Treatment of the drug addict at the Lexington (Ky.) hospital
Author: James V. Lowry
Pages: 9 to 12
Creation Date: 1958/01/01
Medical Officer in Charge, United States Public Health Service Hospital, Lexington, Kentucky
The present paper is a summary of an article published in Federal Probation, December 1956. The editors of the Bulletin on Narcotics wish to thank the author and Federal Probation for their kind permission to publish it.
This article discusses the treatment of addicts at the United States Public Health Service Hospital at Lexington, Ky., and the characteristics of the addicts as they are seen at that hospital. These addicts are not necessarily representative of addicts in the United States of America. No attempt is made to explain some of the observations made.
The word "addict ", as used in the paper, means a person who is physically and psychologically addicted to an opiate drug or a synthetic drug with opiate-like properties, and who is or has been a patient at the hospital.
The treatment of a hospitalized drug addict is twofold: treatment of the physical addiction resulting from the pharmacological properties of the drug taken, which is relatively simple, and treatment of the psychological addiction and of the basic mental disorder underlying it, which is relatively complex. Recovery from physical addiction can be attained in a few months, whereas the treatment of the psychological addiction and the social and vocational rehabilitation of the patient is a long and difficult process, especially because it requires the active participation of the patient himself. Hospitalization is important from the point of view of the patient because it removes him from the environment that nurtured his addiction, and from the point of view of society because it prevents the spread of addiction by isolating a principal agent of dissemination - namely, the addict.
In the case of the patient who began his addiction in the course of treatment of an illness by a physician, hospitalization provides an opportunity to terminate the addiction in those whose initiating illness is no longer present. If it is still present, hospitalization and treatment can result in a reduction in the dosage of narcotic drugs or, in most instances, in the elimination of the use of narcotic drugs because of improvement resulting from specific treatment of the disease.
The hospital, created especially to treat drug addicts, was opened in 1935 and is located about five miles from Lexington, Ky., The 1,300 beds are mostly in dormitories, 350 being in the infirmary wards (medical, surgical, psychiatric, tuberculosis and withdrawal). It is a "minimum custody hospital ", and no more than about four prisoners depart without authorization each year.
The hospital is authorized by law to treat federal prisoners and probationers, addicts committed from the District of Columbia, and voluntary patients who are addicted to nar cotic drugs as defined in the Federal Law of the United States of America.
The prisoner addicts are sent to the hospital by the Bureau of Prisons after conviction in a federal court. The probationers are required to remain in the hospital after treatment is completed, and are under supervision on return to their home community. Voluntary patients are admitted at their own request if beds are available. The record of their admission, treatment and discharge is treated as confidential.
The hospital accepts females from the whole of the United States, and males from east of the Mississippi (male patients from west of the river are usually treated at the United States Public Health Service Hospital in Fort Worth, Texas). Men and women have quarters in separate parts of the hospital; there is no separation by race or age.
A. Characteristics of the Addict as an Individual
Physical addiction to opiate drugs is characterized by two phenomena: physical dependence, with its sequel of abstinence syndromes when the opiate is discontinued, and tolerance. The addict gets used to some of the effects of the drugs (the analgesic, euphoric and sedative effects which are all-important to him), and because of this tolerance, requires increasing amounts of the drug to obtain the desired effect. Physical dependence and tolerance appear to be related to changes in the sympathetic and central nervous systems 1 and in the endocrine glands.2
The etiology of drug addiction cannot be given in general terms, because the answers vary with each individual. For some persons the narcotics provide an escape from anxiety, frustration, etc.; for others, narcotic usage is a purely hedonistic experience. For others they provide total satisfaction, so that the addicts have little interest in anything else. The motivation for drug usage has to be replaced by a desire to live without narcotic drugs if treatment is to be successful.
1A. Wikler, "Recent Progress in Research on the Neurophysiological Basis of Morphine Addiction ", American Journal of Psychiatry, 105: 329, 1948.
2A.J. Eisenman, H. Isbell, H.F. Fraser, & J. Sloan "17-Ketosteroid Excretion in a Cycle of Morphine Addiction and Withdrawal, " Federation Procedings, 12:200, 1953.
Psychological addiction is related to a basic mental disorder of the patient. Usual diagnostic studies give enough information to establish the presence of a mental disorder. Kolb3 and later Felix4 developed classification systems of these disorders that were operationally useful, but these have been superseded by utilization of the nomenclature in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association published in 1952. The mental disorders most frequently present are personality trait disturbances, sociopathic personality disturbances, psychoneurotic disorders, and personality pattern disturbances. Occasionally patients are admitted with schizophrenic or affective reactions.
