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Dealing with Drug Abuse

A Report to the Ford Foundation

THE DRUG ABUSE SURVEY PROJECT

STAFF PAPER 3

Treatment and Rehabilitation

by James V. DeLong

Introduction * Abstinence Programs * Methadone Maintenance * Antagonists * Multimodal Programs * Heroin Maintenance * Treatment of Users of Nonopiates

INTRODUCTION

HISTORY OF TREATMENT

The beginnings of our current narcotics problem go back over a century. As many authors have noted, the United States had a large number of opiate addicts in the period between the Civil War and the passage of the Harrison Act, which limited the availability of drugs, in 1914. These addicts were primarily white, female, rural, lower to lower-middle class, and middle-aged.' They regularly injected morphine or took morphine or opiated patent medicine orally. Opiates were freely available from the local pharmacy, so they were not criminals.

Some of them did not even know that they were addicted to narcotics. Patent medicines were not always labeled, and the user may have known only that he felt sick when he did not take a particular medicine, not realizing that the problem was withdrawal from the medicine itself. Most were knowingly addicted, of course, and addiction was a matter of great individual concern. Physicians had developed many different "cures" between 1856 and 1914, and the effort continued thereafter. In 1928, Dr. Charles Terry and Mildren Pellens, after reviewing these efforts extensively, stated:

. . . for the most part, the treatment of this condition has not emerged from the stage of empiricism. The various methods described in general indicate that the basis of the majority of them is merely the separation of the patient from the drug. Very few of those who have described the details of treatment have given a rationale for their procedures but rather have outlined dogmatically the adoption of certain measures whose primary object is the withdrawal of the drug and have stated or left the reader to infer that the completion of the procedure brings about cure .2

True to the spirit of the age, there were also numerous patent medicine "cures" available, some of which were themselves laden with opiates.

It is difficult to recapture the dominant attitudes toward addiction during this period. Terry and Pellens cite contemporary sources contending that addiction was a vice, a physical disease, a moral perversion, a product of neurotic inheritance, or a result of morphine poisoning.' Much of the debate is cast in terms of virtue and vice, and it is hard to tell what these terms meant to the participants. On the whole, however, the arguments are remarkably similar to those used in current debate about addiction.

While there was no consensus on the nature or causes of addicrecognized as a significant publiclegislative action developed. The Act in 1914 changed the problem opiates were to be controlled and than freely available on the open market.

It is not clear what response the lawmakers expected from the medical establishment. They may have expected doctors to keep on supplying existing addicts while avoiding the creation of new ones; they may have expected doctors to force addicts to give up their habit by refusing to prescribe narcotics; they may not have thought about it at all. In any event, at passage of the Harrison Act, the country had at least 200,000 to 300,000 opiate addicts who were now cut off from their normal sources of supply and unable to receive drugs except through physicians.

One result was predictable, although not necessarily predicted: Physicians were deluged with addicts seeking drugs.' A survey conducted by a Treasury Department committee in 1918 that reached 31 per cent of the physicians in the United States found that they had 73,150 addicts under treatment. Treatment, the committee believed, meant supplying drugs.' In addition to, and partly in replacement of, private physicians, more than 40 maintenance clinics were opened from about 1918. Most were sponsored by cities.

Whatever the lawmakers may have thought about the nature of addiction, the law enforcers considered maintaining existing addicts on opiates unacceptable. This group believed that, once the drug was removed and the addict had gone through withdrawal, he should have no further problems. Rufus King has given some examples of this view:

the medical conclusion, propounded as not open to question [was] that drug addiction was a correctable and curable condition, viz. the following preface to the Prohibition Bureau's Regulations: "It is well-established that the ordinary case of addiction will yield to proper treatment, and that addicts will remain permanently cured when drug addiction is stopped and they are otherwise physically restored to health and strengthened in will power."

Moreover, a small but strident segment of the medical community went even further than the authorities ... In 1921 a member of the American Medical Association's Committee on Narcotic Drugs, purportedly speaking officially for the Association, was quoted [as saying]: "The shallow pretense that drug addiction is a disease which the specialist must be allowed to treat, which pretended treatment consists in supplying its victims with the drug which has caused their physical and moral debauchery .... has been asserted and urged in volumes of literature by the self-styled specialists.",,

To people with this mental set, the maintenance clinics served no useful purpose; they simply prolonged the addictive state instead of curing it. If one assumes that abstinence is relatively easy, then drug maintenance does appear to be the equivalent of drug pushing. The government put severe pressure on the clinics, and the last one was closed in 1923.'

