Lessons from the Anti-Narcotic Voluntary Treatment Programme in Hong Kong

Sections

TABLE I
The Voluntary Treatment Programme
Major issues encountered
The necessity for "feed-back" information
Conclusions
References

Details

Author: Pow Meng YAP
Pages: 35 to 44
Creation Date: 1967/01/01

Lessons from the Anti-Narcotic Voluntary Treatment Programme in Hong Kong

M.A. M.D. F.R.C.P. D.P.M. Pow Meng YAP
Head of the Division of Psychiatry, Hong Kong University Medical College; Senior Psychiatric Specialist, Hong Kong Government; formerly Medical Superintendent, Castle Peak Drug Addiction Treatment Centre, Hong Kong

Until 1946, the non-medical consumption of narcotics was legal in Hong Kong, and opium was obtainable from officially controlled opium stores. The effect of prohibition after the Second World War was to induce addicts to turn from opium to heroin smoking (the latter practice popularly known as "chasing the dragon" and "firing the ack-ack gun "), and ultimately to heroin by intravenous injection. The reason for this transition was the desire to obtain a more powerful pharmacological effect from money expended as well as to avoid discovery by the police. This process bas been repeated in other parts of South-East Asia where there is similar prohibition, and it produces a certain diversity in the addict population coming for treatment. Table I shows dearly what has been happening.

In Hong Kong, narcotic addiction has become widespread. Estimates of the number of addicts are often the merest guesses and these tend to gain a spurious validity with appearance in print. Nonetheless the Research Sub-Committee of the Narcotics Advisory Committee in Hong Kong came out early in 1966 with a reasoned estimate of a maximum of 65,000 male addicts and a minimum of 30,000 known to the law-enforcing agencies; female addicts were thought to be 3% of this number. These figures were reached on the basis of a 5 % sample survey of the files of all convicts during the period 1945-1965. Certain assumptions were made with regard to the life-span of addicts, their probable relapse rate and their emigration from the territory. In Hong Kong, three-quarters of all prisoners admitted to prison are addicts, and of these addict-prisoners one-third had not come into prison directly because of narcotic offences. Furthermore, the number of persons convicted per year for narcotic offences has varied roughly between 40 and 60 per 10,000 inhabitants. These figures are from official sources and are quoted in the studies of Hess (1965) and Whisson (1965). From all indications, Hong Kong with its population of 3,800,000 is one of the most heavily addicted countries in the world.

TABLE I

Natural history of narcotic addiction in sixty-two unselected cases

Full size image: 36 kB, Natural history of narcotic addiction in sixty-two unselected cases

On the way to a normal life: patients under the eyes of a friendly and sympathetic staff are helped to recover physical strength and some zest for life.

Full size image: 95 kB, On the way to a normal life: patients under the eyes of a friendly and sympathetic staff are helped to recover physical strength and some zest for life.

Rehabilitation must give the addict the confidence to be an independent and earning member of the society to which he will return. The teaching of skills such as those shown above must be part of the treatment.

Full size image: 92 kB, Rehabilitation must give the addict the confidence to be an independent and earning member of the society to which he will return

The Voluntary Treatment Programme

Treatment on a voluntary and informal basis by general practitioners and hospital doctors has always been and still is available. The so-called "British system" allows a physician to give a minimum maintenance dose to ensure effective social functioning when necessary for certain patients, and also in cases where deprivation of the drug may endanger life; but he must act in good faith and in accordance with medical ethics. There has been in Hong Kong little abuse of this right accorded to the medical profession, and the criminal courts have not had to decide on any case brought before them. However most practitioners are disinclined to treat drug addicts in private practice. The treatment of convicted addicts has been described elsewhere (Norman, 1961). The dangers of the "British system" in allowing over-prescription of narcotic drugs have aroused concern, and in 1965 the Inter - departmental Committee on Drug Addiction, headed by Lord Brain, recommended the development of treatment centres in mental hospitals or the psychiatric units of general hospitals where addicts could be compulsorily treated if necessary. Provisions were envisaged for forcible detention during the acute withdrawal phase after voluntary commitment. The problem of voluntary versus mandatory treatment has long been debated and schemes advocating various compromises have been advocated. The discussion by Schur (1962), although in some ways dated, is informative in this respect. A study group of WHO in 1957 suggested that some addicts of mature personality could be effectively treated on a voluntary basis both outside as well as within institutions, but thought that most would require civil commitment.