The personal history of many patients shows the absence of the father, or a weak father or mother during the patient's childhood. The failure of emotional maturation may be related to these absences or of any constant person with whom identification could occur.
B. Characteristics of the Addict Population
The average daily population in the hospital has varied relatively little over the years, but changes have occured in its composition - mainly in the great increase in voluntary patients.
The annual admission rate has varied considerably, due mainly to fluctuations in the annual rates of voluntary patients.
The age and race distribution shows very interesting variations if we compare the situation in 1936 with that in 1956. The typical addict described in Pescor's study of 1,000 admissions5 in 1936 was: "White male prisoner, 38 years of age, given a two-year sentence for illegal sale of narcotics." The typical addict of 1956 is a Negro male voluntary patient in his twenties.
Whereas the earlier addict preferred morphine, the later prefers heroin. Inasmuch as the first was "subject to some chronic disease, such as heart trouble, arthritis, etc.", the second is free of such afflictions. Whereas the 1936 series in Pescor's study showed 8.9% Negroes, the percentage in 1955 was 52. The age distribution of the white males in 1936 and 1955 was similar (a fairly equal distribution by decades from 20 to 60). In the 1955 study, 70% of the Negro males were under age 30, as compared with 27% of the white males.
The following table gives information about the age of onset of addiction:
3 L. Kolb, "Types and Characteristics of Drug Addicts ", Mental Hygiene 9 : 300-313, April, 1925.
4R. H. Felix, "An Appraisal of the Personality Types of the Addict ", American Journal of Psychiatry 1 : 462-467, 1944.
5 M. J. Pescox, "A Statistical Analysis of the Clinical Records of Hospitalized Drug Addicts ", Supplement No. 143 to the Public Health Reports, 1943.
19 and under
40 and over
The treatment programme is based on more than twenty years of clinical experience and research. The planning takes into consideration the individual and group characteristics of the patients, and at the same time the limitations imposed by such circumstances as the number of staff available, the requirements of the law, etc. The goal of the programme - and it is as simple as it is difficult to attain - is to prepare the addicts to return to their home communities and live without using narcotic drugs.
When the addict enters the hospital his treatment programme begins: he surrenders any narcotic drugs he possesses and is immediately subjected to a physical examination. If there is a physical dependence, he is admitted to the withdrawal ward (if there is no complicating disease requiring admission to some other infirmary ward).
Thus the first stage, if there is a need for it, is the treatment of the abstinence syndrome. If a patient has physical dependence on an opiate drug, the severity and time of onset of the abstinence signs will be related to the dosage and the particular drug used. A system of measuring the intensity of the syndrome was developed by Himmelsbach6 and Kolb7. These signs may he precipitated by the use of nalorphine8. With competent medical care and use of the methadone substitution method, the discomfort and dangers of the abstinence syndrome are minimal. This method is described in a number of publications by Isbell,9 Wilker l0 and Fraser,11 of the Addiction Research Center of the National Institute of Mental Health, which is located at this hospital. The method, in brief, is to administer methadone orally in quantities just sufficient to keep signs of abstinence at a tolerable level and then steadily to reduce the dosage. The treatment of the acute phase of the abstinence syndrome which results from physical dependence on narcotic drugs usually requires less than two weeks. This is followed by a period of convalescence or subacute symptoms lasting about two weeks, when the patient regains his strength, weight, and appetite, but is irritable, restless, and has difficulty in sleeping. Complete recovery from physical addiction takes about four months. The time and severity will vary somewhat according to the degree of tolerance and physical dependence of the patient, and this in turn is determined by the drug used, duration of use, and daily dosage. When the patient is no longer receiving methadone and the acute abstinence signs and symptoms have abated, transfer from the withdrawal ward to an orientation ward is made. When necessary, patients are transferred to another infirmary ward - medicine, surgery, tuberculosis, or psychiatric.
6 C. K. Himmelsbach & L. F. Small, "Clinical Studies of Drug Addiction ", Supplement to the Public Health Reports : 125, 1, 1937.
7L. Kolb & C.K. Himmelsbacb, "Clinical Studies of Drug Addiction ", Supplement to the Public Health Reports, 128, 1938.
8H. Isbell," Nalline, a Specific Narcotic Antagonist ", Merck Reports 62, 2; 23-26, 1953.
9H. Isbell, "Medical Aspects of Narcotic Addiction ", Bulletin of the N.. Y. Academy of Medicine, 31 : 886-901, December 1955.
