A Canadian programme of voluntary treatment of drug dependence
Author: H. F. HOSKIN
Pages: 45 to 48
Creation Date: 1968/01/01
The work of the Narcotic Addiction Foundation of British ColumbiaH. F. HOSKIN
Executive Director of the Foundation
The Narcotic Addiction Foundation of British Columbia has been a pioneer in the voluntary treatment of narcotic addicts, since it was set up in 1955 as a private, non-profit-making organization, with the support of the Government of the Province of British Columbia and of the Government of Canada. In the years up to 1966 the Foundation has provided voluntary in-patient and out-patient treatment for 1,380 narcotic addicts and 100 persons addicted to other psychotropic drugs such as barbiturates, amphetamines and LSD-25. In 1966, for example, voluntary treatment was given to 579 addicts, some once or twice, some many times, with an average monthly case load of 175.
There has been a measurable improvement in the narcotic drug situation in British Columbia; though the number of persons using narcotic drugs has remained fairly constant (1965 - 1,907; 1966 - 2,068) the greater percentage is using less drugs than ever before and very few addicts now display the severe withdrawal symptoms experienced in the past. This reduction in the availability and use of narcotics has been achieved by constant and effective pressure by the Federal and Municipal law enforcement agencies, the impact of the opening of the new Federal Matsqui Institution specifically designed for narcotic offenders, and the ability of the Foundation to offer an increased and more effective service to the addict, to the community physician involved in the treatment of addicts, and to the community by way of information and preventive education.
Note: The phrase "voluntary treatment" used here describes treatment when it is given to drug dependent persons who seek it voluntarily.
Despite this improvement, the Foundation is seriously concerned about the changing pattern of drug abuse.
There has been an appreciable increase in the use of barbiturates and amphetamines, and considerable evidence that marijuana, LSD-25 and amphetamines are being used increasingly by young people, including those of high school and university age, who intellectually and socially have displayed no desire for, nor susceptibility to, the hard (narcotic) drugs.
Treatment of drug dependence of morphine type
In the treatment field, in 1966 there was a 45 % increase in the number of addicts seeking help. We believe this to be a direct consequence of our ability to increase our service to the addict. We were heartened to observe that although our active case load increased by 45%, the amount of medication (methadone) prescribed during the corresponding period had only risen 16%. This improvement was due in the main to the scarcity of heroin in the local area, resulting in less heavy dependence, which meant that the withdrawal programme was quicker and easier. Generally, the prolonged withdrawal programme with many patients stabilized on relatively small amounts of methadone has been successful, and it was found that more intense social support to the addicts seems to eliminate the need for heavy medication.
The treatment programme has changed only slightly over the past few years, but drastic changes are foreseen when better treatment facilities, including a thin-layer chromotography laboratory, become available. Treatment so far has been of two types - regular withdrawal and prolonged withdrawal.
Regular withdrawal is given on an out-patient or in-patient basis. The latter, we feel, is the more satisfactory form of treatment, but because of the shortage of beds, is only possible on a very limited scale. If a patient is treated as an in-patient, it is possible to treat him for actual physical symptoms, rather than just complaints. Thus, we find the amount of medication used in this form of treatment is very small when combined with the constant support given by the nurses and social workers. The average amount of methadone used in a withdrawal in residence is 50 mg as compared to 240 mg on an out-patient withdrawal.
Our prolonged withdrawal programme has now been in operation for over four years, the first such voluntary programme to be started in North America. Results of a comparative follow-up study showed that for the addict over the age of 50, a maintenance dose of methadone is very beneficial. The majority of this group has had no further problems with the law and is functioning well in the community. This group continues to receive support from our staff, and it is felt that the older addict would revert to illegal drug use if such support were withdrawn. The younger age group on the other hand, appears to do less well on this programme. This could be due to our inability to offer a more extensive rehabilitation programme, as well as the nature of the young addict. Controlled research is needed to assess the effectiveness of our treatment programmes.
It has always been the aim of the Narcotic Addiction Foundation to do everything possible to control drug abuse among its patients. In 1966 we have seen a considerable improvement in this regard. In March we instituted the use of liquid methadone. This was the first such preparation to be used in Canada in the treatment of the addict.