This paper describes the unique experience gained in Hong Kong from running a Voluntary Treatment Centre and the largely unexpected complications that arose. This Centre was probably one of the earliest of its kind set up anywhere in the world.

The Drug Addiction Treatment and Rehabilitaton Ordinance was enacted in 1960. In March of the following year the Castle Peak Addiction Treatment Centre was established in a separate and independent block of the new Castle Peak mental hospital. It was charged with the task of developing an appropriate system of voluntary treatment for male patients and conducting relevant research on the general problem of addiction in Hong Kong. The Ordinance was based on the principles guiding voluntary admission for psychiatric patients under the Mental Health Ordinance, also enacted in the same year. The unique feature was that an addict who applied for admission acknowledged a legally-binding obligation to remain in the Centre for a period of six months and the Medical Superintendent had powers forcibly to retake him if he absconded. Also, the applicant could be required to enter into a bond of up to HK $3,500 to secure his continued presence in the Centre. Leave of absence and visits by relatives were possible and the Superintendent could at any time discharge a patient. Those who could pay for treatment were required to enter into a bond for this purpose. An Addiction Treatment Appeal Board was also set up to hear appeals from patients who felt aggrieved by their continued detention. Information obtained from the patient in pursuance of the aims of the Ordinance was not to be admissible as evidence in any criminal proceedings that might be taken against him under the Dangerous Drugs Ordinance and related legislation.

The Centre consisted of two wards of 60 beds, each with its own day-dining room and grounds, and patients also had access to the general recreation areas of Castle Peak Hospital. The original staff were three doctors working part-time, of whom two were qualified psychiatrists. Later a fourth doctor joined the Centre, again on strictly part-time basis, after returning from a period of study and observation in the Lexington Public Health Service Hospital for Drug Addicts. There were two social workers, and for the day shift three nurses as well as seven ward orderlies (aides). It was very soon realized that the staff was inadequate in numbers and the maximum number of patients had to be kept at 60. Active withdrawal was accomplished with the help of methadone, the dosage of this being adjusted according to the objective symptomatic criteria of the Himmelsbach Scale.

TABLE II Summary of the work of the Castle Peak Addiction Treatment Centre (1961-1965)

Cases registered 2,220
   
     
Submitted to selection procedure
No
Yes
  187 2,033
     
Eligible for admission
No
Yes
  819 1,214
     
Admitted for treatment
No
Yes
  232 982

Note: Patients not eligible for admission were actually placed tm the waiting list with a low priority. Patients not put to selection, or having been selected, not subsequently admitted, failed to turn up when required to do so.

Table II gives a summary of the work accomplished during the existence of the Centre from 1961 to 1965

Major issues encountered

Siting and staffing the Centre

The siting of the Centre within the mental hospital (one of modern design built on the "villa system ") was largely a matter of expediency, and it unfortunately led to misjudgement on the part of the public. The nature of psychiatric treatment was not understood, and advocates of a regime of open-air physical rehabilitation, especially among those working in the penal field, pointed disparagingly to what was mistakenly thought to be merely a programme of indoor occupation and recreation and face-to-face "psycho-analysis ". It was moreover difficult for many to see why addiction should be regarded as a mental disease and given specific psychiatric treatment. The penal approach was familiar, the psychiatric less so; and if public support was to be obtained, it was necessary not to confuse the minds of lay persons with the image of "madness" and all its dread implications. How far this affected the willingness to seek treatment is difficult to say, but those who were actually admitted appeared not to object to the possibility of being regarded as insane. Still, it would be wise even in countries where the function of psychiatrists is better understood to avoid the association with insanity. The endeavour of the psychiatrist to cope with problems of personality and behaviour on the borderline of medicine and morality, such as drug addicts show, will always be liable to distortion by bias and ignorance.

Concerning ward staffing, it is necessary to say only that, apart from a sufficient provision, female nurses of less than mature age would be unsuitable unless perhaps they are actively backed by male colleagues. On the other hand, female social workers who are loosely attached to the Centre and in close touch with patients' families proved to be a great success.

