Current trends in the treatment of drug dependence and drug abuse

Sections

I. Introduction
II. Basic treatment procedures A. PRE-WITHDRAWAL
B. WITHDRAWAL FROM DRUG USE: DETOXIFICATION
C. POST-WITHDRAWAL FOLLOW-UP
III. Current treatment innovations
B. LEGISLATIVE PROGRAMMES
C. PHARMACOLOGICAL APPROACHES
IV. Ambulatory treatment
VI. Prevention: education

Details

Author: B. M.D. NATHAN EDDY
Pages: 1 to 9
Creation Date: 1970/01/01

Current trends in the treatment of drug dependence and drug abuse

B. M.D. NATHAN EDDY
Consultant, Bureau of Narcotics and Dangerous Drugs, United States Department of Justice

This paper was prepared at the request of the United States Bureau of Narcotics and Dangerous Drugs and is published by permission; the views expressed are the personal judgments of the author.

Contents

 

Page

I. INTRODUCTION: SHIFTING ATTITUDES AND EMPHASIS ON THE UNDERLYING PRINCIPLES
1
II. BASIC TREATMENT PROCEDURES
 
A. Pre-withdrawal
3
B. Withdrawal from drug use: detoxification
3
C. Post-withdrawal follow-up
3
III. CURRENT TREATMENT INNOVATIONS
3
A. Self-help programmes, guidance clinics and halfway houses
 
1. Synanon
4
2. The Addiction Research Centre of the Commonwealth of Puerto Rico
4
3. Daytop Lodge
4
4. Guidance clinics, rehabilitation centres and halfway houses
4
B. Legislative programmes
 
1. California
5
2. New York
6
3. Maryland
6
4. Federal civil commitment
6
C. Pharmacological approaches
 
1. Methadone maintenance
6
2. Cyclazocine and other antagonists
7
IV. AMBULATORY TREATMENT
8
V. VOLUNTARY V. INVOLUNTARY COMMITMENT TO TREATMENT
8
IV. PREVENTION: EDUCATION
9
REFERENCES
9

I. Introduction

Shifting attitudes and emphasis on underlying principles

Up to about three decades ago, almost exclusively, and for most of the time since, principally, when addiction was considered, the problem was one of abuse of morphine, heroin or their congeners. It was known of course that many persons used and craved cocaine and that many more abused cannabis.

In spite of the diverseness in their effects cannabis and cocaine were also classified legally as narcotics and attempts were made to define addiction in a way which would cover their abuse as well as that of the opiates. Only within the past five years has the realization come to the fore that a developing drug dependence is the common factor in drug abuse. At last it has been recommended that we abandon the term and concept of addiction and deal with the nature and problems of drug dependence of this or that type [ 1]

Similarly treatment programmes have been designed almost without exception for drug dependence of morphine type (narcotic addiction), forgetting or overlooking that the person involved, the patient, may be using one or more other drugs or may turn his attention to other drugs in the course of treatment. Primarily then a discussion of treatment trends will be concerned with the treatment of opiate dependence, but one of the trends is the need to consider simultaneous involvement with other drugs. Some persons still use an opiate only; some use another drug and never an opiate. Most turn from one drug to another partly at least according to availability but partly also because they seek release or satisfaction in the abnormal state produced by a drug effect, whatever that may be. This trend may complicate markedly the manner, the course and the outcome of treatment.

Drug dependence, then, is a state, psychic or sometimes also physical, resulting from the interaction between a living organism and a drug, and characterized by behavioural and other responses that always include a compulsive drive or need to use the drug on a continuous or periodic basis in order to experience its effects and/or avoid the discomforts of its absence.

The phenomenon of psychic dependence and the compulsive drive must always have been recognized in the chronic use of opiates and some other drugs. Recognition of physical dependence, however, developing in connexion with the use of the opiates, was slow and in the case of some other agents, the barbiturates for example, even very recent. Psychic dependence is apparent throughout drug use, may persist long after drug administration is suspended and in fact, may never entirely disappear. Physical dependence becomes manifest only when administration falls below a critical level or is stopped and a characteristic symptom complex develops, the abstinence syndrome or withdrawal sickness, which may be relieved by administration of the drug or a congener and is self-limited if the drug is discontinued altogether. The symptoms vary according to the type of agent with which they are associated.