At the same time, a very tough policy toward physicians was maintained. The Narcotic Division of the Treasury Department arrested or threatened 14,701 persons registered to dispense drugs under the Harrison Act in 1918, 22,595 in 1919 and 47,835 in 1920.' Between 1914 and 1938, 25,000 doctors were arrested for supplying opiates, and 5,000 of them actually went to jail.' Those doctors who maintained that addiction was more complicated than what the official view held, and who advocated maintenance, were purged from the field.

It is tempting today to condemn this enforcement policy as both cruel and ineffective. It was certainly cruel, but its real effect will never be known. To begin with the most elementary question, no one knows whether the policy of closing off legitimate sources of supply decreased the total number of addicts. The Federal Bureau of Narcotics has estimated that the number of addicts declined from 200,000 at the time of the Harrison Act in 1914 to 118,000 in 1930, 60,000 in 1936, and 20,000 in 1945. Dr. Alfred Lindesmith has pointed out that these estimates are improbable, since they depend on the proposition that new addicts were not being recruited to replace those who died or quit the habit. if this were true, the average age of addicts would have risen as the population aged. In fact, the average age declined steadily throughout the period, and the other demographic characteristics of the population also changed, so there must have been substantial recruitment. Lindesmith reached no firm conclusion on absolute numbers, but pointed out: "Since the range of estimates of the addicted population at present is at least as great as it was before 1914, one can make out a case for any trend one chooses by judiciously selecting the estimates.""

One can argue that the policy worked fairly well for the addicts of the early part of the century, who were 60 per cent female, 90 per cent white, rural rather than urban, and middle or lower-middle class rather than impoverished. By 1945, the addict population was about 85 per cent male and only 75 per cent white, a substantial change in character. Since then, the addict population has remained about 85 per cent male and become steadily younger as well as more minority-group-concentrated. In New York City, for example, the Narcotics Register shows 47 per cent of the addicts to be black, 27 per cent Puerto Rican," and 26 per cent white. During the last two or three years, addiction has been spreading back into the middle class, but this is not a marked trend as yet. Clearly, the population of the 1910's and 1920's did not replace itself, and this could be judged a successful result of sorts.

By any account, a hard core of addicts remained after the closing of the clinics. During the 1920's, they were largely ignored, and treatment for opiate addiction disappeared for a decade. Then, in 1935 and 1938, the Public Health Service clinics in Fort Worth and Lexington were opened, largely because of problems created by addicts in the prisons. The basic theory of treatment remained unchanged since the earlier period-if an addict could be separated from his drug for a time, he could be counted as cured. It was generally believed by this time that the horrors of withdrawal were so great that few real addicts would undertake it on their own, but that a few months at one of the clinics would see them through withdrawal and allow them to recover. Once they went back to the community, it was presumed, they would never want to go near the drug again because of their fear of withdrawal.

Subsequent studies have indicated that the PHS clinics did not work very well." This was not generally recognized at the time, however, and there was another hiatus in the development of new treatment techniques until the explosion of urban addiction in the 1950's and 1960's. During the latter part of this period, several new methods came into being in response to the obvious inadequacies of the old ones.

Synanon, founded in 1959, became the precursor of a line of therapeutic communities that emphasized the psychological component of readdiction and tried to restructure the addict's character. During the next decade, many such communities were founded across the country. The apogee of the movement was probably reached in New York City's Addiction Services Agency between 1965 and 1968. At the same time, civil-commitment programs more or less on the Lexington model were applied on a large scale by California starting in 1961 and by New York State and the federal government starting in 1967.

In 1964, Dr. Vincent Dole pioneered in the use of methadone, a synthetic opiate substitute for heroin. Methadone maintenance has grown rapidly in the last few years, and, as of 1971, it is the technique into which most new money is going.

Contemporaneously with methadone, researchers at Lexington in 1965 began experimenting with the use of antagonists-drugs that block the effects of opiates without themselves being addictive. This method, however is still experimental, has a great many problems, and is not yet an operating modality.

At present, the dominant treatment modalities are therapeutic communities, civil commitment, outpatient abstinence, and metbadone maintenance. A large number of hybrid programs, however, have developed in response to the concern over addiction during the late 1960's. Some are explicitly multimodal, utilizing all the major techniques. There are also detoxification programs that simply take an addict through withdrawal, often using methadone but sometimes not; there are also crisis intervention centers, and programs that supply very small doses of methadone on demand. Many community organizations have become active in the field, with operations of all types and combinations.

