been in and out of our federal narcotics hospitals as high as twenty and some as high as thirty times, although never staying long enough at any one time to be "cured" of drug addiction. The result is a "revolving door" type of operation which is expensive for the hospitals, and of very little benefit to the addict-patient and the community.

3. Voluntary admission is a loose, hodge-podge procedure, without federal or state control or supervision.

Because of the voluntary system of admissions, the federal narcotics hospitals are processing, and often re-processing, a continuous stream of drug addicts. Their addiction to narcotic drugs and their stay at the Federal hospitals are confidential.[5] In most instances, state authorities do not know the addicts are, under treatment, and the federal authorities are prohibited by law from telling them. This prohibition applies not only to disclosing their names to appropriate agencies, but it applies also to clinical data which might otherwise be forwarded to community social and welfare agencies to help the addict when he returns home. The Federal Government has no follow-up facility for rehabilitation, and the effect of the law is that it even prevents the hospital authorities from advising and working with state and municipal agencies in order that a discharged addict-patient might receive every opportunity for rehabilitation and, in the event of relapse, that he might be promptly re-committed.

Hospital authorities told the sub-committee that, because of the law, they do not know what happens to two out of three discharged addict-patients. They are released upon their own demand to descend upon an unsuspecting community like carriers of a contagious disease, except that these individuals also plague the community with crime to support themselves and, inevitably, their recurring narcotic addiction.

4. State and local treatment facilities are meagre, and state courts lack authority to commit drug addicts directly to federal narcotics hospitals.

It is a regrettable weakness in the federal programme that permits an individual addict from any city or State to volunteer for treatment and leave as he wishes, and yet denies to state courts the authority to commit an addict to the Public Health Service hospitals, even on a reimbursable basis. This is particularly significant when we recognize that State and local treatment facilities are extremely meagre.

Because of the enormous capital investment which would be required to establish suitable treatment facilities, only one State-New York-has beenable to assign a hospital solely to the treatment of drug addiction. It is available, however, only to addicts under twenty-one.

New Jersey has a special narcotics commission working on a new set of laws and regulations making it possible for drug addicts to receive treatment in the state hospital system. Los Angeles County in California also has a plan in process of development which would provide treatment in country hospitals. Measures to permit treatment in state institutions are under consideration in California and Ohio.

Because of the limited state narcotics hospital facilities and, also, because of the abuses inherent in the voluntary type admission in the federal hospitals, many federal and state authorities told the sub-committee that it was a matter of urgency that the Surgeon-General be authorized to accept in federal narcotics hospitals drug addicts committed for treatment by state courts. We were cautioned, at the same time, that all efforts to cure drug addiction without long-term supervision have met with consistent failure and that, consequently, state commitment authority must depend upon establishment of local rehabilitation programmes.

Attorney-General Jacob K. Javits, of New York, chairman of the committee on narcotics of the National Association of Attorneys-General, made several constructive proposals to the sub-committee regarding treatment and rehabilitation, and presented the following resolution by the National Association of Attorneys-General which was adopted at its meeting at Bretton Woods, September 1955:

NARCOTIC DRUGS

Whereas this association, by appropriate resolutions adopted at its annual meetings in 1952, 1953, and 1954, established a committee on narcotic drug control, which has sought to advance the care, treatment, and rehabilitation of narcotic drug addicts, and has urged the enactment by the Congress of legislation to permit the institutionalizing of such addicts in appropriate Federal hospitals upon commitment thereto by courts of competent jurisdiction of the States and other measures;

Now, therefore, be it resolved by the 49th annual meeting of the National Association of Attorneys-General:

1. Supports the enactment of legislation by the Congress now contained in the Payne bill, Senate Joint Resolution 19, to permit narcotic addicts committed from the States to be treated in the special United States Public Health hospitals, subject to reimbursement for the care cost, and urges its members to work for such enactment.

2. Supports the development of a permanent national narcotics policy and urges a national review conference to be called under the auspices of the Federal Government to consider means for the co-ordination of existing Federal and State narcotics laws and procedures, stricter enforcement of laws dealing with the narcotics traffic, and the establishment of a programme of research into the causes and cure of narcotic addiction through the National Institutes of Health, with the aid of a national council.

5 . Community follow-up, or rehabilitation facilities and services for the discharged addict-patient are virtually non-existent.

A major weakness in current efforts to treat and rehabilitate drug addicts is the almost complete lack of follow-up or post-hospitalization facilities on the community level to check upon and aid the addict once he leaves the federal narcotics hospital. The Federal Government does not and should not take the initiative in following through hospital care by providing the addict with rehabilitation services after he has returned to his home community. This is an area which properly calls for action by state and local governments, but it is also one in which inaction can completely nullify federal efforts. Emphasizing the vital importance of community follow-up, Dr. Raphael R. Gamso, medical superintendent of Riverside Hospital for juvenile addicts in New York City, said:

"The period in the hospital is a very important period, but the period after return to the community is equally important, probably more so, because when a person leaves the hospital he is again subjected to the same forces which caused him to use drugs, and if we cannot protect him from those forces and help him to sustain himself, he has lost the benefit of hospital care."