In the past, whether or not it was assumed that psychic dependence would disappear with complete withdrawal of the drug, little was done about it. Realization that psychic dependence with marked compulsive craving can occur with or without physical dependence is essential and the effort towards its relief in both pre-withdrawal and follow-up rehabilitative treatment is an important current trend.

One attack upon physical dependence, a preventive measure, is the attempt that has been and is being made to prepare a medicinal agent, an analgesic for example, which affords symptomatic relief comparable to that of morphine, without producing physical dependence and an ultimate withdrawal sickness. There is no doubt of the worthwhileness of these efforts since their success must facilitate the use of the agent for symptomatic relief and remove one of the drives to continuation of drug use when such relief is no longer needed. Naturally this work began with modification of the morphine molecule; it has continued also with a wide variety of chemical syntheses. An early incident in this programme had significance in our understanding of dependence, though it added materially to the over-all problem [ 2] . In 1898 diacetylmorphine (heroin) was prepared from morphine and promptly shown to be able to replace morphine in dependent persons with adequate relief and without the appearance of abstinence symptoms. It was hailed as a cure for opiate addiction, but, unfortunately, it was shown very soon to produce physical dependence itself more rapidly than morphine. Its substitution for morphine only replaced dependence on one agent by dependence on another. Nevertheless, from this sort of observation the hypothesis was developed that an agent which could substitute for morphine in an established dependence with suppression of abstinence phenomena, could be expected to produce physical dependence, and a procedure was evolved for measuring physical dependence liability. However, heroin was easily produced; it was a potent euphoria-producing agent, and smaller amounts than of morphine were required for effectiveness. Hence, heroin gradually became the drug choice for drug-seeking persons without medical need and a principal agent in illicit drug traffic.

The United States Public Health Service opened hospitals at Lexington, Kentucky in 1935 and at Fort Worth, Texas in 1938 specifically for the treatment of narcotic addicts. Since then more than 89,000 patients have been admitted to these institutions. The primary purpose was to treat persons who had violated narcotic laws and regulations, but others could be admitted on a voluntary basis as space permitted. Major attention was given to drug withdrawal and attenuation of the abstinence syndrome. There was some vocational training but little psychiatric care was afforded. A significant lack was provision for follow-up of the patients after discharge. Many measures, which had been proposed to relieve the withdrawal sickness, were reviewed; a scheme for evaluating its intensity, at least semiquantitatively, was developed, and significant improvement in the treatment of abstinence emerged.

Clearly emphasis on the withdrawal procedure and on the relief of its symptoms was not an effective programme for the treatment of the addict in terms of keeping him drug free. In one study of persons who had been successfully withdrawn from narcotics at the Federal hospitals and returned to society a rate of relapse to drug use within six months of more than 90 per cent was reported [ 3] . This result is typical of programmes of withdrawal generally and constitutes the basis of what has become known as the "revolving door" pattern in addiction, whereby the individual goes through a cycle of confinement, "cure ", and relapse, without apparent progress.

Obviously freedom from reliance on drugs is an ultimate objective in the treatment of drug dependence, but abstinence is not the only criterion of progress. However, the poor result when it alone was the goal has led gradually to a broader treatment perspective. Attention is being given to the personality and environmental factors which bring about drug abuse, to the motivation for relief, and to helping the individual before, during, and after withdrawal. The total treatment concept brings into play medical, psychological, sociological and legislative efforts and enlists to the fullest extent the help of the family and community.

II. Basic treatment procedures A. PRE-WITHDRAWAL

Not so long ago withdrawal of drug or drugs was considered the obligatory first step in treatment and no doubt this was contributory to many failures. A more reasonable approach involves a preparatory period in which rapport and confidence are built up, a study is made of the factors which led to and facilitated the development of drug dependence, there is a careful analysis of the drugs used together with the amount and manner of their use, and an effort is made to demonstrate that life without drugs is possible. The extent and detail of this preparatory phase will vary with the individual; it should not be unduly prolonged if withdrawal is to be accomplished.