Selection for admission and conflict of purpose

Any scheme to introduce an earnest and realistic treatment programme must be based on the selection of cases who will best respond to the therapy. To say that some are more worthy of treatment than others may be blatant cynicism, but this problem is also to be encountered in other fields of therapeutics wherever resources are unequal to the demand and efficacious knowledge is lacking. Once the principle is accepted we are confronted with the dilemma that selection, while essential for adequately testing individual treatment, also makes it more than ever difficult to secure a representative sample for study with a view to developing a scheme for the community as a whole. Therapeutic aim conflicts with epidemiological purpose.

At first, despite opposition from the Hong Kong Narcotics Advisory Committee, it was decided not to select in order to obtain a sample that could be approximately representative of Hong Kong addicts, granting that self-selection and geographical factors introduced a bias. The census-type of epidemiological study in this area under conditions of prohibition is not possible. Both sexes came up for registration at a special clinic held in the Hong Kong Psychiatric Centre in town. The ratio of male to female was initially 12 to 1. A few female cases were admitted as voluntary patients into the mental hospital but because of overcrowding this had to be stopped. The news passed round and the number of female registrants then dropped. The experience of treating female addicts put amongst psychiatric patients within an ordinary psychiatric ward was however useful, since it revealed that the former were prone to consider themselves a group apart from the others and demanded special attention and privileges.

Another reason for the selection of registrants was to avoid taking in potentially disruptive patients. How important this turned out to be can be seen from the fact that in the early stages of the project considerable dissension was caused by patients speaking certain dialects ganging up together against others and at the same time defying authority. Because there was no selection to begin with, they had been admitted all together in the same manner as they had been registered. At least one-third of the unselected cases had had experience of prison life before.

Whom to select

After some 60 unselected patients had come in, strict selection was introduced. The criteria for this had to be based on collective clinical wisdom and previous experience of handling addicts. The following were formulated as the basis for the selective intake policy: Promise of employment after treatment; a good work record; evidence of family support rather than social isolation; freedom from serious physical and mental disease; a good previous personality; a relatively brief history of addiction; comparatively good response to previous attempts at cure; addiction resulting from medical treatment whether orthodox or traditional; absence of a serious criminal record; and a genuine desire for cure. Clearly these criteria were subject to varying individual interpretation, and some of them could be arguable as an index of good prognosis. The criticism might be made that we had been wrong-headed and had inverted causal sequences or at least over-simplified them. However, selection was not only based on good prognosis, but also on the need to ensure the smooth running of the Centre, as well as to avoid deterring volunteers who might not like to be treated alongside others already hardened to prison life. In practice the selection criteria could hardly be considered in a mechanical way each by itself, and the need for flexibility was always borne in mind. The strictness with which these measures were applied moreover had to be related to the vacancies available. When later the number of volunteers dropped it was possible to admit patients of lower standard. In the case of physical disease (commonly phthisis, advanced dental caries and the ulcer syndrome), it was from the first realized that this might be an important causal factor of the addiction, so that the curability of the underlying disease was as a rule given careful consideration.

The response of the public was initially overwhelming and a long waiting list had to be kept. This was for some rather discouraging and it undoubtedly kept certain addicts from volunteering. The very passage of time caused many on the list to drop out, or rather it gave rise to difficulty in contacting them when their turn for admission came around. Many were illiterate and without a fixed address, and the need to keep their application for treatment and admission confidential meant that letters could not be sent them through the post in case these went astray. The Centre could not allow itself to be accused of carelessness in this matter and messages had as a rule to be despatched by reliable messengers, who nevertheless could not always find the addressees.

One grave problem to be surmounted was how to maintain confidence in the good faith of the Centre when there was the long wait and, what is more serious, the impossibility of telling the applicant that he was altogether unsuitable for treatment. Very few could be rejected out of hand and told why. Many were assigned (in their own interest a low priority, but the reasons for this could not be clearly revealed to them for fear that the knowledge of the bases of our intake policy would become generally known and capitalized upon in initial selection interviews. There can be no doubt that this was a real danger, one that would undermine the whole function of selection. On top of this, there were bound to be a few persons disposed to seek admission, not because they were true addicts or even users wishing to be cured, but only mendicants hoping for free board and lodging. Certainly there were several cases who after admission showed no clearcut withdrawal symptoms. Screening for admission was therefore charged with considerable responsibility, it was also delicate and liable to thoughtless criticism on every side. It is necessary for persons in authority to have implicit trust in those undertaking the job and to give them all possible backing.