A survey of the addict population who came to the Foundation showed that a large percentage was "mainlining" its methadone, i.e. taking it by intravenous injection. We felt that if the "ritual of the needle" played such an important part in the addict's life, efforts should be made to curb this by the form of medication employed. Furthermore, when given methadone in tablet form, the patient was always aware of his dosage by the number of tablets he was receiving. Since we are dealing with a strong psychological problem, we felt it would be helpful in treatment if the addict could not tell the strength of medication by appearance or taste. With this in mind, we began to dispense methadone by mouth in a lime base, the lime masking the bitterness of the methadone, and this helped to reduce the desire for injections. At the same time the dosage could be varied, giving the Foundation doctors the opportunity to study the psychological dependence on drugs in more detail.
The patients were told approximately three weeks before implementation of the intended change from tablet to liquid methadone, and although we had considerable complaints for about two weeks following the use of the liquid, we did not find a significant drop in our patient load. This programme has now been in effect for over nine months and is well accepted by the addict.
Although Lorfan testing (a test used to measure the extent of physical addiction) had been used sporadically, we have now stepped up its use. The test is time-consuming but we find it essential. When used on those patients where true addiction seemed doubtful, approximately one-half had a negative test. Consequently, no medication was dispensed.
It is hoped that a laboratory will soon be in operation using thin-layer chromotography for determination of heroin, methadone, barbiturates and amphetamines in the urine. This will help to decrease drug abuse among our patients, and at the same time give us a more accurate picture of their drug dependency.
Some 545 patients received social worker services during the year 1966. These patients attended the Foundation for varying lengths of time, some receiving minimal service, some average service, and others intensive care. The following table reflects the length of contact, number of patients, and their percentage:
Length of contact
Number of patients
over 1 year
One of the major difficulties was to have patients leave the "sub-culture" of addicts and put a stop to their association with active users. In some 18.7% of the cases, patients were helped with plans to leave town. In 55% of the longer term cases, patients were helped to make varying degrees of separation by finding employment, new accommodation and constructive leisure time activity. Sixty-eight per cent of the patients were helped to find employment, of whom 30% actually did obtain a job. Ten per cent of those patients who came to the Foundation were already employed, but 40% of the employable patients were either helped to keep their jobs or to obtain employment.
There were 249 patients (46%) who were legally married or had a common-law marital relationship. Some of these patients had children. Sixty-five per cent of these patients received case-work services to improve marital relationships and to enhance the ability of parents to care adequately for their children. Wherever indicated, existing services in the community were enlisted for this purpose.
In April 1966, the Comparative Methadone Withdrawal Study of the Foundation was completed, but due to the difficulties arising from the uncontrolled pre-selection of the two treatment groups, the findings of the study were somewhat disappointing. There was no indication of any specific direction for narcotic addiction treatment programmes without further trial and error. We did learn, however, that addicts over 50 years of age could function well on prolonged maintenance with a minimum cost to the community.
One outcome of this study was the submission of a research proposal to the Department of Health, Education and Welfare in the United States for support of a research programme that would test the effectiveness of various kinds of treatment.
A second result of the comparative study was a partial confirmation of the "maturation" hypothesis. This hypothesis predicts increased abstinence from drugs as the addicts become older, either physically or mentally. It is a fact that we really do not know what happens to older addicts; do they die, change to other addicting substances or manage to live their lives without the use of drugs? Consequently, a research proposal was submitted for a National Health Grant, seeking support for a longitudinal study of the 1,300 addicts seen by the Foundation in the eleven years of its operation. This study was approved and will deal with the onset, duration and cessation of drug use. Data will be retrieved from the files of the Narcotic Addiction Foundation and the Division of Narcotic Control in Ottawa, as well as obtained in personal interviews with each of the 1,300 addicts.
Dependence on psychedelic drugs
A preliminary report on psychedelic drug use in Vancouver has been made for the Foundation, by Williams and Paulus, and additional data from 72 questionnaires and 40 interviews is being evaluated. Those questioned indicated that in their view strict law enforcement of the Narcotic Control Act with regard to marijuana serves as a deterrent to only a small number of people.
Although the use of marijuana seems to have diminished, the use of LSD increased tremendously in 1966. Reports of admissions to hospitals for emergency treatment after LSD ingestion also rose. Psychiatrists reported an increasing number of persons under psychiatric care who had previously used LSD and who were no longer able to cope with their suicidal tendencies, anxieties, and severe tensions.
With the decrease in the availability of heroin in Vancouver, we were faced with an increase in barbiturate abuse by the addict. Among patients treated in the Residence of the Foundation, the increase in dual addiction (that is, heroin use supplemented with bar- biturates) rose by 120 % in 1966 compared with 1965. This placed a tremendous strain on our medical staff and budget, for the danger of possible convulsions during the withdrawal required special nurses to maintain continuous supervision over the patients. The use of barbiturates by heroin addicts treated by the Foundation has also been assessed by Cumberlidge. It was found that barbiturates were used mainly to potentiate heroin when it was either poor in quality or high in price. Only 33% of the addicts questioned said that they would continue to use barbiturates if they were able to obtain enough narcotics.