B. WITHDRAWAL FROM DRUG USE: DETOXIFICATION

It is important to learn as nearly as possible the kind or kinds of drugs which have been taken as well as the amount and pattern of their administration. Withdrawal may be abrupt (" cold turkey "), rapid or slow. Since there is no apparent relationship between the severity of the abstinence syndrome and the tendency to relapse to drug use, there is no justification for abrupt withdrawal of narcotics and it may be dangerous if barbiturates also have been taken to the point of dependence. Nor is it desirable that the withdrawal be unduly prolonged; one or two weeks should suffice for withdrawal of narcotics or barbiturates. If the drug is one which does not produce physical dependence, abrupt withdrawal is desirable and hospitalization may not be necessary.

Withdrawal of narcotics or barbiturates should be carried out in an institution, except under most unusual circumstances, under conditions which prevent access by the patient to drugs other than as prescribed by the physician. There should be rapid reduction of dosage with careful watch for the kind and severity of the abstinence phenomena. In drug dependence of morphine type the severity of the withdrawal sickness may be kept to a minimum by the oral administration of small doses of methadone [ 4] , also reduced from day to day during the withdrawal. Methadone is morphine-like essentially in all of its effects and will substitute completely for morphine (or heroin or other morphine-like agent). It is more effective orally and longer acting in respect to its dependence supporting property. Methadone came to our attention in 1946. Prior to that and to some extent since many agents, such as tranquillizers, have been employed to alleviate abstinence, but in the main none of these do more than reduce awareness of the discomfort without reduction of physical signs.

In drug dependence of barbiturate type there is no agent comparable to methadone to reduce abstinence. The severity of the symptomatology is held in check by provisional suspension of the dosage reduction schedule or by returning to higher dosage temporarily.

In drug dependence of other types, amphetamines, marijuana, etc., supportive measures may be indicated and temporary sedative medication sometimes to relieve anxiety. Since there is no physical dependence, combating the craving for drug constitutes the problem.

C. POST-WITHDRAWAL FOLLOW-UP

As indicated earlier the most important and most difficult part in the treatment of drug dependence, whatever the drug involved, is the relief of the compulsive craving for drug and the prevention of return to drug use. For success there must be constant supportive care involving all possible facilities of the physician, the family and the community. It is this portion of the treatment which has in recent years and is currently being given the most attention with many innovations. Perhaps craving for drug is never lost completely. One cannot predict, therefore, the length of the follow-up period; it will always be a matter of years. What is required is development of other interests and the realization and confidence on the part of the patient that problems and frustrations can be met without drugseeking behaviour.

While follow-up procedures have been designed primarily for persons with drug dependence of morphine type, most of them are applicable when other drugs have been taken or drug dependence of another type exists.

III. Current treatment innovations

In general terms individual psychoanalysis, group therapy, vocational training, job placement, resumption of educational effort and some sort of authoritarian control have been involved. In addition, pharmacological approaches are under investigation.

A. SELF-HELP PROGRAMMES, GUIDANCE CLINICS AND HALFWAY HOUSES

  1. Synanon, a unique private institution, made up entirely by voluntary patients without professional staff. It was founded in 1958 by Charles E. Dederich, a former alcoholic and is operated by former addicts who were at one time its patients. Although addicts enter Synanon voluntarily, once accepted they are quickly incorporated into an autocratic family structure [ 5] and become subjected to a constant stream of orders, criticisms, rewards and subtle controls. Withdrawal is said to be accomplished without medication, but during this period the patient is constantly aided and encouraged by regular members of the society. Post-withdrawal treatment consists primarily of group therapy sessions conducted by an experienced ex-addict and also of work task assignments.

The organization is selective and attempts to admit only applicants who are strongly motivated and sincere in their desire for cure. Subsequently, unco-operative patients are virtually thrown out. The degree of success which Synanon enjoys in holding voluntary patients and in "curing" them may be attributable to the process of screening and to the quick incorporation of the patient into the autocratic family-like structure in which he may rise to increasingly important positions. The patient is surrounded constantly by other former addicts who, having themselves suffered his weakness, are aware of the temptations and illusions which beset him. Pressure is applied accordingly. Another striking feature is that the "cured" addicts tend to remain as members of the organization and its work becomes their primary interest.

There were about 400 addicts affiliated with Synanon in 1964. Started in Santa Monica, branches have been set up in other parts of California and in a few other locations. Their record is reportedly good but statistics on the degree of their success are not given out. The philosophy seems to be: there are some failures and, if their number were revealed, the candidate for admission would say, "So many failed, I am bound to be one of that group, so why try".

