Treatment, Care and Rehabilitation


The United Nations Commission on Narcotic Drugs, at its last session, took cognizance of the importance of the curative and remedial aspects of drug addiction. It adopted, for the first time on the international level, a resolution recognizing the need of governments setting up means for the treatment, care and rehabilitation of drug addicts on a planned and compulsory basis, in properly conducted institutions.


Author: Nathaniel L. Goldstein
Pages: 18 to 20
Creation Date: 1954/01/01

Treatment, Care and Rehabilitation

Nathaniel L. Goldstein

The United Nations Commission on Narcotic Drugs, at its last session, took cognizance of the importance of the curative and remedial aspects of drug addiction. It adopted, for the first time on the international level, a resolution recognizing the need of governments setting up means for the treatment, care and rehabilitation of drug addicts on a planned and compulsory basis, in properly conducted institutions.

As a member of the United States delegation, I was privileged to pilot this resolution through the Commission and to have been the sponsor of an amendment to Section 41 of the proposed Single Convention, following in the main the pattern of the resolution, with the added proviso that "the programme be adopted in those countries where the seriousness of the problem and their economic resources warrant such measures".

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Attorney General of the State of New York; Member of the United States Delegation to the United Nations Commission on Narcotic Drugs; Chairman of the Committee on Narcotic Drug Control of the National Association of Attorneys General.

As I pointed out in my argument, the nine existing international treaties are essentially concerned with control or preventive measures, although the 1931 Convention contains a provision which appears to suggest an additional approach-that is remedial and curative-the subjective aspect which deals primarily with identification, treatment and rehabilitation.

Public opinion now demands that World governments take not only strong penal steps, in the matter of drug addiction, but also attack the problem from a medicosocial point of view. For the problem of narcotics is not susceptible of quick and easy solutions. It has plagued mankind, literally, for hundreds of years.

To bring back the ordinary narcotic user to a life of normalcy, therefore, presents a complex but soluble problem.

It is not enough to confine him in a place where he cannot obtain the drug. His mind and body must both be cured and attuned to a point where there will be neither physical nor mental desire for narcotics. His activities in the community, after he is released from confinement as "cured", must be carefully watched, both for his own sake and for the protection of the public.

Effective cure must proceed in a series of coordinated steps. One is ineffective without the other.

First, physical withdrawal of the drug. In the early or "milk and sugar" stage, it could be accomplished by abrupt withdrawal from the drug, coupled, where necessary, with mild sedation. In the more advanced stage, a gradual withdrawal from narcotics would be necessary. In either case, the treatment could only be accomplished with the patient in custodial care in an institution where each class or stage of addiction could be properly segregated, with due regard for sex and criminal history of the patient.

Second, physical rehabilitation. Here the user would be afforded the medical and physical care necessary to alleviate the damage which the drug may have inflicted on his body. In the main, this, too, is part of the treatment which must be given while the patient is in custodial care.

Third, psychotherapy. This phase of the treatment must be available during custodial care. The causes which lead the user or addict to partake of narcotics must be analysed and removed. In the process, it can readily be determined whether, and to what extent, post-institutional psychotherapy should be made available to the individual patient.

Fourth, occupational therapy. Treatment through specific forms of exercise and work, after initial withdrawal from the drug, is essential to the promotion of effective rehabilitation. A programme of occupational therapy must be afforded while the patient is in custody.

Fifth, after care and follow-up. Past experience has proven beyond any doubt that many users, despite all the efforts expended in the institution, will return to narcotics unless they are protected by an adequate after care and follow-up programme when they are returned to the community. From a practical viewpoint, it is obvious that adequate post-institutional care will also effect a substantial reduction in the amount of time which the patient must spend in custody, and make the facility available for other needy patients.

On still another point do we find expert opinion in unanimous agreement-provision must be made for mandatory treatment of the user or addict. It is not enough to make facilities available; both for his own good and for the protection of the public, the user of narcotics must be quarantined and compelled to submit to treatment or isolation. Both the initial treatment at the institution and the post-custodial programme must be made mandatory and not left to the option of the addict.

The proceedings must not be made criminal in nature and the commitment for want of a better term, does not assume the character of punishment for an illegal act. The after care, although in the nature of parole, must similarly be mandatory, even though in no sense criminal.

This five point programme and the methods of admitting patients are not to be considered immutable laws but rather as standards subject to variations suggested by experience. At the same time it must be emphasized that these standards have been designed with the best expert counsel, as a result of an investigation and study which I conducted in New York State under legislative mandate, in the years 1951 and 1952.