10A. Wikler, "Rationale of the Diagnosis and Treatment of Addictions ", Connecticut State Medical Journal 19 : 560-568, (July) 1955.
11 H.F. Fraser, "Treatment of Drug Addiction ", American Journal of Medicine, 14 : 571-577, 1953.
When the patient leaves the withdrawal ward he is placed under the supervision of an administrative physician, who is responsible for co-ordinating and supervising his programme until his discharge from the hospital. These administrative physicians are psychiatric residents, and their work is supervised by staff psychiatrists. The patient may be in individual or group psychotherapy with another psychiatric resident. The administrative physician follows the progress of the patient and, except for prisoners, decides when the patient is ready to return to his home community. This system has been in operation since July 1955 and is based to a large extent on the research of Stanton & Schwartz.12
The patient remains in the orientation ward for about two weeks after leaving the withdrawal ward. During this time, group discussions for orientation purposes are held and the patient is interviewed individually by members of the vocational, correctional, social service, and psychiatric staff for diagnostic purposes. The patient's administrative physician prepares a diagnostic summary, which is reviewed by a staff psychiatrist, and the treatment programme for the patient is formulated.
Every patient who is physically able to work has a job. Most of the young addicts have had erratic or no work records. One purpose of the work assignment is to enable them to work with other people and to accept authority. Many of them regard authority as hostile and punitive. Constructive relations with authority figures different from the ones they knew permit a modification of previous reaction patterns.
The programme varies from patient to patient. One element, however, is common to all: residence in a drugfree environment for a minimum period of four months. This period initiates the disestablishment of the habit of using narcotic drugs as a pattern of living, to relieve anxiety, or for euphoria. Thus patients who appear to be suitable are offered the opportunity of psychotherapy individually or in groups. In many cases this should be continued after release from the hospital.
Group psychotherapy and activity therapy appear to be more suitable than individual psychotherapy for patients with personality trait or sociopathic disturbances. Because of their emotional immaturity, dependency, and hostility, the most useful programme seems to be one similar to the activity programmes used with disturbed children. The immediate "therapist" is the person with whom the patient spends the most time. In most instances this would be the vocational supervisor. Consideration is given not only to the vocational needs of the patient, but also, when indicated, to the needs of the patient for continued association with a particular kind of staff person. The vocational supervisors are apprised of the patient’s problems when this appears to be indicated, and the supervisor can discuss the patient with the administrative physician at any time. Staff psychiatrists provide consultation in discussions with groups of vocational supervisors.
12 A. H. Stanton & M. S. Schwartz, The Mental Hospital. New York: Basic Books, Inc., 1954.
The hospital is not a vocational training school, but it does have a large variety of well-organized and active vocational training programmes which it is hoped serve as a medium for nurturing emotional maturation. The educational and vocational training unit chief assists the section chiefs in the design of training programmes preparing patients for "payroll" jobs. The accomplishments of the patients in these programmes are amazing when viewed in the light of their past vocational history or lack thereof. They demonstrate the unactivated potential for change that exists within these patients. Each month the vocational supervisor sends a report to the patient's administrative physician rating the patient on co-operation, attitude, interest, dependability and progress in skill learning. Ratings have been found to be useful indicators of ability to adapt to living in the hospital. Towards the end of his hospitalization, assistance in getting employment is provided.
For many of the patients narcotic drugs were the only source of pleasure in living. One source of pleasure for most people is recreation - reading, athletics, films, television, bowling, music, etc. The hospital attempts to provide the patients with opportunities for developing interests in recreation as one facet of living. These patients are able to participate more readily in passive recreation or individual activities than in any endeavour that requires active co-operation as a team member. Recreation can serve as a vehicle for learning to live with other people and to accept the limitations of behaviour imposed by the rules of the game.
Part of the patient’s day and evening is spent in the dormitory with other patients. This presents many opportunities for constructive, destructive, and neutral associations. Since narcotic drugs were the central and sometimes the exclusive preoccupation of the patients before hospitalization, much time is spent in discussions on this subject. Until a few years ago the women patients were in a separate small building a short distance away from the main building. A frequent comment by the staff at that time was that the men spent so much time talking about drugs. Now the: comment is that they spend so much time talking about: women.
The aid on the dormitory has an important role in the hospital programme. The responsibilities include helping the patients to learn to live with other persons without more than the ordinary amount of strife; helping the patients to learn other adult patterns of living and, most important, the aid can listen to patient’s problems and when indicated, provide advice and encouragement. The dormitory aid can get assistance from his supervisor or, if the problem is with regard to a particular patient, then he can consult with the patient's administrative physician. A twelve-month training programme of classroom, demonstration, and supervised assignments is used to prepare aids for their work.