Synanon operates on the theory that it serves as an "anti-epidemic" force to drug addiction. Its own measure of success is the number of "clean man-days" compiled. A clean man-day is a day during which a patient remains without narcotics. Its claim is that by taking the addict off the street and keeping him off the street, it is helping to halt the spread of addiction by association. Moreover, every clean man-day is regarded as a day to the benefit of the patient and of society in the amount of crime which was not committed for the purpose of procuring drugs. Any institutional form of treatment can of course be credited with the same virtue.

  1. The Addiction Research Centre of the Commonwealth of Puerto Rico. Some years ago, Dr. Efron Ramirez [ 6] set up a self-help programme which is in some respects similar to Synanon. His philosophy, however, was to exploit any success with the argument that this would persuade the candidate to embark on treatment, since so and so of his acquaintance had made it, he could also. The treatment programme, entirely voluntary, is arranged in steps and once a patient is admitted he is helped, guided, and encouraged by other patients a step ahead of him. Recruitment of patients is through community clinics by persons from the community who have gone through the treatment steps to becoming drug free and socially rehabilitated. The treatment steps are orientation and motivation towards treatment, detoxification, psychiatric personal and group therapy and social readjustment. Dr. Ramirez has endeavoured to spread his doctrine of self-help as a treatment modality to other areas, believing that no one is better able to understand and, therefore, constructively aid the patient through treatment than one who has had the experience of drug dependence and has accomplished recovery. Other treatment centres seem to accept this belief since they are to an increasing extent employing ex-addicts as treatment assistants. The Ramirez programme has claimed only moderate success in numbers of persons drug free and socially rehabilitated, but significant progress in many more persons still in treatment.

  2. Daytop Lodge is a domiciliary treatment facility and halfway house under the direct management of an ex-addict, with outside sanction and support. Selected individuals are given the opportunity by court authority to submit themselves to the Daytop Lodge regimen and are immediately subjected to the influence of a population which, as in Synanon, has gone through the addiction process. The philosophy seems to be: "how stupid could you be to get yourself 'hooked' and are you going to be so stupid as to stay hooked?" This is another variant of self-help programme.

  3. Guidance clinics, rehabilitation centres and halfway houses. There are at present a large and increasing number of these facilities, differing in the detail of their sponsorship, organization and management, with varying degrees of community involvement. Many employ formerly drug dependent persons as counsellors and treatment aides. Most of them depend on detoxification before admission. They concentrate on keeping the person drug free and strive for his useful employment and social rehabilitation. Attendance generally is voluntary. Many private groups, churches, medical practitioners, hospitals and social workers are involved. Some examples are:

Mount Carmel Centre, Paterson, New Jersey. A church operated facility consisting of a free hospital clinic

equipped to handle twenty addicts at a time on a three month programme which includes detoxification, vocational training, and job placement.

Haven Clinic, New York City. A privately operated clinic, claiming facilities for detoxification, vocational training and group therapy for a small number of addicts.

Halfway House, San Antonio, Texas. Conducted as a research programme which includes individual and group therapy as well as vocational training for a small number of addicts.

Samaritan Halfway House, Long Island, New York. A community facility operated by church groups for large scale vocational training, group therapy and rehabilitative effort for addicts recently released from prison.

Mobilization for Youth, New York City. Operated in co-operation with city welfare agencies, engaged in educational and rehabilitative activities after detoxification.

Dempsey's House of Hope, Inc., New York City. Operated by a church group, engaged in education and counselling.

Westside Rehabilitation Center, New York City. Operated by Department of Health, it offers group therapy sessions, counselling and psychiatric services.

East Harlem Protestant Parish Narcotic Centre, New York City. Provides counselling and vocational training.

Drug Addiction Treatment Rehabilitation Centre, Washington, D.C. A recently opened programme of the Department of Health, intended to comprise in- and out-patient facilities which will employ and compare various treatment facilities. It has presently a counselling centre, a few in-patient beds and a halfway house.

The above is a very small sampling giving some indication of the diversity of the programmes. The American Social Health Association has compiled a list of treatment facilities throughout the country.