The situation as it was described to us by medical authorities, enforcement officials, probation officers, and even the addicts themselves, can be summarized as one of rejection and abandonment by the home community. This is not solely because they have been drug addicts, but because inevitably most of them have criminal records, and according to law enforcement opinion and statistics, a majority of today's addict population became involved in law violations prior to addiction.

Some of the specific difficulties encountered by returned addicts in New York City and outlined in a special report prepared for the sub-committee by Mr. Morris Kuznesof, United States probation officer, Southern District of New York, are typical of many of the problems described to the sub-committee in cities throughout the country:

"Because, as a rule, the public abhors the addict, his problems of adjustment are greater after he returns from the hospital than are other prisoners' released from jail. In the first place, he cannot let a prospective employer know where he has been, or that he is a former user, as addicts are considered to be very undependable, unreliable workers. To add to his difficulties, the New York State Employment Service will not refer any adult individual who has a history of narcotics use, presumably for the same reasons.

"The returned addict requires a good deal of help immediately after his arrival. If he does not have a sympathetic family, which can supply his needs, he must turn to social agencies for help. Private casework agencies have religiously refused to assist former addicts. Local psychiatrists have also refused to accept the cases of addicts, even though they were able to pay the fee."

As long as State and local communities thus fail to provide even the minimum after-care programmes, the vast expenditure of funds and energy at our federal narcotics hospitals will be virtually wasted. Dr. G. Halsey Hunt, Assistant Surgeon-General, USPHS, in his testimony before the subcommittee stated:

"It is our increasingly overpowering feeling that hospital care is only the first step, and that the local communities to which the patients return after they leave the hospital must, if treatment is to be successful in any appreciable number of patients, pick up the ball and provide facilities for rehabilitation of the individual in his home environment."

That the failure of the local communities to provide suitable follow-through procedures and facilities is mainly responsible for the narrow success of Lexington and Fort Worth in obtaining permanent cures, is pointed up in the testimony of Dr. Harris Isbell, Director of the Addiction Research Center at Lexington:

"The main weakness we suffer from is the lack of follow-up treatment. A man may come to us and stay for 4? months, and a lot of money is spent on him; he then goes back to his local community and leaves our jurisdiction. It is hardly appropriate for the Federal Government to go into those cities and set up follow-through facilities and agencies to aid the addict.

"A man can go through a period of institutional care and leave with all the best intentions in the world, returning to his community to find there is nothing there for him. He cannot get a job, and he has no resources, he has nothing. He goes to the social agencies and finds that they are already tremendously overburdened with many other problems. They are afraid of the addict and will do nothing for him and, in order to eat, that man almost immediately has to drop back into some kind of criminal activity. But the minute he goes back into criminal activity, he is going to head back to drugs. A person going home after a period of institutionalization ... needs a great deal of help, support, supervision, which is, I think, properly the responsibility of the community."

Only two communities - Chicago and Detroit - offer rehabilitation services on a local basis.[6]

Both of these agencies attempt to help the former addict adjust to a normal drug-free life in the community by providing a variety of services. For example, workers help the ex-addict find a job, give him financial assistance to tide him over until he gets a job, and encourage him to talk over his emotional problems with professionally trained members of the staff in an effort to better understand himself and prevent relapse. The Detroit clinic, with two full-time employees and the part-time assistance of a psychiatrist, is unable at the present time to offer the comprehensive services originally envisioned for the clinic. Its main contribution so far has been in the identification of addicts for hospital treatment.

Experience at these two clinics has already indicated that this phase of treatment, like the hospital phase, must contain a strong element of coercion to bolster the addict's resolve to stay off drugs. Dr. Walter A. Adams, director of the Chicago clinic, in a statement prepared for the Committee, indicated that almost all of the addicts who come to his clinic are poorly motivated to persist in the long-term efforts required for successful rehabilitation. Dr. Raphael Gamso recommended not only that comprehensive after-care services be made compulsory for released addict patients, but also that such services be thought of as a five or six year programme for each patient.

Federal law may have contributed, at least in some degree, to the failure of the States and local communities to adopt programmes to aid the discharged addict, for as we have stated, even if adequate facilities and services were available at the present time, federal hospital authorities would be absolutely prohibited by law from forwarding the names and related clinical data to such community agencies. The confidential nature of the hospital records, therefore, actually may have prevented local communities&rsquo access to the very information essential to them in determining the extent of the problem and, of course, the necessity for follow-through facilities.

