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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664opiates may be ingested in several ways. Oral use is simplest and widelyused, but it has several disadvantages as far as users are concerned. Onset ofeffect is slow and the surge of euphoria (or relief) which characterizes the moredirect routes, is absent. Some opiates lose potency orally, and crude opium israther nauseating both becau.se of its central effects and its direct irritantproperties. Because rather large quantities of the drug can be taken orally it ispos.sible to develop considerable physical dependence by this route.SnutUng powdered heroin or inhaling the fumes of vaporized heroin has hadperiods of popularity. Evidently it is now a primary technique of ingestionamong our men in Southeast Asia who erroneously believe that they cannotdevelop a dependence by using this technique.The technique of "smoking" opium is unlike that of smoking tobacco. TheoiMum itself does not burn, rather it is vaporized. Crude opium is speciallyprepared and then is made to adhere to the .small bowl of an opium pipe whichis heated by a flame, thus valorizing the opium which is then inhakxl. Though.serious dependence may have occurred among opium smokers, this pattern ofuse in the social context of Eastern and Southern Asia seems to have been morebenign than has generally been depicted. Since the outlawing of opium in mostof Southeast A.sia follovsiug World War II, the alternate which took its place,most noticeably in Hong Kong, has been the inhalation of the vapors of a heroinbarbituratecombination. This pattern of ingestion of almo.st pure heroin cancreate a dependence more profound than that caused by opium smoking.The parenteral use of opiates for .several reasons is the most damaging. Becauseit is tlie most eflicient and expeditious technique of delivery, even verysmall amounts of drug produce effects. Because of tlie immediacy of the effect theact of injecting is clearly and unquestionably related to the pleasure (or relief)which the injection provides. Add to this the hazards of overdose and nonsteriletechnique and the picture is complete.Though the life of regular users is generally depicted as one of rathercomplete degradation, this is not necessarily the case. Usei-s can and do, particularlyin other times and places, have legitimate occupations which are.sufficient to supply their drug needs and they often carry on their lives withreasonable efficiency. In other instances the drug use may produce such lethargythat they are not usefully employed though they may not be involved in illegitimateactivities other than the simple pos.session and use of drugs. In most instancesin the U.S. opiate users must engage, at least in part, in some illegitimateactivity in order to .secure sufficient funds to support the habitAs has been mentioned above, the "tyi^ical" addict in the United States currentlyis a heroin u.ser who is young, lower-class, male, and black or brown.thougJi as this committee is aware, even this pattern is changing to include morewhite, middle class youth. Prior to 1914 tlie typical addict was middle-aged,middle-class, female, and white. There is a good chance that she was quite respectableand that her "vice" was known only to her pharmacist, her doctor, andher husband. Elsewhere the characteristics of the typical addict vary even more.In Hong Kong today addicts are mostly middle-aged male laborers, while in somesocieties, the use of opiates was the prerogative of the wealthy and powerful.Obviously, societies differ in their acceptance of drug use. Still, even where nolaws exist there is usually some social condemnation, particularly in instanceswhere drug use comes to dominate the individual's life. Legislation controllingdrug use is a relatively recent historical phenomenon, though there have beenoccasional examples in the past of judicial control of drugs. Though most nationshave enacted control laws, enforcement is often intermittent and selective. Inmany Western nations, most notably the United States, both the legal and socialsanctions against certain forms of drug use are enforced vigorously. Obviously,the psychological meaning and the social consequences as well as the kind of druguse, the pattern of use. and even the route of ingestion may be determined bythese social events independent of the psycliological pattern of the user andthe pharmacology of his drug.For a variety of historical and social reasons we have today in the UnitedStates about 150.000 to 200,000 people who are currently or who have recentlyl>een dependent on opiates. Many are incarcerated in in-isons, jail.s. or other institutions.Some wlio are free are not curi-ently engaging in the illegal use ofopiates for any one of a variety of rea.sons. including personal detei'mination,religious conversion, pharmacological blockade, close parole .sui)ervision. membershipin an anti-drug organization, or the substitution of other drugs. Different

:665communities laave different programs, though many have none at all. The only"treatment" modality available everywhere is prison or jail.Let us examine several of these approaches to the treatment of opiatedependence.NARCOTIC MAINTENANCEIt has long been observed that people can function for prolonged periods withoutdisability or serious toxic effect while receiving regular daily doses ofoidates. When such a regime is carried out with the acquiescence of the patientand under careful supervision of a knowledgeable and ethical physician, thepatient feels normal, acts normal, and seldom seeks out supplemental sourcesof drugs.There are instances in which maintenance programs have not worked well.The fault here lay in one or several errors in management. Among the errorshave l;een treatment of a patient whom the doctor does not know adequately;allowing the patient to determine his own dose of the drug; or supplying the drugin such form and quantity that it can easily be resold or misused.Opiates have pharmacologic characteristics which permit a maintenance approach.Though overdose can cause death, sublethal doses have uegigible toxicity.INIaintenance even on substantial doses of opiates produces sufficient toleranceso that neither motor nor intellectual functions are disrupted, unlike barbituratesand alcohol which will induce persistent ataxia and lethargy when usedin high regular doses or stimulants which will ultimately induce toxic psychosisif so used.In a number of countries (Britain is not the only one) physicians have beenpermitted, tacitly if not officially, to prescribe opiates on a maintenrtuce schedulefor patients wlio have a siibstantiated history of intractable addied

:665communities laave different programs, though many have none at all. The only"<strong>treatment</strong>" modality available everywhere is prison or jail.Let us examine several of these approaches to the <strong>treatment</strong> of opiatedependence.NARCOTIC MAINTENANCEIt has long been observed that people can function for prolonged periods withoutdisability or serious toxic effect while receiving regular daily doses ofoidates. When such a regime is carried out with the acquiescence of the patient<strong>and</strong> under careful supervision of a knowledgeable <strong>and</strong> ethical physician, thepatient feels normal, acts normal, <strong>and</strong> seldom seeks out supplemental sourcesof drugs.There are instances in which maintenance programs have not worked well.The fault here lay in one or several errors in management. Among the errorshave l;een <strong>treatment</strong> of a patient whom the doctor does not know adequately;allowing the patient to determine his own dose of the drug; or supplying the drugin such form <strong>and</strong> quantity that it can easily be resold or misused.Opiates have pharmacologic characteristics which permit a maintenance approach.Though overdose can cause death, sublethal doses have uegigible toxicity.INIaintenance even on substantial doses of opiates produces sufficient toleranceso that neither motor nor intellectual functions are disrupted, unlike barbiturates<strong>and</strong> alcohol which will induce persistent ataxia <strong>and</strong> lethargy when usedin high regular doses or stimulants which will ultimately induce toxic psychosisif so used.In a number of countries (Britain is not the only one) physicians have beenpermitted, tacitly if not officially, to prescribe opiates on a maintenrtuce schedulefor patients wlio have a siibstantiated history of intractable addied

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