These treatment efforts are worth while not only for their limited success but also for their arousal of community awareness and interest in the whole problem of drug abuse. What is strikingly lacking is any uniformity of record-keeping in respect to persons involved, treatment modalities in detail and results both positive and negative as a basis for evaluative comparison. The National Institute of Mental Health has co-operated . in the preparation of forms for history taking and progress reports. Their broad use would accumulate valuable information on the epidemiology of drug dependence and the effectiveness of various treatment approaches.

The halfway house concept as a step in rehabilitation, whether or not its employment is compulsory, provides the post-withdrawal patient with a partially sheltered existence while he is trying to become re-established in the community through employment, educational pursuit or otherwise. The individual is given living accommodation with some degree of counselling and encouragement concerning his daily problems. Daytop Lodge on Staten Island, operated under the New York State Supreme Court for addicts on probation, and East Los Angeles Halfway House operated by the California Department of Corrections are examples which are a part of compulsory treatment programmes.

B. LEGISLATIVE PROGRAMMES

  1. California. The first steps towards the State's compulsory treatment programme were taken in 1959 with the initiation of the narcotics treatment control project in the Department of Corrections. This pilot experimental programme was designed to control, supervise and treat the prisoners with a history of narcotic addiction who were released on parole. It continues in operation. It did not alter or modify prison treatment but when release time came the prisoner was assigned to a field control unit made up of experienced parole agents, specialists in supervising former narcotic addicts. Each agent's case load was small, thirty, permitting intensive supervision and close contact to help the individual to solve his problems without return to drugs and to encourage him to make maximum use of constructive community resources. The project required the parolee to undergo frequent medical examination and introduced the Nalline anti-narcotic test to detect narcotic use. A halfway house in connexion with the programme was opened in 1962. Parolees where also required to accept gainful employment. If the parole agent learned or the medical examination revealed that the parolee had returned to the use of narcotics, he might be immediately confined in a detention-treatment unit and held there up to ninety days. Subsequently, he might be returned to parole if he appeared to respond or he might be returned to prison.

Mounting concern over the narcotics abuse problem in the State resulted in the compulsory treatment law which became effective 15 September, 1961. It also made the Department of Corrections responsible for enforcement for both immediate treatment and postinstitutional supervision. The law provides for civil commitment proceedings which are essentially those employed for the commitment of the mentally ill and which may be initiated in three ways: (i) the addict, or any other person who believes that he is addicted, may report his addiction to the district attorney, who may then petition the superior court for the addict's commitment; (ii) any person convicted of any crime in a municipal or justice court may, if the judge believes he is an addict, be sent to superior court for determination of that issue; and (iii) with some exceptions, any person convicted of a crime in superior court may be tried on the issue of addiction, in which case imposition of the criminal penalty is suspended. The proceedings insure that the constitutional rights of the person sought to be committed 'are protected: that he is informed of his rights before a judge, can undergo medical examination, present witnesses in his behalf, make personal appearance at the proceedings, have legal counsel, and ask for trial by jury on the issue of his addiction if he wishes.

The commitment is for a definite period, five or ten years, the first six months of which must be spent as an in-patient. Upon commitment the person is received at a special reception centre where a variety of tests are administered: intelligence, educational achievement, vocational aptitude and personality. A social and criminal history is compiled and a recommended treatment programme structured. After this study is completed the patient is transferred to the California Rehabilitation Centre or one of its branches where the programme is primarily group centred activity; i.e., community living. The institutional treatment attempts a corrective experience for the addict. Upon discharge to outpatient status, the patient is under close supervision and guidance by the field staff where again the case load per agent is limited. The patient must also submit to periodic Nalline tests. If he abstains from narcotics for three consecutive years, he is discharged from commitment and criminal charges against him, if any, may be dropped. The law provides for return to inpatient status upon detection of narcotic use. It also provides that if the person is ineligible for discharge from the programme, he shall return to the court for imposition of the original sentence, or, perhaps, for recommitment [ 7] .

  1. New York. After brief trial of a civil commitment provision, the State has established a Narcotic Addiction Control Commission and under its supervision procedure for compulsory commitment to treatment. The commitment may be civil up to 36 months for criteria comparable to (i) or (ii) of the California law, or criminal up to sixty months for criteria comparable to (iii). As of 31 January, 1968, 5,000 addicts were under care and treatment, about half in private and half in public agencies accredited to or certified to the Commission. If record keeping is adequate, there should be opportunity eventually of ascertaining amenability of addicts to treatment and effectiveness of various treatment modalities.