At the outset the question had to be faced whether or not a patient should be given more than one chance of treatment. It was decided not to do this in order to discourage relapse, and also out of fairness to others who had not yet received treatment. Thus it was highly important to make this policy plain beyond misunderstanding to all who were newly admitted. However, after three years or more, with less pressure on beds, a very few specially deserving patients were given a second chance. Inevitably this became generally known and could be expected to have exercised an effect on those already in as well as on others newly discharged and still in danger of relapse. Every innovation or change in policy entailed indirect consequences that had to be foreseen, and either accepted or forestalled.

Meeting pressures from different segments of the Administration

Overall planning in the drive against narcotics was in the hands of the Narcotics Advisory Committee, which included senior officials from interested Depart- ments as well as community leaders. In the day-to-day work of the Centre the staff faced certain pressures and demands from different sectors directly impinging on its basic policies. These sources of strain deserve recognition.

Community attitudes towards addiction are always ambivalent, but there is usually a desire more to help than to penalize. This applies also to the outlook of the magistrates in Hong Kong. With the inception of formal voluntary treatment there was an increased number of persons under prosecution for dangerous drugs offences discharged with advice to seek treatment at the Centre, or put on probation on condition of treatment. Some magistrates failed to appreciate the indispensable function of selection and questioned the need to keep a waiting list for admission. Acceptance of cases simply on the court's recommendation however would undermine the voluntary nature of the programme. Also, if this were allowed, there was certain to be an unusually heavy burden of such cases on our hands, many of whom would be insincere over treatment. Even with true volunteers there had been one or two cases who had come in with heroin concealed in little phials in the rectum. Moreover, there was nothing to prevent addicts wanting treatment simply to surrender themselves to the police, go through the Courts in the ordinary way, and thus jump the line waiting for admission. Sometimes addicts on our register for selection happened to be arrested, and the fact of registration not unexpectedly influenced the judgement of the Court in the direction of leniency. The Centre however could not give special and automatic priority to such cases since it was necessary to prevent the situation from developing whereby registration became merely an insurance against possible conviction on drug charges. Quite a number of ordinary addicts after first registering did not come up again for the two routine interviews, physical examination and X-ray. Finally, it was important not to associate the Centre with the courts and the police in order to avoid any stigma of criminality attaching itself to the ordinary volunteer from the public.

For all these reasons, cases on drug charges under probation were not accepted until much later, when there were vacancies open to be filled. The terms of probation were altered so that probation officers did not have to visit their charges in their official capacity at the Centre. Those under police supervision were admitted on condition that they were not required to report regularly to the latter while under treatment.

Civil servants as a class posed another prob1em. They could not be denied the opportunity for treatment, yet this involved confession of addiction and also the grant of prolonged sick-leave. For obvious reasons the Police, Prison and Preventive Service Departments had to be especially wary of the existence of addiction among their members and try as much as possible to root it out, or at least abate it. A general amnesty for addicted civil servants declaring their plight in order to get treatment was mooted, but was thought impractical because of the possibly large numbers that might come up. Finally it was laid down that all civil servants like the general public should be given a chance of treatment on the recommendation of a Medical Board made up of three doctors attached to the Centre. After the completion of treatment another Board would be convened to decide the question of return to duties. Relapsed cases were asked to be examined by a further Board, which might recommend a second course of treatment or state that further treatment was of no possible avail, in which circumstances compulsory retirement would follow. The whole problem was therefore placed on an essentially medical basis. The task of the Board deliberating on such cases was onerous because it was necessary to avoid giving the impression that civil servants were to be given more favourable consideration than the rest of the public as regards retreatment. Actually civil servants comprised from the start a group with good outcome as far as guaranteed employment was concerned, and they were of course a selected band working under relatively secure conditions of service, with regular medical attention. No civil servant was ever turned down for initial treatment. It may be mentioned here that, in spite of early fears, civil servants did not appear in great numbers for treatment. Possibly the prospect of up to six months' enforced stay at the Centre proved to be forbidding; or there may be fewer of them addicted than at first thought.

Disciplinary restraint a threat to therapeutic endeavour

The great majority of patient although seeking treatment initially with the best of will were not convinced that a stay of more than some weeks was essential for sustained abstinence. They became restless in the second or third month on regaining weight and strength, and almost everyone pressed for discharge after about four months. Leave of absence over the week-end was usually given at this time, to be followed by a nalline test on return to rule out re-addiction. A few cases, e.g., older opium addicts, might be given early discharge. It was necessary to explain clearly to the others the justification for early discharge in particular cases. There were unfortunately always dissident patients who sought to precipitate prematurely their own discharge by annoying conduct, or who were inclined to incite others to do so.

