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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668Many people have benefited from their experiences in these programs, andmany have not. For reasons vi^liich are sufficient for tliem, Synanon does notrecord the number of people who departed and returned to their fomier ways.In most instances they are no worse oif for tlie experiences."Gateway" in Chicago and "Daytop Village" in New York have been modeledafter Synanon. Though governmentally supported and resiwnsible to a professionalboai'd these programs are run by the addicts themselves and thus avoidthe "we-they" split which can obstruct other programs.It is mandatory to acknowledge that Synanon is a remarkable creation, mostremarkable because it flew in the face of tlie accepted idea of the intractabilityof addiction ; tliey refused to accept that notion at a time when almost everyoneelse did.CIVIL COMMITMENT FOR ADDICTSCalifornia in 1961 and more recently New York State and the federal governmenthave initiated and implemented programs for the civil commitment ofnarcotics addicts. The thrust of these statutes is to maximize the number ofaddicts committable and minimize their opportunity to choo.se to leave.The roots of these commitment laws can be traced to the Federal narcoticshospital in Lexington. In recounting the initial. expectations for that institutionIsbell writes * * *Drug addicts were to be treated within the instituiticn. freed of theirphysiological dependence on drugs, their basic immaturities and i)ersonalityproblems corrected by vocational and psychiatric therapy, after which theywould be returned to their communities to resume their lives. It seems tohave been tacitly assumed that this program was the answer and wouldsolve the problem of opiate addiction. Within a year it was apparent thisassumption was wrong * * ** * * a more adequate treatment program (required) :(1) Some means of holding voluntary patients until they hadreached maximum benefit from hospital treatment.(2) Greater use of probation and parole. * * *(3) Provision for intensive supervision and aftercare. * * *Isbell goes on to say that the reasons why these problems were not solvedwere complex.In 1961 the California Legislature enacted laws establishing a commitmentprogram for addicts which was designed to accomplished those objectives recommendedbut never carried out at Lexington.Though the program has been useful for a small proportion of those committed,for the majority it has proven to be merely an alternative to prison.The majority have entered a revolving system of admission-release-admissionrelease,and spend a majority of their commitment incarcerated in an institutionwhich re.sembles a pri.son more than it does a hospital.Commitment, strictly speaking, is not a treatment technique, it is a legaltechnique to bring an unwilling patient into a treatment situation. Whether thetreatment is effective or he receives any treatment at all depends upon the programoffered.An important consideration in evaluating civil commitment for addicits is thefact that many people in positions of authority see commitment primarily as ameans to get the addict off the street. Their justification for this position is thatopiate dependence, particularly heroin addiction, is a life-threatening, communicabledisease and it is therefore morally justifiable to incarcerate addicts,to place them in quarantine, so that they win not infect others. The soundness ofthis position is arguable both on constitutional and epidemiological grounds.It is unlikely that all compulsion can be removed as one aspect of ]>nhlic policyin the management of opiate dependence. The presence of drug control laws i-* aprimary motivating force behind the entrance of addicts into voluntary programs.We must provide sufficient useful voluntary approaches and back them up byinvoluntary programs for those unable or unwilling to receive help from theformer, but commitment programs for addicts like any other medical program.should be flexible, imaginative, and unhindered by excessive legislative and administrativerestrictions.COMPREHENSIVE COMMUNITY PROGRAMSIt is generally conceded that traditional psychiatric techniques have not beenuseful in the management of opiate dependence. In a psychoanalytic frame of

:669reference symptoms are considered to be the behavioral or somatic representationsof an underlying intrapsychic conflict. Once the conflict is resolved orreduced to manageable proportions, the symptoms will diminish or disappear.This conceptual model fails to account for two different issues, either or bothof which may play a role in people who abuse drugs. First, though intrapsychicdeterminants may play a part in whether a person uses drugs, other circumstancessuch as drug availability, subgroup attitudes, peer pressures, and plainchance are very often more important. In other words, in some individuals,there may be no serious underlying conflicts, though there may be considerableconflict with the community. Second, whatever the original determinants ofdrug use may be, the symptom, dependency on drugs, can become so central anissue that it, so to speak, assumes a life of its own, and even solving the underlying conflicts may have no influence on the drug dependence itself. An analogymay be drawn with a depressed person who in an attempt at suicide breaks hisneck and becomes paraplegic. Psychotherapy may relieve his depression butwill not restore function to his legs.Because drug use has been invested with such great importance in our society(an importance it did not always have) it is assumed that the intrapsychicevents which cause, or contribute to it, are of equal magnitude. Hence the view,that since drug use potentially subjects the pei'sou to such serious consequences,the psychological problem he has must be equally big. Experience with drugusers does not validate this view. Some do indeed have clearly definable psychiatricproblems, but many do not. Where it is sought, some subtle psychiatric defectcan always be found, as has been the case with addicts. Further investigation mayclai'ify this question. In the meantime a functional approach, handling the symptoms,educating and giving practical assistance as well as offering psychotherapyin selected instances seems desirable.To this end, the Federal Government through the NIMH has been offeringsupport for comprehensive, community-based treatment programs for narcoticaddiction. It has become evident that programs of limited scope functioningalone, whether a hospital, an outpatient clinic, or a social service agency, areof limited effectiveness. At different times an addict may need different services,and to preserve continuity of treatment it is most reasonable for all servicesto be available under the auspices of a single organization. Thus, the comprehensivedrug addiction centers are expected to provide, at a minimum, suchservices as( 1 ) inpatient treatment, including withdrawal,(2) outpatient services,(3) aftercai'e services; for example, vocational and educational programs,(4) partial hospitalization services (day hospital, night hospital),(5) preventive services: Consultation, education, and community organizationprograms, and(6) diagnostic services, including drug detection techniques.These programs are also expected to provide ongoing evaluation both of theprogram itself and the nature and extent of drug use in the community it serves.Special techniques such as the third community approach, narcotic blockadetechniques, the use of ex-addicts as staff, or other innovations are acceptable andare encouraged.The Federal Government should prepare to fund treatment programs and trainingprograms for treatment staffs as well as certain specific urgent research.Massive application of the methadone maintenance treatment should be thekeystone of the treatment effort. In methadone programs ancillary services shouldbe supported as well. Particularly in areas where extensive addiction existscomprehensive programs and abstinence programs should receive substantialassistance.One or several training centers are necessary to prepare staffs for theseprograms.All federally sponsored programs must be required to collect data on theirresults and experiences in order that the task can be accomplished quickly andeffectively.Development of long-acting narcotic antagonists may provide an important advancein treatment, not only of longstanding addicts, but more particularly forthose with a short history of addiction or even a nonaddicted population at seriousrisk.And lastly, development of a longer acting form of methadone will help to reducethe risks of illicit diversion.