For purposes of clarity, this paper imposes more order on the field than exists in practice. Methadone receives by far the most detailed analysis. In part, this is because methadone treatment is expanding very rapidly, and thorough analysis is therefore especially important. It is also due to the fact that, since methadone maintenance has been in the hands of physicians and scientists who believe in records, evaluation, and research, information on these programs is more readily available.

GOALS OF TREATMENT

The apparent goals of treatment are obvious. Society wants the addict to stop using heroin and committing crimes and, instead, to find a job, stabilize his personal life, generally improve his character, and become a useful and productive citizen. Analyzing programs in terms of these objectives presents a series of problems, however. The first is mechanical, although important: It is extremely difficult to get good information on the results of programs in terms of these or any other measures of success.

The second is more subtle. Even when information on treatment results can be obtained, it tends to focus on whether the patient has stopped using heroin. This represents in part a moral judgment that this is the most important goal of treatment and in part the belief that abstinence is a valid proxy measure of the achievement of the other objectives. Historically, there has also been a tendency to believe that treatment has failed if an addict subsequently uses narcotics for any length of time whatsoever, on the assumption, perhaps, that any relapse automatically means total relapse.

Increasingly, experts have become aware that this concentration on abstinence is questionable. While abstinence is to some extent a proxy for the other possible benefits of a treatment program, it is not completely accurate. The many facets of the addicted life-style are not totally inseparable, and, equally important, they need not all be treated at once. After treatment, an addict might hold a job, support a family, refrain from criminal activity -and still go on occasional benders of drug use. Or, he might continue to commit crimes, but fewer than before. His physical health might be improved even if nothing else were changed. It is also possible for a program to have a reverse effect. It might, for example, eliminate opiate addiction at the price of alcoholism, a dubious bargain.

In short, there is a range of possible benefits and adverse effects that can be produced by treatment programs. Different programs attach different importance to each; conflicts of value are inherent in comparisons of effectiveness. Since such questions are not easily resolvable, an objective examination of treatment programs should, ideally, use varying measures rather than only two categories-success (total abstinence) or failure (anything else) . Abstinence, stabilization on methadone (or, in fact, stabilization on heroin), employment, decreased criminal conduct or non-criminal conduct, support of a family, improved physical health and psychological functioning-any of these outcomes represents at least partial success for a treatment program and should be so regarded.

Despite the strong reservations about using abstinence as a measure, this paper repeatedly uses freedom from drug use as the major criterion of the success of treatment programs. While evaluation of even this factor is fragmentary, it is far more common than evaluation in terms of other possible measures. Anyone trying to analyze program results has to use it as a proxy or refrain from any judgments at all, and it is sufficiently important to be of use. It should be emphasized, however, that good multifactor evaluation might drastically change many of the conclusions contained here.

The third problem is even more fundamental. No one knows whether the goals of treatment as set forth in the beginning of this section are realistic or even desirable. Since no one knows why people become narcotics addicts, no one knows either how to make them stop or what will happen to them if they do stop. For example, NIMH officials recently stated that about 25 per cent of the addict population are people who suffer from depression and chronic anxiety, another 25 per cent are hedonists who like to get intoxicated, and the rest are psychopaths who need immediate gratification and are not particular about how they obtain it." Other researchers have also concluded that there is no one addict type, and that addiction can serve as a functional and adaptive characteristic for people with different types of psychic problems.

Yet, there are also a number of researchers who, denying this stress on psychopathology, contend that people are inducted into drug use through peer pressure and that large numbers of addicts may not suffer from severe psychopathology. The argument can be made that whatever characteristics addicts appear to have in common are forced upon them by the requirements of sustaining the addiction once it exists. Still another view is that addicts do have psychological problems but that these are in many cases no more severe than those shown by many nonaddicts. If one conducted a mental-health survey of the population from which most addicts are drawn, one might discover as many symptoms of mental disorder among the nonaddicts. Finally, some argue that heroin itself causes a metabolic change in the body that makes it difficult to cease being an addict. Thus, one can become addicted casually and then be unable to rid oneself of the addiction no matter what therapeutic techniques are brought to bear. 14

Treatment programs have disparate philosophies on these questions. Some, though by no means all, methadone programs assume some physiological basis of addiction. Most therapeutic communities probably assume a character disorder that can be helped by group therapy. Some outpatient abstinence programs assume that addiction may be an almost accidental event for many addicts, and that they can be helped with minimal intervention. But these assumptions are not constant within any modality, and almost all spectrums of opinion exist in each.