  2. Maryland. An arrangement has been worked out for parole of prisoners from State correctional institutions, former narcotic addicts, to a clinic in Baltimore to determine the deterrent effect of follow-up by urinalysis on relapse to drug use. If relapse occurs before expiration of parole, the person may be returned to prison (8).

  3. Federal civil commitment. In 1966 the United States

Congress passed legislation providing for civil commitment of addicts. The commitment is to the custody of the Surgeon General of the Public Health Service. The criteria and court procedure are similar to what has already been described; among other things addicts accused of crime may elect to be civilly committed in lieu of prosecution. Commitment is for a period of 36 months or, in those cases in which an addict is found guilty of participation in illicit drug traffic primarily to raise funds to purchase his own drugs, the commitment may be up to ten years or the length of his sentence. In all cases the basic treatment techniques are designed to be the same: a short period of in-patient care followed by an extended period of compulsory post-withdrawal care. (Public Law 89-793; 89th Congress, H.R. 9167; November 8, 1966).

C. PHARMACOLOGICAL APPROACHES

  1. Methadone maintenance. It has been claimed from time to time through the years that some individuals can lead reasonably normal lives if narcotics are continuously administered at a constant level and are unable to do so if they are not. The United Kingdom has in the past left it to the private physician to determine if narcotics should be continued in a particular case more or less in accord with the above claim. Abuses of this permissiveness have led recently to some modification of procedure.

A few years ago Drs. Dole and Nyswander [ 9] undertook, also in accord with the above claim, a specific experimental programme of maintenance of drug dependence, using methadone as the maintaining drug. Methadone is a substance which is produced completely synthetically, which is capable of duplicating the effects of morphine in all essential details, but which has a different time-action curve, especially in respect to the production and maintenance of dependence. It is more effective and longer acting than morphine when it is taken by mouth. It is classified legally as a narcotic and is controlled nationally and internationally in the same way as morphine. Many reports on the progress of the methadone maintenance programme have been published, as well as attempts at critical evaluation [ 10] .

Patients admitted initially to the programme were reported to be volunteers, heroin users for four years or more with a history of repeated relapses after withdrawal, not psychotic, and having no major dependence on barbiturates or alcohol. The treatment begins with a period of hospitalization. After a thorough medical. workup with remedial measures scheduled as indicated, methadone administration is begun with small doses orally twice a day, given always in three or four ounces of fluid. The dose is increased gradually and after a time is given only once a day. Tolerance to methadone develops rapidly and when it is established the patient is equally tolerant to morphine, heroin and other morphine-like agents but not to barbiturates, amphetamines, etc. The objective is to obtain little or no acute effect per dose and a state of tolerance in which the patient is tranquil, free of anxiety and of the drive to seek another heroin "fix ". The amount of drug required varies with the individual but is around 150 mg per day. In some elaborations of the programme, lower daily doses, 40 to 50 mg, have been used. In the beginning, medication is taken under direct supervision. Since it is in a large quantity of fluid, accumulation or diversion is not feasible. The patients are initially in an open ward and when stabilization at a high level of tolerance is accomplished, they are discharged to community living. They return daily and later less frequently for medication and on each return are checked by urinalysis for use of heroin or other drugs. The methadone tolerant patient appears free of depression and euphoria. He is free of compulsive drug-seeking behaviour at least for narcotics, the trial of which is unrewarding. He may have curiosity in respect to drug effects and may turn to other drugs, such as alcohol, which will have its usual effect. Since he is supplied with drugs at a satisfying level, there is no need for criminal activity and anti-social behaviour for his drug supply and a high degree of social rehabilitation is claimed for most patients.

The patients admitted to the original programme have been and are very carefully selected. Perhaps selectivity has been less in other attempts to exploit methadone maintenance, but controls and comparisons with other treatment modalities to assess the role of contributing factors and the applicability of a maintenance regimen to the narcotic addict population generally have not been carried out. The programme is not suitable for use by private physicians and prescriptions should not be written for methadone for self-administration for maintenance of dependence. The private physician does not have the time or skill to control the programme or to prevent accumulation or diversion of prescribed drugs. Methadone maintenance is a multi-disciplinary effort and at least until the proper controls are carried out, even as such must be classified as experimental. Methadone is morphine-like and not in any sense anti-narcotic. The patient on methadone maintenance has a drug dependence of morphine type of high degree. If methadone is considered to block the desire for and response to heroin, it must be clearly understood that this is accomplished because the patient has been made tolerant to all morphine-like agents.

