Appendix A

Some Basic Problems in Drug Addiction and Suggestions for Research*

by MORRIS PLOSCOWE

XII. PROPOSALS FOR RESEARCH

It is obvious from the preceding pages that a fundamental attack on drug addiction requires some basic research.

The author would 1ike to recommend the following research projects:

1. An Outpatient Experimental Clinic for the Treatment of Drug Addicts

The Council on Mental Health of the American Medical Association has suggested, as we have seen, that a limited experiment be devised which would test directly the hypothesis that clinics would eliminate the illicit traffic and reduce drug addiction. But an experimental clinic can do more than this. It can also aid in the determination of whether it is possible to rehabilitate addicts, in a noninstitutional setting, so that they can live and function without drugs. Heretofore, the opinion has been that this could not be done outside institutional walls. An experimental clinic can also try out varied techniques in the rehabilitation of addicts and decide which are most useful.

Finally, an experimental clinic can resolve a basic problem in dealing with addiction; whether confirmed, unrehabilitable addicts can be transformed into productive members of the community if their drug needs are met.

The Committee should sponsor an experimental clinic for the outpatient treatment of drug addicts with the broad objectives outlined above. The clinic should be organized in a metropolitan center like Washington, D. C., Chicago or New York, where hospital facilities can be made available for the use of the clinic. It should be restricted to dealing with only a limited number of drug addicts; one hundred may be found to be sufficient, for experimental purposes. The clinic should provide facilities for a thoroughgoing study and diagnosis of each addict. The disciplines of medicine, psychiatry, psychology, social casework and education should all be used in making such a diagnosis and study. After the diagnosis and study, the attempt should be made to take the addicts off drugs and keep them off drugs through the use of all the techniques available in the disciplines aforementioned.

For the purpose of diagnosis, study and withdrawing the addict from drugs, a short stay in a hospital may be necessary. The clinic should have access to hospital facilities for its addict patients. It is desirable that the personnel of the clinic use every device and every technique presently available to try and keep the addict patients off drugs. Success or failure in this connection can be determined through a process of periodic reporting to the clinic and periodic follow-up in the field. Besides concentrating on the drug problems of the addict, the clinic should offer psychotherapeutic guidance to the patient in dealing with his personality problems; social work help with his family difficulties; vocational guidance on how to find and keep a job; and help in overcoming his educational shortcomings.

Every effort should be directed toward enabling the addict to become a productive individual without drugs.

If the clinic does not succeed in taking and keeping the addict patient off drugs after a period of intensive treatment, its personnel then should consider supplying the addict with sufficient drugs for his needs, so that he does not have to patronize the illicit peddler. The clinic will obviously have to determine what the minimum needs of the addict are for drugs. It will also have to struggle with the problem of tolerance and the demand of the addict for increasing doses of the drug. It will need to determine whether the addict is supplementing the supply of drugs from the clinic with "junk" obtained from illicit peddlers.

The clinic should also continue to provide every patient with vocational, educational, social work and psychotherapeutic guidance in the effort to make him a productive individual and wean him away from drugs.

It is obvious that many coming to the clinic will need to be supplied with drugs and will be unable to function without drugs. This will give the clinic the opportunity of testing the hypothesis that an addict is in a state of apparent normality when his drug needs are satisfied, and can function productively, with relative efficiency. But can he do so in the community in which he must live, work and bring up a family, and where he is subjected to the strains and stresses of everyday living? No demonstration of the relative normality of addicts under drugs in the controlled conditions at Lexington will be as effective as a similar demonstration made by addicts whose drug needs are satisfied, yet who are able to live and function in the outside world, hold down jobs and meet their family responsibilities.

In connection with the confirmed addicts who may be unable to function without drugs for a considerable period, the clinic will have to determine the best means of supplying such drugs to such patients with the least danger to the community. Since ambulatory treatment of drug addicts is frowned upon, the clinic may decide to dispense the drugs only on the premises of the clinic itself. In that connection, the clinic will have to determine whether an addict can hold down a job if he must come to the clinic for his supply of drugs several times daily. The clinic may also experiment with the so-called "depot morphine," if such a drug can be made available in order to obviate the necessity of repeated trips to the clinic daily. On the other hand, the clinic may decide that some form of ambulatory dispensation of drugs is a necessity in dealing with confirmed addicts. In that event, it is to be expected that the clinic will work out the best means of supplying drugs to addicts on an ambulatory basis.

It will be relatively easy to get the addict patients to attend the clinic if they are to receive drugs. It will be far more difficult to get them to attend in the earlier stage when the clinic is trying to take them off drugs. In that event, some degree of official control over the addict patients may be necessary. This may be provided by taking the addict patients from the courts of the city in which the clinic is located and working out cooperative agreements with the courts and their probation departments concerning the patients that the clinic will handle.