In short, there is no uniform theory of addiction and no adequate description of the addict population. Further, addiction has spread rapidly in recent years, and we know less about the new population than we do about the old. And we knew little enough before.

The difficulties these factors create in judging treatment programs are obvious. We do not know what expectations are realistic or desirable. We do not even know for certain that it is good for addicts to stop taking drugs. Some programs may be better for certain types of addicts than others, but we are not sure what types, or whether the programs are attracting the type with which they do best.

All the figures given in this paper are gross figures-the programs are judged by effects on the total number of people who were involved without any breakdown of results for different hypothetical subgroups of the addict population. The conclusions, therefore, are tentative, at best.

ABSTINENCE PROGRAMS

DETOXIFICATION

The most straightforward way to help a heroin addict is to detoxify him-reduce his daily heroin intake to zero and see him through withdrawal. The addict can be maintained on an inpatient basis without any drugs for the five-to-ten-day period necessary for primary withdrawal symptoms to disappear; or he can be treated with tranquilizers but not opiates; or methadone can be used to decrease his opiate dosage gradually until he is drugfree.

Detoxification services are offered in many places and modes across the nation-in hospitals, therapeutic communities, free clinics, and government programs. There is no way of learning how many addicts receive them each year.

Detoxification has several clear benefits for both the addict and society. Even if the addict does not intend to stay off drugs, it reduces his habit and decreases its cost. This spares him the hassle and society the crime costs of his addiction for some period, even if only a few days, after the process is complete. For some addicts, it is also a step toward rehabilitation. After repeated failures to remain detoxified, they become ready for other modalities.

On the whole, however, it is not clear that detoxification itself contributes greatly to the achievement of long-term abstinence. One program that used methadone in decreasing doses found that 74 per cent of the patients either did not finish the withdrawal program or relapsed to drug use within 48 hours after leaving it. Another, which effects withdrawal without opiates, found that only 10 per cent successfully completed the withdrawal, and almost all of these soon relapsed." The New York Narcotic Addiction Control Commission has estimated that only 24 per cent of those who receive detoxification without other services "remain drug-free for any length of time.""

The Haight-Ashbury Clinic in San Francisco has been experimenting with outpatient withdrawal, utilizing analgesics but not opiates. It reports the results with 450 patients:

56 per cent dropped out before they were clean and were lost to follow-up for at least two weeks; 5 per cent of these resumed their habit, 22 per cent were in treatment, and the rest were apparently not known. 12 per cent had decreased their habit to "chipping" no more than once a week.

5.5 per cent had been clean for one month or more.

38 per cent were lost track of after only one clinic visit."

This population differs from the standard drug-addict population because it includes individuals who are basically middle class and who began using heroin after being involved in the San Francisco speed scene; many have not been addicted for long. No one knows whether this population is harder, or easier, to work with than the more familiar ghetto populations. Other program examples could be cited-some better and some worse-but the general picture remains: Detoxification does have some benefits, but it is primarily a service for the drug user who needs a respite and a short-term way of protecting society against crime rather than a long-term treatment for addiction. As such, it is valuable, especially for anyone who believes that addicts should be treated more humanely than they are at the present time and that bandaids can be valuable things. But expectations should not be too high.

CIVIL COMMITMENT

In theory, civil commitment is the nonpunitive incarceration of an addict for purposes of rehabilitation. This method of treatment was started in the 1930's at the Lexington and Fort Worth hospitals, where the programs were part voluntary and part coercive. In the 1960's, civil commitment was applied on a wider scale, first in California then in New York. Subsequently, the federal government started using civil commitment as an alternative to imprisonment through the Narcotic Addict Rehabilitation Program. Dr. John Kramer has traced the relationship between the earlier programs and the massive investment of the 1960's:

The roots of these commitment laws can be traced to the federal narcotics hospital in Lexington. In recounting the initial expectations for that institution Isbell writes . . . "Drug addicts were to be treated within the institution, freed of their physiological dependence on drugs, their basic immaturities and personality problems corrected by vocational and psychiatric therapy, after which they would be returned to their communities to resume their lives. It seems to have been tacitly assumed that this program was the answer and would solve the problem of opiate addiction. Within a year it was apparent this assumption was wrong . . . a more adequate treatment program [required]: (1) Some means of holding voluntary patients until they had reached 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 solved were complex. "In 1961 the California Legislature enacted laws establishing a commitment program for addicts which was designed to accomplish those objectives recommended but never carried out at Lexington."18

It is generally thought that the programs started in the 1930's were almost total failures. Between 1935 and 1964, there were 87,000 admissions to the two centers, of which 63,600 were voluntary and 23,400 were federal prisoners. Of the voluntary patients, 70 per cent left against medical advice. A series of studies of addicts released from the abstinence facilities found that up to 90 per cent of those followed up relapsed into drug use within a few years."