Social service participates in the diagnostic studies and has the responsibility of identifying the social service needs of the patient. The principal activity is to provide casework services to patients. The problems presented range from personal problems of the patient in the hospital to family problems in a community many miles away. The staff does all the work related to parole and is the liaison with the federal probation officers.
Religion is an important part of the lives of many patients. The hospital has Catholic, Jewish, and Protestant chaplains whose duties include conducting services, individual counselling, and group discussions. The College of the Bible of the Christian Church at Lexington operates a chaplain-training programme at the hospital which is supervised by the Protestant hospital chaplain. The trainees work with patients as a part of their training.
Acting out behaviour of persons with neuroses or character disorders is a problem whether at home, in the community, or in the hospital. For twenty years this hospital had a so-called "adverse behaviour clinic" which has been discontinued. Patients with problems are assisted by the staff members who have direct relations with them. When necessary, the supervisor, the administrative physician, or a staff psychiatrist is available. Action that appears most helpful to the patient is taken.
The termination of hospitalization depends on the status of the patient. If he is a prisoner it is determined by the sentence or action of the Board of Parole. If he is on probation it takes place when hospital treatment is completed. If he is a voluntary patient it can be at any time he wishes.
Thus it has been seen that many persons have important roles in the treatment programme at the hospital - the aid on the dormitory, the vocational supervisor, the physician, the social worker, the consultant, etc. It should be realized that completion of hospitalization is not completion of rehabilitation for the patient. This can occur only after the patient has left the hospital and returned to his home community.
From the opening of the hospital in 1935 until the end of the fiscal year 1955, 23,625 addicts were admitted a total of 45,058 times.
The results of hospitalization can be expressed by comparing the condition of the patient at the time of discharge with his condition at the time of admission. Patients are classified as" unimproved" if physical dependence is present at the time of discharge, or if there is no progress towards freedom from psychological dependence. " Hospital treatment completed" means that at the time of discharge there is freedom from physical addiction and enough progress towards freedom from psychological addiction has taken place for discharge to the community to be indicated. " Improved" is the status between these two.
In 1955, about one-third of the addict patients admitted stayed in the hospital for such short periods that their condition on discharge was "unimproved" (these were voluntary patients). About one-third of the patients were discharged as "improved ", and one-third reached the status of "hospital treatment completed ".
It would be interesting to know how many patients did not become re-addicted after their hospitalization. Pescor13 attempted such a study of 4,766 patients discharged from 1936 to 1940. He did determine that 39.9% of the patients had relapsed in periods varying from six months to six years. Twenty-five per cent of those about whom information was available were abstinent. It is interesting to note that prisoners on parole had the best records. This group received the most post-hospital supervision and could not leave the hospital until there was a satisfactory plan for a job, place to live, etc.
From the statistical point of view it is also of interest to study the work done by Rayport14 on 1,020 male patients, in which he classifies addicts who at first received narcotic drugs from a physician to the point of addiction in the course of treatment for an illness.
There are a number of difficulties involved in the treatment of the narcotic addict: for instance, the patient must remain in hospital long enough for the physical addiction to be treated, yet 40% of the voluntary patients leave in less than two weeks. As regards psychological addiction, the patients must have some motivation to live without narcotic drugs, and it is not possible to give such motivation artificially. Even with every care and attention there is no way of knowing whether that motivation does exist or not.
The treatment of physical addiction presents no difficulties if the patient is in a drug-free environment: the methadone substitution method has proved very satisfactory.
(The reports stating that chlorpromazine and reserpine are of value in the treatment of the abstinence syndrome seem to lack a firm foundation.)
It is unfortunate that the treatment of psychological addiction is not as well known and developed as that of physical addiction. The fact is that since it is usually closely related to a mental disorder, only improved methods for dealing with the latter will prove efficacious in the treatment of psychological addiction.
Finally, it should be borne in mind that, if hospital treatment can put a patient on the way to recovery, it cannot provide a life-long immunity and can only initiate rehabilitation. This must be completed after the patient returns to the community.
13 M.J. Pescor, Follow-up Study of Treated Narcotic Drug Addicts, Supplement No. 170 to the Public Health Reports, 1943.
14 M. Rayport, "Experience in the Management of Patients medically addicted to Narcotics ", Journal of the American Medical Association, 156: 684-691, October 16, 1954.