The experimental clinic can be envisaged as primarily a research enterprise which will provide data on the best methods of dealing with narcotic addicts outside institutional walls. Such data are indispensable for the establishment of public health clinics and will contribute greatly to their ultimate success. The experimental clinic will have to keep thorough records on what it does to and for its addict patients. Only through such records will it be possible to evaluate the possibility of success or failure in the use of specific techniques for dealing with addicts. The thorough case studies made by the clinic should also throw considerable light on causative factors in drug addiction and help in the formulation of prevention programs. It could also provide indispensable data on the procedures and techniques for dealing with addicts which could be used by the individual physician in the smaller communities which cannot support public health clinics.

In proposing the experimental clinic, the author is not unaware of the legal problems involved in supplying drugs to addicts. However, it is his belief that the operation of the experimental clinics proposed herein will not violate present federal statutes on narcotics, as interpreted by our courts. This is apparent from our discussion concerning the doctor and the drug addict. (See supra.)

The addicts coming to the experimental clinic will be treated as patients in the effort to overcome their addiction, and will only be supplied with drugs when it is determined that such drugs are absolutely necessary to their health and well-being and their ability to function as productive individuals in the community. If they are supplied with drugs it will be in a desire to avoid the discomforts and physical difficulties arising out of addiction. The good faith of the doctors supplying the drugs can hardly be questioned within the experimental clinic setting. In our view supplying drugs to a confirmed addict in the research setting of an out-patient clinic is no more illegal than the similar supply of drugs to an addict at Lexington in connection with studies made there. Both efforts advance materially the frontiers of our medical knowledge of how to deal with the problem of addiction.

2. A Study of Relapse and Causative Factors in Addiction and Rehabilitation

We have indicated that our present social policy demands that an addict be treated only in a hospital, in a drug free environment. We have expressed doubts as to whether hospital treatment, given our present knowledge, is very effective and can effectuate many cures or rehabilitate many drug addicts. We have noted the lack of good studies of the relapse of addicts after treatment at such institutions as Lexington, Fort Worth and Riverside. The author would like to propose a thorough research study of the after careers of graduates of Lexington, Fort Worth and Riverside. A study of addicts should be made with the same thoroughness as that used by the Gluecks in their classic studies of the after careers of delinquents and criminals.'" This will necessitate careful detective work to locate the subjects studied and thorough case work to determine what they have been doing since they left the institution in which they were originally treated.

Through such detective work and case work analysis we should be able to determine the relative effectiveness or ineffectiveness of hospital treatment. We should also be able to determine periods of abstinence and periods of relapse after leaving the institutions in which they were treated.

If a relapse study is undertaken, a thorough psychological, psychiatric and sociological study of the same addicts would be desirable. It should be able to determine why these individuals became addicted to drugs, while others who grew up with them in the same neighborhoods with roughly the same background did not become addicted. The basic concern will be causative factors in addiction based on a comparison of drug addicts and control groups. At the same time, a study of cured and rehabilitated addicts should be made in order to determine how and why men and women conquer the drug habit as well as how and why they became addicted in the first instance.

Success in dealing with addiction has as much to teach us as failure. A comparison is therefore desirable of those addicts who succeeded with those who have failed.

2. Educational and Preventative Research

There is need for sound, authoritative, educational materials that could be used in campaigns for the prevention of narcotic addiction. Materials are required on both the adult as well as the adolescent level. The preparation of such materials and the planning of campaigns for the prevention of narcotic addiction will require the collaboration of the disciplines of public health, mental hygiene and education. The challenge to be met by such collaboration is not unfamiliar. It is similar to the challenges which were met and the campaigns undertaken in connection with the prevention of venereal disease, heart disease and the dissemination of better information concerning problems of mental illness and emotional disturbance.

It is the author's belief that it is possible to prevent narcotic addiction through a dissemination of knowledge concerning the nature and effects of narcotics and understanding concerning the methods whereby narcotic patterns of behavior are transmitted from one individual to another. Preventative materials on narcotics, developed by the disciplines of public health, mental hygiene, and education are particularly necessary for use in those areas of our large cities, where narcotic addiction is a common phenomenon.

Sound educational and preventative materials on narcotic addiction have not been developed largely because of the fear that the dissemination of information about narcotics would lead adolescents to experiment with drugs.

It is the author's belief that ignorance is more to be feared than knowledge and that knowledge of the nature and effects of narcotic drugs would prevent experimentation rather than lead to it. As Justice Singer observed, sound education on narcotics would no more stimulate increased narcotics use "than education on fire prevention leads to more fires by stimulating people to become pyromaniacs."105 Prevention through education, however, is but one facet of a narcotics addiction prevention program. There is at the present time little available information on what community and neighborhood techniques are effective for preventing experimentation with drugs by juveniles and adolescents. This problem is closely related to the prevention of juvenile delinquency and crime, since many of those who experiment with narcotics engage in such anti-social activities. There are many programs for the prevention of juvenile delinquency and crime, but such programs are generally not geared to the prevention of drug addiction.

The author would like to propose a research project which would attempt to formulate community preventative techniques for dealing specifically with narcotic experimentation and narcotic addiction. If sound preventative techniques could be devised and applied in our cities, they might considerably cut down the incidence of narcotics addiction.