Narcotics research, rehabilitation, and treatment. Hearings, Ninety ...
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Narcotics research, rehabilitation, and treatment. Hearings, Ninety ...

Narcotics research, rehabilitation, and treatment. Hearings, Ninety ... Narcotics research, rehabilitation, and treatment. Hearings, Ninety ...

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642Mr. Perito. Thank yoii. Mr. Chairman.Dr. Kramer, you have submitted to the committee a report whichrelates to an iipclated version of an article which af)peared in the NewPhysician in March of 1969. Is that correct ?STATEMENT OF BH. JOHN C. KRAMER, ASSISTANT PROFESSOR,DEPARTMENT OF PSYCHIATRY AND HUMAN BEHAVIOR, DE-PARTMENT OF MEDICAL PHARMACOLOGY AND THERAPEUTICS,UNIVERSITY OF CALIFORNIA, IRVINEDr. Kramer. That is correct ;j^es.Mr. Perito. Mr. Chairman, at this point, I wonld ask that that articlewhich has been submitted as a statement to the committee beincorporated in the record.The Chairman. Without objection, so ordered.Mr. Perito. Dr. Kramer, you have been kind enoufrh also to preparea summary of your testimony and I would ask at this point that youproceed, with the permission of the Chair.Dr. Kramer. Thank you. I would like to read that.In an introduction to a book on prohibition, the historian, the lateRichard Hofstadter said : "Reformers who be^fin with the determinationto stamp out sin usually end by stamping out sinners.''Since about 1920, in the United States we liave been stamping outheroin addicts without stamping out heroin addiction.In this statement I address myself to the treatment of addicts alreadymade with full awareness that ideally we should attempt to preventthe process from ever starting.P^very treatment ever offered for opiate dependence has had someindividual successes. It is important to keep in mind that when peoplewith an emotional investment in a particular progi-am make their case]nil>licly, or before such forums as congressional connnittees, they showtheir successes and not their failures.Regarding civil commitment programs, notably those of California,Xew York, and the. Federal Government, T note that they liave l>eenstructured so that a patient sj^ends a period of time, usually a numberof months in an inpatient facility and is subsequently placed on parolesubject to close scrutiny regarding his general behavior and drug use.For the most part these programs have opted for complete abstinencein their patients. Tliese programs are very expensive; the Federalprogram, for example, costs in excess of $10,000 per patient-year forinpatient care, and $2,000 to $3,000 per year for outpatient care. TheXcw York and California ]')rograms have had veiy little success inI'ehabilitating their clients. Tlie Federal ])r()grams have ai)])eared sofar to be more successful, but this may be in part accounted for bymassive rejection of difficult candidate^, and because aftercare is contractedout to local agencies Avhich are paid in part on the basis ofthe numl>er of ])atients they retain.Despite its limitations some form of cixil connnitment j^robablyshould be retaine