This brings into focus the weakest point of the system as it has been developed, and at the same time highlights a flaw in the Drug Addiction Treatment Ordinance. It was found necessary at all times to keep close supervision of patients, and unauthorized cigarette smoking in w.cs had to be forbidden because of the practice of inhaling heroin through lighted cigarettes. Mail had to be checked in case heroin powder was sent in. Patients were routinely searched after receiving visitors and on return from leave. In spite of these precautions, there were several attempts to smuggle in drugs. Many addicts, are intolerant of discipline and unable to withstand frustration. The fact that they volunteer for treatment, it appears, makes little difference. It is easy to say that better management and more intensive counselling could have diminished the lack of co-operation and other destructive behaviour encountered, but the programme had to be carried out within the limits of the staff available, and none of the doctors and social workers could be posted there fulltime. Regular visiting by relatives, an occupational programme with monetary reward including outwork in a nearby factory, outdoor walks and swimming, indoor recreation and group meetings, English language classes and leaves of absence must have all helped to maintain morale and minimize ennui, but there were still occasional attempts, mostly in the early stages, at defiance. These took the form of hunger or sit-down strikes and threats against the ward aides. On one occasion the police had to be called in to prevent rowdy behaviour from getting out of hand. To meet ill-discipline, the staff resorted to deprivation of recreational privileges, reduction of the cigarette ration, and on a few occasions confinement to single rooms for brief periods; but on the other hand more liberal leaves of absence and flexible visiting hours were also introduced.

Disciplinary measures could hardly be evaded when the patient's motive was deliberately to provoke his own release or to extort privileges which, if conceded, could lead to a lowering of guard against the smuggling in of drugs. The problem was to know how far to go, and in this respect it was felt that the Ordinance, while rightly providing for penalties against ill-treatment of patients, should also be more specific in laying down the disciplinary powers of the Superintendent. Measures of punishment seldom advance therapeutic aims but if the law indicated more clearly what could be allowed in this regard any damage done might be lessened, and indeed possibly redeemed by further work on individual patients. It was soon learned that wisdom lay in giving solely to the Medical Superintendent the responsibility for disciplinary correction, while the other doctors and the social workers devoted themselves essentially to psychotherapy and cultivating the necessary rapport between staff and patients. During the existence of the Centre the Appeal Board had not once to be called into session. Patients preferred to take matters into their own hands, as it were, rather than go up to the Board.

The necessity for "feed-back" information

As an experimental project, the Centre was obliged to build into its programme a means for assessing the results of its work. Follow-up study of patients was in the hands of the social workers. These are required to make annual reports on the status of a cohort of ex-patients, treated entirely at the Centre, for as long as it is possible. (Patients were transferred to the new Shek Kwu Chau Treatment Centre, after acute withdrawal, from June 1963 onwards.) The labour of tracing these persons is perhaps more difficult than in other kinds of disorders, for the addict population on the whole belongs to the socially unstable fringes of society and a history of previous addiction tends to interfere with a regular livelihood. The responsibilities of the social workers are made easier by the existence of the Pui Sun Association, a society of ex-patients first formed with the help and encouragement of the Centre and now functioning under the guidance of the Lutheran World Service, which has given it much needed financial and other assistance. Through this Association many discharged patients can be contacted by the workers who attend its meetings regularly as official advisers. Other ex-patients come back to the Psychiatric Centre where they first registered, for help and medical attention. A considerable number of these have vague psychosomatic symptoms, as well as social problems, complicated in some cases by moderate alcoholic consumption. Apart from the requirements of follow-up, their continued need for supportive treatment and assistance creates a certain amount of anxiety, in view of the unavoidable staff shortage. This problem associate with follow-up must always be kept in mind in devising any scheme of treatment for addicts. Patients in the follow-up group are persuaded to come back to the Clinic for a nalline test 1 to establish their freedom from addiction if they have not themselves admitted relapse, but it is never possible to do this in every case. To the best belief of the workers, who are experienced, capable and trusted, about half of the patients treated entirely in the Centre were abstinent in November 1965 or were abstinent when they died. The details, which may require minor amendment with further verification, are given in Table III, (see next page).