Types of addicts and drugs used
The number of new patients seeking treatment at the Narcotic Addiction Foundation in 1966 (169) increased 40% over the 1965 (120) figure. The majority of the patients were under 30 years of age when first seen (58 %), born outside the Province of British Columbia (64%), lived in Vancouver since leaving school (54%), received formal education between grades 8-11 (74%) and have either never been or are no longer married (70%). Many have had no employment at which they earned a living during the three years previous to coming for treatment (41%), and 76% were unemployed when first seen. The majority had started to use drugs before the age of 21 (59%), had used drugs for more than five years before coming for help (58 %) and were addicted to heroin (87%). Forty per cent stated that they had not been convicted of any criminal offences, either as juveniles or adults, before becoming involved in drug use, while 42 % had one or more convictions for violations of the Narcotic Control Act.
More addicts received withdrawal treatment in the year 1966 than in any previous year; 105 male and 54 female addicts were withdrawn from narcotics and barbiturates on an in-patient basis: The Foundation recognizes the value of in-patient detoxification, in that it allows the addict time to think about and understand his own problems away from the usual pressures of the "street". It also enables him to take stock of the "non-institutional" facilities offered, and it has been noticed that patients are voluntarily committing themselves to longer-term care.
The average length of stay in residence increased from 15 days for males and 10 days for females to 27 days for males and 17 days for females. This is a significant improvement when one considers the desire of the addict to abandon the treatment the moment he has sufficiently recovered physically to discontinue treatment, and has passed the medication phase of withdrawal. The Foundation was also encouraged by the number of addicts (23) who had previously received withdrawal treatment and returned to the residence for support (non-addicted admission) when they felt threatened or in danger of relapsing to drug use.
Dually addicted patients (using narcotics and barbiturates) continue to strain our facilities and present a serious nursing problem. The Foundation treated 46 patients at the Residence for dual addiction. It anticipates that an ever-increasing number will turn to other drugs to support their narcotic addiction, or will make use of other drugs in times of narcotics scarcity.
The educational functions of the Narcotic Addiction Foundation, always an important feature of our work, have been emphasized by the establishment of a specific department to meet the growing and differing requirements of the drug abuse situation. An effort has also been made to co-ordinate the work of our own several departments and the educational roles of the community bodies in the professional, student and lay public fields. The intent is, of course, to develop the kinds of educational services which will be of most value in the area of prevention, hopefully at the primary level, but also at the secondary and tertiary levels (of treatment and rehabilitation).
A continuing programme of staff education has been intensified, and numerous papers were prepared for presentation at medical and other professional conferences, articles were published in various professional journals in Canada and the United States, and various other papers and pamphlets were prepared for use in seminars and discussions, as well as for distribution on a wide basis.
By these efforts we hope to increase our own professional knowledge of drug use and dependence, and to assist in the definition of an educational-preventive approach to the population "at risk" in terms of vul- nerability to drug dependency. We believe this effort should be directed mostly at young people and their parents, and the growing incidence of abuse of such drugs as marijuana, LSD and various forms of "glue" in this population tends to confirm our assessment.
By and large, in so far as methods of implementing this programme are concerned, we have focused on "educating the educators ", both in the school system and in the universities. This has been very well received, and is reflected in the growth of our own library, the increasing requests for educational services and some modifications of traditional attitudes towards addicts and dependence-producing drugs.
It is the opinion of the Foundation that drug dependence is a major social ill, which cannot be combated effectively until control legislation, particularly legislation dealing with psychotropic drugs other than opiates, is reviewed on the basis of clinical research as to the real or potential danger of the drug, and not passed as a result of public panic or pressure. The need for a much closer liaison among all agencies, both government and private, is long overdue, and it would appear that a great deal of duplication of effort in terms of research and the testing of treatment procedures could be avoided if the United Nations could assume responsibility for over-all co-ordination. A wealth of information could be made available to all agencies involved in this field if a free exchange of research, treatment and preventive education material was made available through a co-ordinating agency. It is also necessary to have a central allocation of priorities for research which would benefit all governmental and private agencies everywhere which are involved in the treatment and rehabilitation of persons dependent upon narcotic and other psychotropic drugs.