668Many people have benefited from their experiences in these programs, <strong>and</strong>many have not. For reasons vi^liich are sufficient for tliem, Synanon does notrecord the number of people who departed <strong>and</strong> returned to their fomier ways.In most instances they are no worse oif for tlie experiences."Gateway" in Chicago <strong>and</strong> "Daytop Village" in New York have been modeledafter Synanon. Though governmentally supported <strong>and</strong> resiwnsible to a professionalboai'd these programs are run by the addicts themselves <strong>and</strong> thus avoidthe "we-they" split which can obstruct other programs.It is m<strong>and</strong>atory to acknowledge that Synanon is a remarkable creation, mostremarkable because it flew in the face of tlie accepted idea of the intractabilityof addiction ; tliey refused to accept that notion at a time when almost everyoneelse did.CIVIL COMMITMENT FOR ADDICTSCalifornia in 1961 <strong>and</strong> more recently New York State <strong>and</strong> the federal governmenthave initiated <strong>and</strong> implemented programs for the civil commitment ofnarcotics addicts. The thrust of these statutes is to maximize the number ofaddicts committable <strong>and</strong> minimize their opportunity to choo.se to leave.The roots of these commitment laws can be traced to the Federal narcoticshospital in Lexington. In recounting the initial. expectations for that institutionIsbell writes * * *Drug addicts were to be treated within the instituiticn. freed of theirphysiological dependence on drugs, their basic immaturities <strong>and</strong> i)ersonalityproblems corrected by vocational <strong>and</strong> psychiatric therapy, after which theywould be returned to their communities to resume their lives. It seems tohave been tacitly assumed that this program was the answer <strong>and</strong> wouldsolve the problem of opiate addiction. Within a year it was apparent thisassumption was wrong * * ** * * a more adequate <strong>treatment</strong> program (required) :(1) Some means of holding voluntary patients until they hadreached maximum benefit from hospital <strong>treatment</strong>.(2) Greater use of probation <strong>and</strong> parole. * * *(3) Provision for intensive supervision <strong>and</strong> aftercare. * * *Isbell goes on to say that the reasons why these problems were not solvedwere complex.In 1961 the California Legislature enacted laws establishing a commitmentprogram for addicts which was designed to accomplished those objectives recommendedbut never carried out at Lexington.Though the program has been useful for a small proportion of those committed,for the majority it has proven to be merely an alternative to prison.The majority have entered a revolving system of admission-release-admissionrelease,<strong>and</strong> spend a majority of their commitment incarcerated in an institutionwhich re.sembles a pri.son more than it does a hospital.Commitment, strictly speaking, is not a <strong>treatment</strong> technique, it is a legaltechnique to bring an unwilling patient into a <strong>treatment</strong> situation. Whether the<strong>treatment</strong> is effective or he receives any <strong>treatment</strong> at all depends upon the programoffered.An important consideration in evaluating civil commitment for addicits is thefact that many people in positions of authority see commitment primarily as ameans to get the addict off the street. Their justification for this position is thatopiate dependence, particularly heroin addiction, is a life-threatening, communicabledisease <strong>and</strong> it is therefore morally justifiable to incarcerate addicts,to place them in quarantine, so that they win not infect others. The soundness ofthis position is arguable both on constitutional <strong>and</strong> epidemiological grounds.It is unlikely that all compulsion can be removed as one aspect of ]>nhlic policyin the management of opiate dependence. The presence of drug control laws i-* aprimary motivating force behind the entrance of addicts into voluntary programs.We must provide sufficient useful voluntary approaches <strong>and</strong> back them up byinvoluntary programs for those unable or unwilling to receive help from theformer, but commitment programs for addicts like any other medical program.should be flexible, imaginative, <strong>and</strong> unhindered by excessive legislative <strong>and</strong> administrativerestrictions.COMPREHENSIVE COMMUNITY PROGRAMSIt is generally conceded that traditional psychiatric techniques have not beenuseful in the management of opiate dependence. In a psychoanalytic frame of

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