In an area where treatment procedures are controversial and emotions easily aroused, undue importance may be attached to the results of follow-up, as though these could be the sole and simple index of the worth of the therapeutic regime developed. The difficulties of making meaningful comparisons between different sets of follow-up statistics are seldom appreciated. 2 It is necessary to take note of pre-selection of cases, the time elapsed from completion of treatment, the criteria of "cure" used, whether or not "cure" was assessed with the help of objective tests, and above all the completeness of the follow-up itself. Since the problem of drug addiction is the concern of so many groups in the community and almost as many departments of government, each espousing its own favourite approach, an active effort to publicize these points would be of value.

Before conclusions can be validly drawn concerning the outcome of treated cases it is necessary to view them in the light of the natural history of the disorder. As exemplified in Table I, addiction tends to run a fluctuating and progressive course, and this is related to factors of physical health, income, the life-situation, the price of drugs and the severity of police pressure-quite apart from the fact of habituation and tolerance. Undoubtedly, from what we know of addicts in general, this kind of progression is characteristic of most of those who require to be helped. Addicts are clearly a heterogenous group of people, each afflicted in different degree. The seriousness of the addiction can be assessed in terms of the information given in Table I. It is well known to the populace that opium has certain desirable effects in comparison with heroin, which is a more toxic and a much more masterful drug, very difficult to throw off. Social and psychological circumstances force the opium addict to switch over to heroin by smoking and then by injection. If he does not do so he may be presumed to have a certain socio-psychological as well as constitutional resistance to the progressive course that is paradigmatic of addiction. Some addicts for example may be more accurately called "users" only, since they can stop their drug (commonly opium) for varying periods and there are others who may have no need to increase the dose - the "stabilized addicts ". Each type of addict carries a different prognosis. Thus comparison of the results of treatment between different groups cannot tell anything worthwhile about the efficacy of the treatment without taking into account the proportion of different types of addicts in each group. The fact that addicts in Hong Kong (as in other parts of South-East Asia) are rather more heterogenous than addicts, say, in the United States must be borne in mind when assessing the value of the scheme developed in the Centre.

____________

Evaluation and standardization of the nalline test was one of the studies pursued in Castle Peak. Cf. E. Leong Way, P. M. Yap et al., "Evaluation of the nalorphine pupil diagnostic test for narcotic usage in long-term heroin and opium addicts ", in J. Clin. Pharmacol. Ther. (1966), in the press.

Nevertheless, note may be taken of the finding of a 40% abstinence rate in prognostically favourable addicts recently by N. Retterstol and A. Sund (1964), "Drug addiction and habituation ", Act. Psychiat. scand., 40, Suppl. No. 179. Cf. also H. Bewley (1965), "Heroin addiction in the United Kingdom (1954-64)", Brit-med. J., 2, 1284

TABLE III

Follow-up of a group of 314 patients treated wholly in Castle Peak Addiction Treatment Centre (November 1965)

Total number of patients (admitted between March 1961 and August 1963) followed-up
314 (100%)
Currently abstinent, or abstinent at time of death
158 (50.3%)
Abstinent ever since discharge
102
Abstinent after one relapse
41
Abstinent after two relapses
4
Abstinent after three relapses
3
Abstinent until time of death
8
Currently readdicted
139 (44.3 %)
Untraceable and regarded as readdicted
9
Currently under treatment after relapse (in Shek Kwu Chau)
17 (5.4%)

There is finally the question whether the all-or-none criterion of total abstinence is the only valid and useful one that can be applied, rather than measures of a relative kind like working capacity and reintegration into the family. But discussion of this cannot be further pursued here.

Conclusions

Towards the end of 1965, after more than four and a half years, the Castle Peak Centre was closed down, having transmitted its experience, and finally conducted its remaining charges, to the newly developed Centre on the island of Shek Kwu Chau run by the Society for the Aid and Rehabilitation of Drug Addicts.

Prohibition of narcotics obliges the community to provide facilities for the voluntary treatment of addiction. Ambulant treatment is risky for the practitioner where the maintenance of professional standards is concerned, and in most cases meets with only limited success. A voluntary treatment centre with legal requirements binding the addict to stay in a controlled drug- free environment for some months has special advantages, although in some states such legal provisions may be unconstitutional. It also provides protection and security to addicts seeking treatment, and in Hong Kong the demand for such a scheme was publicly, though anomymously, expressed by addicts. The unusual fact that in treating addiction we are helping patients regarded by the law as criminal is often overlooked. Comparison may be drawn with voluntary treatment in a psychiatric hospital, but experience strongly suggests that addicts as a group are best treated away from other hospitalized psychiatric patients.