  1. Cyclazocine and other antagonists. Cyclazocine is a powerful specific opiate antagonist and may properly be called anti-narcotic and a blocker of morphine-like effects. It also possesses some morphine-like properties, but when single doses were administered to post-addicts, they were received generally with indifference. Cyclazocine, like nalorphine, produces disturbing subjective effects at relatively small doses.

Tolerance to these subjective effects develops during chronic administration, but tolerance to antagonism of the subjective effects of morphine does not. This suggested that, if persons who had been dependent on heroin or other opiates could be persuaded to take cyclazocine daily, they would lose their urge to resume the opiate which would have become ineffective, hence relapse to dependence of morphine type would be deterred.

For whatever reason patients with drug dependence of morphine type (heroin users) may have agreed to take cyclazocine, the procedure is as follows: In hospital the patient is rapidly withdrawn from his narcotic with the help of methadone if necessary. In about ten days, administration of cyclazocine is begun with small doses, 0.1 or 0.2 mg, orally twice a day. The dose is increased as tolerance develops to about 4 mg once a day. The patient is released to out-patient status after about a month on cyclazocine, returning about every other day for his daily dose under supervision and his intermediate daily medication. The patient on cyclazocines is tranquil, free of anxiety and the drive to find the next dose of narcotics, without the appearance of sedation or disturbance of mental or psychomotor function. Many have attained social rehabilitation as in the methadone maintenance programme with cessation of heroin abuse and anti-social actions. The antagonistic effect of cyclazocine at the tolerance dose level lasts about 24 hours, being at its peak eight to twelve hours after the daily dose and the patient's condition, if he does not miss a dose, remains uniform from day to day. The blocking of heroin effect has been demonstrated by administration of heroin challenge doses from time to time. This is not done blindly since it is desirable that the patient and his associates be made aware that trial of heroin will be unrewarding. Cyclazocine tolerance does not block the effects of non-opiates, barbiturates, amphetamines, etc. and a switch to them is possible.

The use of cyclazocine as a deterrent requires first complete withdrawal of the narcotic on which the patient is dependent, dose supervision and careful build up of the dose to the tolerance level. This cannot be done with the patient ambulatory and should not be undertaken by the private physician.

The blocking action of cyclazocine is possessed in more or less degree by the specific opiate antagonists so that another of them might be used as a deterrent. Nalorphine is not satisfactory, though tolerance to its subjective effects develops in similar fashion. Its duration of action is too short and it is very poorly effective when given orally. Naloxone is being tried and appears to be satisfactory. It is shorter acting than cyclazocine and the dose required is larger, but it has the advantage that it seems to be purely an antagonist and exhibits no morphine-like effects.

IV. Ambulatory treatment

Since 1924 the American Medical Association has opposed attempts at ambulatory treatment of addiction in the withdrawal phase. This stand has been reiterated in a joint statement by the committees on drug addiction of the American Medical Association and the National Research Council published in 1963 [ 11] and revised in 1967 [ 12] . "Withdrawal on an ambulatory basis is generally medically unsound and not recommended on the basis of present knowledge." It has been pointed out that the drug abuse picture has changed in recent years, usually involving more than one drug and with drugs causing psychic dependence only coming into prominence. Even so a brief period of hospitalization may be desirable to assess the drives and needs of the patient. Withdrawal of agents which produce physical dependence still should be done in a closed institution but the duration of institutional care is a moot question. There seems to be no advantage in its being prolonged and rehabilitation can only be established in the community.

V. Voluntary v. involuntary commitment to treatment

Through the years voluntary commitment to treatment has been emphasized but it has been accompanied by a high percentage of failure, lessened perhaps in some self-help programmes and lessened also when attention is given to pre-withdrawal treatment, building up motivation and an understanding of the inadequacies and frustrations which led to and facilitate continuance of the dependence. The trend today is toward the judgment that some degree of compulsion to treatment is necessary. The argument may be stated as follows: Without legally enforceable commitment, a large percentage of drug dependent persons will not undertake treatment. Given the opportunity an extremely high percentage will leave treatment against medical advice. Without a legally enforceable commitment there is no way that post-institutional treatment can be insured and the lack of such treatment is widely blamed for the high rate of relapse. Involuntary commitment provides a measure of public protection, reducing anti-social behaviour and the contagion of the drug dependence phenomenon.