As is true of almost every other aspect of the field, this conclusion is debatable. Recent research has suggested that it may exaggerate the failures. Dr. John O'Donnell points out that all the studies had problems with data collection and with categorization of those addicts who could not be found. He also questions the assumption that any relapse-any use of drugs-should be regarded as a failure, an assumption that was made by several of the studies. As has been pointed out, an addict may become basically abstinent, even though he does relapse a few times; and, even if he relapses regularly, he may spend more time off drugs than he would have without the treatment. This is also a net social gain.

O'Donnell uses the following example. If one has 2,000 exaddicts in a two-year study (a total of 4,000 man-years) and defines relapse as a two-week period of heroin use at any time, then a 90 per cent relapse rate could mean that anywhere between 69 and 3,600 of the 4,000 man-years were spent in a state of addiction. That is, 90 per cent of the addicts could have relapsed for exactly two weeks each, or, at the other extreme, 90 per cent could have relapsed for the entire two years, or anything in between." The social and individual consequences of these polar possibilities are very different.

The revisionist approach to the Lexington experience has caused many observers to soften their adverse judgments somewhat. Most still believe that it was not effective with very many addicts but concede that the question probably cannot be answered definitely. The data that would allow methodologically acceptable studies are lost. This does not seem to bother anyone too much, however, because the Lexington population drew heavily from rural white populations, and the exact results would be of marginal relevance to our present situation.

The three programs that were started in the 1960's built on the Lexington model, although they tried to improve it. They appear to have been started because addiction was either increasing or becoming more visible, and was thus becoming a political problem. In 1961, there was simply no treatment modality available except civil commitment, and even by 1966 it did not appear that there was any clearly better alternative. Under pressure to do something, state and federal authorities picked up the only available model, apparently on the premises that: (1) The failures of the Lexington program were due in part to the fact that the duration of treatment was too short (six months or a year) ; (2) Improved vocational and counseling services would be helpful; (3) Some careful studies had indicated that better supervision in the community after release would improve the success rate; 21 (4) Civil commitment would at least get addicts off the street.

The California program, instituted in 1961, provides for commitment on court order in lieu of sentence or prosecution. Voluntary commitment and commitment by relatives are also possible, but over 90 per cent of the inmates are there involuntarily, after conviction. In fact, the program is structurally and functionally very similar to imprisonment. The main center, in Corona, California, is a maximum-security facility under the direction of the Department of Corrections. There are armed guards and barbedwire fences, and most of the personnel are corrections workers. The minimum institutional stay is six months, and the average is about 14 months. After leaving the institution the addict is required to undergo a three-year period of "community aftercare," which is essentially "parole." During this time, he follows the same regimen as ex-felons, with the additional requirement of regular urinalysis testing and group counseling. Violations of t1parole" can and, in the case of relapse to drug use, usually do mean return to the institution. Attempted escape from the institution and serious parole violations are felonies in themselves.

The facility does provide inmates with a modified form of encounter-group therapy, based on the hypothesis that drug use is a symptom of aberrant personality patterns which must be changed. However, a study of the program's results concluded that the program was interpreted by addicts and professional visitors as more punitive than therapeutic. Whether one were released depended in large part on how well one played the game at group sessions. This was not conducive to the honesty that real group therapy demands.

Evaluation showed that between 1962 and 1964 there were 1,209 persons on release status at some time. At the end of the year, only 35 per cent were still in good standing and only 16 per cent maintained this status after three years. The majority who fail in aftercare do so for drug use, "poor adjustment," failure to report in, or new arrest. During the first year, 56 per cent were detected using drugs and 20 per cent convicted of new crimes. In the three-year period, 81 per cent had been suspended from release status at least once. The usual pattern for the inmate consisted of periods spent in the facility followed by periods of abstinence in the aftercare phase, and then return to the facility in Corona. As a result of this pattern, inmates who would have been serving a felony sentence (70 per cent) actually spent less time "incarcerated," while those who were guilty of misdemeanors (16 per cent) were "incarcerated" longer than if they had served an ordinary prison sentence. No later results seem to have changed this pattern. Felon addicts who receive no therapy while in prison do as well as or better than California Rehabilitation Center addicts while on parole."