Medical therapy is in principle adjusted to the acuteness of the disease and the prospects for cure, and always there is need to restrict numbers to manageable proportions. A voluntary treatment centre such as we have described should take in only the cases it is best fitted to help, and this implies a process of selection, which will have repercussions in several directions that need to be anticipated. Another reason for selection must be to keep away those who are unduly hostile and disorderly, since it is quite easy for a few to put in jeopardy the whole regime of treatment, with injury to all. The crucial task is how to motivate patients to co-operate and remain for the optimum period of withdrawal and rehabilitation, while at the same time invoking sanctions against indiscipline when it occurs, as it inevitably must in greater or less degree. Moreover, the morale of the staff must be maintained at all cost, especially at the level of the ward orderlies or aides who are in the closest contact with patients and have to bear the brunt of any mischief.

The aims of the Centre need to be realistic and therefore limited. Research design cannot in many respects be fitted into the practical requirements of organized treatment, although it may be possible to pursue different ends in succeeding phases as long as the reasons for policy changes are made clear to both administration and public. Therapeutic goals themselves cannot be set too high if we take into consideration the natural history of addiction and its entanglement in the diverse social and economic circumstances which in countries like Hong Kong are perhaps of greater concern than in others. A voluntary treatment centre cannot take the place of institutions for treating convicted addicts, nor the wards of a general hospital. In an urbanized community these will have their place in an over-all programme. But the centre's potential will hardly be brought into full play unless it is organically integrated into an active association of ex-patients and also wherever possible a "half-way house ". In Hong Kong a "half-way house" could not be started for severely practical reasons; and while the Centre gave birth to the Pui Sun Association, this again for primarily financial reasons had to be handed over to other auspices - although our social workers and the follow-up clinic did constitute a continued link between the two.

It would be impossible to plan for the praiseworthy degree of social dynamism and ideological fervour that characterizes the movement for voluntary treatment in Synanon Houses 3 (Yablonski, 1965). The "way of life" Synanon seeks to promote in the face of community fears and prejudice, as well as its group techniques, are probably very much bound to American culture, just as its expansion depends on donations made possible only by private American affluence. In Hong Kong, the Mental Health Service could only provide the conditions for the emergence of dedicated ex-addicts and encourage them to fulfil themselves in an association such as the Pui Sun. However it must not be overlooked that, worthy as the Synanon movement appears to be, it has to reject by its very nature attempts at objective evaluation of its work. A voluntary treatment centre cannot be organized and worked on such a basis, especially if this is to be with State funds. It can, however, be alert to its natural limitations and assist in the development of post-treatment programmes of a lively and imaginative kind.

The author had in May 1966 the opportunity to study the activities of the Synanon House in San Francisco ("Sea Wall").

The author is indebted to Dr. P. M. Lau and Mrs. S. Fung for assistance in collecting and analysing the data herein presented; he is, however, solely responsible for their presentation. Acknowledgement is also made of permission to publish this paper from Dr. P. H. Teng, Director of Medical and Health Services, Hong Kong.

The contents of this paper will appear in a forthcoming book, tentatively titled Community Mental Health Programmes-Some Problems of Research, edited by Richard H. Williams. To be published by Jossey-Bass Inc., Publishers, San Francisco, in 1967.

References

Hess, Albert G., Chasing the Dragon . Amsterdam, North-Holland Publishing Company, 1965.

Interdepartmental Committee on Drug Addiction, Second Report. London, H.M. Stationery Office, 1965

Norman, Cuthbert J., "Hong Kong's Prison for Drug Addicts", UN Bulletin on Narcotics, XIII, No. 1 (Jan.-March), 1961

Schur, Edwin M., Narcotic Addiction in Britain and America. Bloomington, Indiana University Press, 1962

Whisson, Michael G., Under the Rug.Hong Kong, H.K. Council of Social Service, 1965.

WHO, Treatment and Care of Drug Addicts (Tech. Rep. Series No.131). Geneva, WHO, 1957.

Yablonski, Lewis, The Tunnel Back. New York, Macmillan, 1965.