:643Regrettably, few addicts volunteer for these programs, still fewer areaccepted, fewer yet remain, though of those who remain, a moderatej:>roiiortion succeed. From the point of view of the mass of Americanaddicts, these groups, it appears, will play a modest role. These programstoo are very expensi\e.^lethadone maintenance—and potentially narcotic antagonist — programsare the most widely accepted among opiate depen.dent peopleand have proven, beyond a doubt, to be the most elfective teclmique tocontrol addiction. Methadone maintenance, even on the pharmacologiclevel, is not merely a switch from one addiction to another. The longaction of methadone prochices a stable physiology as opposed toa roller coaster physiology with intravenous heroin. Tens of thousandsof addicts are now waiting to get on such programs and camiot becauseof the lack of available facilities. I might point out that I have about220 patients on my own program in Orange County, Calif., while450 are waiting to get on. I have been unable to put additional patientson for the last 3 months because of the lack of facilities which ultimatelyresolves down to the lack of funds.For purposes of treatment, heroin addicts can be divided betweenthose with a relatively short addiction history, that is less than_ 1or 2 years, and those on the other hand with a long history, that is,beyond those limits and especially those who have repeatedly relapsedinto addiction. Those witli shoi-t addiction histories, in general, mightbest be handled through individual interaction programs, such asDaytop, Synanon, and j^erhaps by narcotic antagonists; those whohave beeii long-time addicts will probably, for the most part, be besthandled in methadone maintenance programs.The Federal Government can assist in the treatment of narcoticaddicts by supporting(1) Detoxification facilities. In most communities with an extensiveheroin problem there is serious shortage of hospital space even to allowan addict to get oft' his drug with no further treatment.(2) Massive facilities to provide methadone maintenance to all appropriatecandidates should be provided as promptly as good managementallows. Federal funds will almost certainly be necessarv for thispurpose.(3) Nonestablishment rap centers and self-help programs must havesupport. One problem of such facilities is their distaste for recltape,of making formal applications, and of sending in formal reports.(4) As programs multiply there will be a need for trained staff.One or several national centers for training a wide variety of professionalsand nonprofessionals should be supported through Federalfunds. In addition the Federal Government might support a facultymember at each medical school who will devote himself to training andeducating physicians and other medical personnel. A career supportprogram might facilitate this.One reason for the range of opinion among specialists in the drugabuse field has been the inadequacy of data collection, both of programresults and of the ongoing drug scene. Any Federal effort should providea system of collection of data particularly from federally fundedprograms but also from other programs.Though new research is alwa^'s necessary, there are two projects ofcritical immediate importance; one is the development of a long acting

642Mr. Perito. Thank yoii. Mr. Chairman.Dr. Kramer, you have submitted to the committee a report whichrelates to an iipclated version of an article which af)peared in the NewPhysician in March of 1969. Is that correct ?STATEMENT OF BH. JOHN C. KRAMER, ASSISTANT PROFESSOR,DEPARTMENT OF PSYCHIATRY AND HUMAN BEHAVIOR, DE-PARTMENT OF MEDICAL PHARMACOLOGY AND THERAPEUTICS,UNIVERSITY OF CALIFORNIA, IRVINEDr. Kramer. That is correct ;j^es.Mr. Perito. Mr. Chairman, at this point, I wonld ask that that articlewhich has been submitted as a statement to the committee beincorporated in the record.The Chairman. Without objection, so ordered.Mr. Perito. Dr. Kramer, you have been kind enoufrh also to preparea summary of your testimony <strong>and</strong> I would ask at this point that youproceed, with the permission of the Chair.Dr. Kramer. Thank you. I would like to read that.In an introduction to a book on prohibition, the historian, the lateRichard Hofstadter said : "Reformers who be^fin with the determinationto stamp out sin usually end by stamping out sinners.''Since about 1920, in the United States we liave been stamping outheroin addicts without stamping out heroin addiction.In this statement I address myself to the <strong>treatment</strong> of addicts alreadymade with full awareness that ideally we should attempt to preventthe process from ever starting.P^very <strong>treatment</strong> ever offered for opiate dependence has had someindividual successes. It is important to keep in mind that when peoplewith an emotional investment in a particular progi-am make their case]nil>licly, or before such forums as congressional connnittees, they showtheir successes <strong>and</strong> not their failures.Regarding civil commitment programs, notably those of California,Xew York, <strong>and</strong> the. Federal Government, T note that they liave l>eenstructured so that a patient sj^ends a period of time, usually a numberof months in an inpatient facility <strong>and</strong> is subsequently placed on parolesubject to close scrutiny regarding his general behavior <strong>and</strong> drug use.For the most part these programs have opted for complete abstinencein their patients. Tliese programs are very expensive; the Federalprogram, for example, costs in excess of $10,000 per patient-year forinpatient care, <strong>and</strong> $2,000 to $3,000 per year for outpatient care. TheXcw York <strong>and</strong> California ]')rograms have had veiy little success inI'ehabilitating their clients. Tlie Federal ])r()grams have ai)])eared sofar to be more successful, but this may be in part accounted for bymassive rejection of difficult c<strong>and</strong>idate^, <strong>and</strong> because aftercare is contractedout to local agencies Avhich are paid in part on the basis ofthe numl>er of ])atients they retain.Despite its limitations some form of cixil connnitment j^robablyshould be retaine

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