Only in Synanon and other self-help programmes and in methadone maintenance has voluntary commitment seemed to have greater success and in both there is indeed an element of compulsion. In the one it is the judgment of his peers, in the other drug need as in any drug dependence. Whether compulsory commitment to treatment is necessary in drug dependence on psychotropic drugs which produce psychic dependence only, is an unresolved question. Even here some outside compelling force may be desirable if transfer to a drug free existence is to be attained. Many, if not all, of drug abusing persons have at least some personality disorder and to the extent that compulsion is desirable in ameliorating such disorders, it is as desirable in the treatment of drug dependence.

VI. Prevention: education

It has just been stated that personality disorders are involved in drug abuse and dependence. Inadequacies and frustrations, unwillingness or inability to meet life's problems, association with persons already drug dependent, curiosity and ignorance of drug effects are also factors. The only real cure of drug abuse is its prevention so that the problem boils down to when and how does the effort begin to combat its causes. This cannot be emphasized too strongly and the effort cannot be begun too early. It must be directed to the causes of abuse and the environmental and sociological conditions which favour drug abuse and not simply to dissemination of information on drugs and their effects. Many efforts, especially along the latter lines, are being made, vocal, audio-visual, and documentary, too often containing misinformation, and misdirected and wasteful because of duplication. The recently established National Co-ordinating Council on Drug Abuse Information and Education seeks to overcome some of these things. The Council is made up of representatives of a large number of national organizations, especially youth oriented organizations, having an interest in drug abuse. The Council's charter states the objectives to be: ( a) Provide leadership and co-ordinate educational and informational efforts of organizations interested in the area of drug abuse. ( b) Stimulate regional, state, and local involvement in drug abuse education by aiding in the establishment of interdisciplinary committees to respond to area needs. ( c) Encourage research in the area of drug abuse by identifying critical issues in need of attention. ( d) Evaluate and develop the role of professional and public information in the drug abuse area. ( e) Evaluate drug abuse educational programmes and give visibility to those that are effective.

References

001

Nathan B. Eddy, H. Halback, Isbell, Harris & M. H. Severs, "Drug dependence, its significance and characteristics ", Bull. World Health Organization (1965), 32, 721.

002

Nathan B. Eddy, "Chemopharmacologic approach to the addiction problem", Public Health Reports (1963), 78, 673; Narcotics, Wilner & Kassebaum, eds., McGraw-Hill, New York (1965), p. 67.

003

National Institute of Mental Health, Monograph No. 2, Narcotic Drug Addiction (1963), p. 11.

004

U.S. Department of Health, Education and Welfare, Narcotic addicts in U. S. Public Health Service hospitals (1966), p. 16.

005

Yablonsky, Lewis & Dederich, Charles E. Synanon, "An analysis of some dimensions of the social structure of an anti-addiction society ", Narcotics, Wilner & Kassebaum eds., McGraw-Hill, New York (1965), p. 194.

006

Efron Ramirez , Address at Gracie Mansion Narcotic Conference , New York (1965).

007

Richard A. McGee, "New approaches to the control and treatment of drug abusers in California ", Narcotics, Wilner & Kassebaum, eds., McGraw-Hill, New York (1965), p. 263.

008

Kurland et al ., "Controls in the treatment of narcotic addicts", Reports to the Committee on Problems of Drug Dependence in 1966, 1967, 1068 , American Psychiatric Association, New York, May 1965.

009

Vinvent P. Dole & Marie Nyswander, "A medical treatment for diacetylmorphine (heroin) addiction", J. American Medical Association (1965), 193, 648.

010

Nathan B. Eddy, "The use of drugs in the management of drug dependence ", J. Tennessee Medical Association (1967), 60, 269.

011

"Narcotics and Medical Practice ", J. American Medical Association (1963), 186, 976.

012

"Narcotics and Medical Practice", J. American Medical Association (1967), 202, 209.