The New York program, adopted several years later, differs somewhat in conception." Like California, New York provides for commitment in lieu of sentence or prosecution, for voluntary commitment, and for commitment by relatives or other persons, such as school officials or prosecuting attorneys. Unlike the California system, New York's system is under the direction of an independent Narcotic Addiction Control Commission (NACC) and has a mental-health orientation involving the use of professional mental-health personnel. NACC is also more committed to research and community aftercare programs.

New York's total program, by far the largest in the United States, has spent $475.3 million in the last four years, including its investment in methadone and therapeutic communities as well as in civil commitment. The direct annual investment in the civilcommitment program appears to be at least $50 million out of a total budget of $88.5 million. As of the end of 1970, NACC had 10,764 addicts in its own facilities, and another 10,419 were in facilities accredited or funded by NACC. These population figures were not broken down by modality."

Despite the dominance of a mental-health approach and professionalized therapy, the emphasis on security and remote institutions has apparently produced a penal atmosphere at many of the NAOC facilities. Recreational and entertainment facilities appear to be lacking, and life in a NACC institution has been described as a dreary round of a few hours in a classroom or workshop, some time in group meetings led by civil servants, and the rest of the time watching television or loafing. The peer pressures, ex-addict, encounter-group leadership, and meaningful work assignments needed to create an effective therapeutic environment are absent." The program has been subject to some fierce attacks, as in the 1970 New York gubernatorial campaign, when one candidate claimed that in three years NACC had spent $345 million and cured 120 addicts." It is difficult to know whether all of these accusations are justified. But it is equally difficult to find disinterested observers who contradict them.

NACC officials state their results fairly carefully. In June, 1971, the research director testified that "a relatively small number of people" had been processed through the entire civil-commitment procedure (the three to five years), and that, of those who had gone all the way through, 25 per cent "are currently abstinent, according to a physical follow-up." Another 25 per cent had either recertified themselves to NACC or had entered other treatment programs. The rest (50 per cent) were in jail as a result of new drug-related offenses or had returned to drugs." This statement does not reveal how many addicts had completed the program, how many were able to drop out or escape in some way, or what level of functioning the abstinent addicts were maintaining. The population is referred to as "small."

The federal NARA program of civil commitment for addicts includes three separate programs. Title I provides for addicts charged with violating federal laws (nonviolent crimes only). In lieu of prosecution, the addict can be committed to a three-year treatment period involving both institutional and aftercare treatment facilities. Admissions under this title have been few. Between July, 1967, and June, 1970, only 207 persons were examined and 179 accepted, although a case load of 900 per year had been anticipated. The main reason seems to be a general disinterest by U.S. Attorneys."

Title II offers treatment in lieu of sentencing for addicts convicted of federal crimes. This program is administered by the Bureau of Prisons, which provides facilities for treatment within regular penal institutions. The time of incarceration is not to exceed ten years, and - the addict can be released to aftercare services after six months. Only about 375 addicts are currently being serviced under this title.30

Title III provides for voluntary commitment by addicts who are not involved in criminal proceedings. The commitment is for a period of three years, most of which is spent in aftercare facilities. The term of the institutionalization itself is to be determined by the patient's progress but is not to exceed six months.

Until recently, Title I and Title III patients were sent to the Lexington or Fort Worth facility, under the Surgeon General. (Fort Worth has now been transferred to the Bureau of Prisons and will no longer be used for addiction treatment.) Title III patients receive their initial evaluation at Lexington, but many are channeled into community or state programs funded by NARA grants and contracts. The Lexington facility is the most open of the institutions and has a more relaxed policy toward escape or attempted escape. The primary treatment methods employed are detoxification, counseling, and some work and recreation therapy. They have begun an experiment with a small therapeutic community (Matrix House) but require a longer time commitment for patients in this program.