6. No facilities exist for isolating the chronic or "incurable" drug addict.

Medical authorities and law enforcement officers repeatedly warned of the existence of a "hard core" of chronic or "incurable" narcotic addicts who were neither susceptible to treatment nor isolated to prevent the spreading of drug addiction. Dr. Kenneth Chapman, consultant, Narcotic Drug Addiction, Community Services Branch, National Institute of Mental Health, in his testimony before the subcommittee, stated:

"There is a hard core, and this is the group we hear about repeatedly, who cause the general feeling that drug addiction is incurable. It is those people we continually see, those people who are continually in the hands of the police, who are continually in the hospital, are continually seeking drugs. This hard core are the ones we see all the time; they are the ones who cast doubt on the possibility of any successful treatment."

Despite this knowledge-that chronic addicts are not amenable to cure, that they infect others with drug addiction, that they habitually engage in crime, and that, thus, they are a menace to society-neither the Federal nor State Governments has met the threat with special facilities for the isolation or quarantine, of these individuals. The danger of the situation is pointed up in testimony by Dr. Isbell, when he says:

"A chronic, relapsing addict with a long record might be taken in just for withdrawal of drugs; if we feel we can do nothing for him we will just take him in for two weeks or thirty days, after which we will discharge him again."

The pattern is endless, and so is the cost in terms of crime, taxpayer dollars, and human havoc. These incurable addicts who have in reality lost their power of self-control and who are dangerous to the health and welfare of the community not only are habitual criminals but also spread their addiction to others, much on the same order as persons with contagious diseases. Experts agree, therefore, that both in his interest and in the interest of community protection, the chronic drug addict must be "quarantined" or otherwise confined for long periods of time or permanently if relapses continue after releases from isolation or confinement.

RECOMMENDATIONS

1. That voluntary commitments to the Federal narcotics hospitals be abolished, and that all admissions be processed through the appropriate district court of the United States for civil type commitment requiring a mandatory period of treatment, or by state court commitments under the conditions hereinafter outlined.

2. That the Surgeon-General be authorized to accept addicts committed by a State on a reimbursable basis under state court orders requiring a mandatory period of treatment.

3. That each State be assigned a quota of addict-patients which may be committed to federal narcotics hospitals at any one time, therefore assuring that each State has fair and equal opportunity to avail itself of the limited facilities. In those few States where the number of addicts requiring treatment exceeds the established quota of patients at Lexington and Fort Worth, such States should assume the responsibility of establishing their own special hospital facilities for the treatment of drug addiction.

4. That States desiring to participate in the commitment programme, in order to become eligible, must have satisfied the Surgeon-General that suitable follow-through or post-hospitalization facilities have been established to aid and assist the drug addict upon his discharge from the federal narcotics hospital and to determine any relapse to addiction. That the USPHS continue to provide technical and advisory assistance to States and local communities in developing follow-up programmes.

5. That, for a successful follow-through programme, commitment orders for drug addicts should provide for at least a three-year probation status upon release from federal hospitals; including mandatory provisions for regular reporting and physical examinations, and for re-commitment upon relapse without the institution of new proceedings.

6. That no drug addict be treated at federal narcotics hospitals on more than three occasions, after which, if found to have relapsed again to the use of drugs, he should be subject to state or federal proceedings designating him as an habitual narcotic addict and committing him to an indeterminate quarantine type of confinement at a suitable narcotics farm which, it is recommended, should be established with joint Federal-State planning and financing, such arrangement to include either:

(a) individual States, or

(b) a group of States entering into a compact for such purpose.

7.That the Public Health Service Act be amended to authorize the divulgence of information relating to narcotic addicts to appropriate federal and state authorities in charge of treatment and rehabilitation programmes and to the Federal Bureau of Narcotics.

8.That the Surgeon-General continue and expand, where needed, the existing federal research programme into the causes, treatment, and rehabilitation of drug addicts, and that annual reports on the progress of such research be made to the appropriate committees of the Congress.

It should be noted that these recommendations for treatment and rehabilitation are not intended as a substitute for criminal confinement and punishment of those addicts who are convicted of law violations. They should pay their debt to society the same as non-addicts, and proper law enforcement and confinement in such instances will do much toward minimizing the narcotics traffic and addiction in the United States.

001

See the sub-committee's preliminary report, Senate Report 4440, dated 27 January 1956, summarized in Bulletin on Narcotics, Vol. VIII, No. 2.

2

Further testimony relating to causes, treatment, and rehabilitation was taken by the sub-committee in each of the 13 cities where hearings were held. Extended consideration was given to the local programmes being developed in Los Angeles, Detroit, Chicago and New York.

3

A similar plan was proposed by the Richmond County Medical Society of New York and was subsequently approved by the New York State Medical Society.

5

Public Health Service Act (42 U.S.C., 260(d)): "... and the record of his voluntary commitment shall be confidential and shall not be divulged ".

6

New York City has an after-care clinic which is an adjunct of Riverside Hospital and therefore available only to juvenile addicts who have received treatment at Riverside. The Public Health Service also has a pilot follow-up clinic located in New York City; but it is oriented primarily towards gathering information and is staffed by two social workers.