On one point, we are clear. The so-called narcotic clinic, which comes to life periodically, as the bold new plan for dealing with the drug menace is not new, but an impractical idea which was considered, tried and abandoned in the United States over a quarter of a century ago. Its life was short not only because it was found ineffectual, but because it charted a dangerous course toward increased addiction. The following extracts taken from a Report on Narcotic Clinics in the United States, published by the United States Government Printing Office in 1953, tells the tale.

"During and after the year 1919, forty-four or more narcotic clinics or dispensaries were opened by municipal or State health officials in large cities throughout the United States in an experiment which it was thought might present a simple and easy solution of the problems arising from narcotic drug addiction. Drugs were sold to addicts at prices as low as 2 cents a grain. * * *"

"The clinics were operated for varying periods and in one city as long as 4 years. The most comprehensive series of facts, having real scientific value, that had then been compiled anywhere in the world, was embraced in the published statistics gathered from analytical study of the nearly 8,000 cases of addiction registered and cared for in narcotic clinics during about 10 months by the Department of Health of the city of New York. These cases were subjected to most careful observation and study by specialists qualified to make scientific analysis and arrive at sound conclusions. They reported, 'We have given the clinic a careful and thorough as well as a lengthy trial and we honestly believe it is unwise to maintain it any longer.' * * *"

"By the end of 1925 all of these clinics had been closed by the various State authorities for the reasons quoted herein.

"In New York City it was stated by the Department of Health that 'the purpose of this narcotic clinic is to provide temporary care for addicts who have been patronizing profiteer doctors and druggists.' The clinics practically eliminated this profiteering practice, but there suddenly mushroomed and thrived in its place a tremendous illicit traffic in narcotics which supplemented and nullified the reduction treatments of addicts in attendance at the clinics.

"In a 1-year period in the early 1920's when these clinics were in operation, the volume of illicit peddling of narcotics reached the point where an incredibly large amount of 71,151 ounces of narcotic drugs was seized in the domestic illicit traffic-or more than 14 times as much as was seized in 1952.

"In New York State alone, when 16 or more narcotic clinics were in operation throughout the State, almost 4,000 ounces of narcotic drugs were seized in illicit channels during a year-or almost as much as was seized in the entire United States during 1952. * * *"

"At Sing Sing Prison in 1920, the number of drug addicts received increased over 100 per cent; in 1922 they increased over 500 per cent; and in 1923 the increase was over 900 per cent.

"In 1922, 20 per cent of the prisoners incarcerated in the Atlanta Penitentiary were drug addicts; at the Woman's Workhouse, Blackwells Island, practically all prostitutes committed were drug addicts; and from 60 to 80 per cent of all committed there were drug addicts.

"This illustrates the situation with regard to crime and drug addiction during the period when the narcotic clinics were in operation. * * *"

The ex-president of the American Medical Association stated:

"We have found out here (New York City) that the narcotic dispensaries do not relieve the situation, they simply legitimatize the drug indulgence, and it is for that reason that the American Medical Association recently passed its resolution condemning them and the Public Health Service is endeavouring to close them up.

"The chairman of the Medical Society of the county of New York, Committee on Public Health, stated 'all look upon the New York clinic as a positive demonstration that addicts must be under institutional control or any other kind of absolute control. The only hope is cutting off the supply of drugs as completely as possible. Therefore, no public clinics.'"

It is quite obvious that what proved ineffective 35 years ago would certainly be more ineffective today.

In the final analysis, we must not lose sight of the three factors which are vital in the adequate treatment of addiction; (1) The socially contagious nature of the disease; (2) The need for compulsory institutional treatment; (3) The sine qua non of mandatory after care guidance.

Addicts become addicts from association; every active addict that is loose is a possible source of infection for others. To permit the addict to roam the streets while undergoing treatment is to fight a city-wide conflagration with a trickle of water. More will be spread than is put out.

Expert opinion in this field is in unanimous agreement that provision must be made for compulsory treatment and without a mandatory system of after care and guidance the programme can be of no effect.

The five point programme of treatment, care and rehabilitation represents not only the consensus of expert opinion on the subject of drug addiction, but, of even greater importance, is evolved from trial and admitted error in other facilities.

To achieve ultimate victory, governments must be patient. So ancient and evil is the problem that a thoroughgoing coordinated attack requires planning and development. There is no time to wait for the formulation of a perfect plan. Within their limitations, and with such weapons as are available, governments must start now and not depend upon a tomorrow.