The initial evaluation determines whether the addict is suitable for treatment. The rejection rate is about 55-60 per cent. The grounds for rejection are not clear. Some officials claim that suitability is based on an assessment of motivation-whether an addict has sufficient self-control to be able to function in a relaxed and open environment, and, if not, the availability of other types of treatment facilities. Another view is that decisions on suitability are made on the basis of objective criteria, such as current legal status, criminal record, age, employment, history, prior drug experience, and mental state.

In a study of the first 27 months of operation under the new Act (1966-69), about 2,000 addicts were tested at Lexington. As of September 30, 1969, there were 802 Title I and Title III patients on an aftercare status; 26 per cent had been recommitted to the institution for aftercare violations, and 5 per cent had been discharged. As of March, 1971, 2,000 patients were in the civil commitment program, of whom 1,300 were in aftercare. Of the 2,000, 60 per cent were white. Average age was in the late 20's." In June, 1971, the Director of NIMH stated:

In the civil commitment program, a study of 1,200 patients who were in aftercare in 1970 showed that approximately 85 percent were employed, 70 percent were not arrested and spent no time in jail during that period, 35 percent were in self-help therapy, and 33 percent were pursuing their education. Patients who had been [in] aftercare for 3 months or more were, on the average, drug-free 80 percent of the time. A similar statement can be made regarding the heroin use of patients who were in the community treatment programs. As you know, many patients during the treatment of their addiction may abuse drugs other than heroin occasionally, such as cocaine, marijuana, amphetamines, or barbiturates. Of the patients in the civil commitment program who had been in aftercare for 3 months or more, 60 percent were not abusing any drugs. The same is true of patients who had been in the community treatment program for 3 months or more. Of the patients who are in the civil commitment aftercare phase, we know that 60 percent do not become readdicted during their first year in aftercare. Of the remaining, 25 percent do abuse some drugs or become readdicted and require further hospital treatment. About 15 percent were dropouts .32

It is difficult to know what to make of these results. Even allowing for selectivity in acceptance into the program, they are far better than the New York or the California experience would have led one to expect. Since the detailed studies on which this statement is based are not available, one can only reserve judgment.

The Bureau of Prisons has analyzed initial results from its care of inmates committed under Title II of NARA. As of the end of 1971, 896 inmates had been examined for program eligibility, and 70 per cent (630) had been accepted. The program had released 414 inmates to aftercare after an average institutionalization of 15 months, and 297 (72 per cent) of these were still active. The other 28 per cent had "violated or absconded." Over five thousand months of "successful aftercare" had been accumulated, but the meaning of that term as used in the report is unclear."

Many drug experts believe that programs of civil commitment offer little more than custodial care in a predominantly penal setting. Counseling and therapy, when employed, are imposed on the patients by the staff and are of questionable value. Apparently, most addicts are committed as an alternative to criminal prosecution or sentencing, and view commitment as such. Most do not appear to be motivated toward inner change, and those that do succeed might succeed equally as well in a voluntary community program. In addition, civil commitment is expensive. It requires secured facilities, around-the-clock guards, and large staffs. (Cost estimates for all three of the large programs are $10,000 to $12,000 per year per addict while the addict is in the institution. It is not clear whether this represents full costs, including capital expenditures, or operating costs only.) In spite of these costs, the chief function of civil commitment seems to be nothing more than to keep the addict out of circulation for intermittent short periods.

The NARA information cited above seems to indicate that civil commitment for a limited term followed by aftercare is more

promising than this conclusion suggests. The California program was structured in somewhat the same manner-although with a more open law-enforcement orientation-and it may be that it shows worse results than NARA because it was more carefully evaluated and the patients were more carefully controlled. A definite answer to this will have to await more detailed information on NARA.

THE THERAPEUTIC COMMUNITY

"Therapeutic community" (TC) is a generic term used to describe an institution that attempts to treat the addict by dealing with the underlying causes of his addiction. The basic concept of the TC modality, as of the civil-commitment programs, is that addiction is the result of psychological problems, and that intensive therapeutic techniques utilized within the structure of a residential community can restructure the character and personality of the addict to the point where he no longer needs to use drugs. Although heroin addicts constitute the major part of the TC population, most TC's service users of nonopiates as well. As of mid-1970, there were probably 40-50 therapeutic community programs in the country with approximately 4,000-5,000 residents."

The growth of therapeutic communities is in some ways as much a quasi-evangelical movement as a drug-treatment modality, and it is difficult to describe them without distorting the views of at least some of the participants." The flavor of this modality can be partly conveyed by tracing some analogies and intellectual roots. First, there is a parallel between the TC and Alcoholics Anonymous. Synanon, the original addict-oriented TC, was founded in 1959 by an ex-alcoholic as a treatment program for alcoholics modeled after AA. It drifted into treatment of opiate addicts largely by accident. Many of the TC's retain some of the basic AA characteristics-the concept that there is no such thing as an ex-addict, only an addict who is not using at the moment; the emphasis on mutual support and aid; the distrust of mentalhealth professionals; and the concept of continual confession and catharsis. However, the TC has extended these notions to include the concept of a live-in community with a rigid structure of day-to-day behavior and a complex system of punishment and rewards.

The rise of the TC also parallels the rising popularity of group therapy generally. Encounter groups, support groups, and marathon sessions are as prevalent in the "straight world" as in the TC's, and the many differences in group-therapy methods that exist outside exist in the TC's as well. One reason for the frequent confusion about the different TC's is that they reflect the many variations in approaches to group therapy.

The growth of TC's has occurred at the same time as the growth of interest in communes, and some TC's have an element of the commune in them-the residents are rejecting a dishonest world in favor of a better way of life. Synanon, for example, has residents who have never been addicted to anything but who prefer the Synanon life-style. Dr. John Kramer has referred to Synanon as "the third community," different from the drug-using community and the "square" community. He points out that there is a fundamental difference between Synanon and many of the TC's in that "the Synanon ideal is to retain members in the group indefinitely and to expand steadily, drawing in more and more members, squares as well as addicts. Other TC's differ in that they do expect their members to re-enter the square community. "3r The past decade has seen a movement toward community action and a rejection of services furnished exogenously. Community control is a familiar slogan, and the beliefs that only the poor know what the poor want and only blacks can help blacks are also common. To some extent, TC's reflect this movement. Many of them have adopted the view that the nonaddict does not really understand the problems and world of an addict and therefore cannot contribute as an ex-addict can. Since addicts are often poor and black as well as addicted, this concept is a powerful force.

Finally, the quasi-evangelical aspect of the TC creates an interesting, although certainly not documented or provable, situation. The addict may be replacing his addiction to heroin with an "addiction" to being an ex-addict and to the encounter therapy. The philosophy of the TC becomes a religion for the addict. It is something to believe in and a message to spread to his fellow addicts in the world. The "religious fervor" involved exists in varying degrees. In Dr. Kramer's words:

It has been undiplornatically stated that religiornania is a cure for narcomania. This observation is valid, particularly if one defines religiomania broadly as the devout acceptance of clearly defined tenets of a faith and its principles of behavior, and persistent participation in its prescribed rituals. The faith and its practice will usually encompass all the life activities of the communicant and in its practice he will have the opportunity for both penitence and ecstasy. Obedience is part of it as is the sense of being an accepted member of the congregation, however lowly, and thus possessing an attribute not possessed by anyone outside the sect. The requirements can be fulfilled not only by formal fundamentalist religious groups such as Teen Challenge but by such an organization as Synanon and other programs which have been modeled on it.37

In terms of structure and program, some common features of TC's can be identified, despite wide individual variations. Most have three identifiable phases to their program. The first of these is a testing for admission; the addict must show the genuineness of his desire to become drug-free. In some places, the addict must become drug-free on his own and remain so for a given period of time before he is admitted. In some, he must work in a storefront center for a time, showing the proper attitude. Others do not require abstinence in advance and will have a patient detoxified on methadone or go through withdrawal after formal admission. In some TC's, an addict is put through an encounter session with present residents to test his dedication.

The methods vary, but at some point early in the process every TC tests the candidate's motivation. As might be expected, there is a high loss rate at this point, although numbers are difficult to find. The different entrance procedures must be kept in mind in evaluating TC's, because they can obviously make a substantial difference in the statistical records of the program. A community that does not formally admit addicts until they have passed stringent tests is likely to show a higher success rate than a community that does its weeding out after formal admission.

Whatever the form of testing used, relatively few addicts pass it. In most TC's, somewhere between 50 per cent and 90 per cent of the applicants are rejected or quit at this initial stage. Once admitted, the addict enters a treatment ladder. The program of treatment is usually highly structured and extremely rigid, with an enforced system of rewards and punishments. The resident starts at the very bottom of the ladder, with little freedom, no responsibility, and the lowest types of tasks. As he proves himself, he begins to acquire more freedom, better jobs, and increased responsibility. This period of treatment lasts at least a year and is characterized by clearly marked stages in status. The emphasis is usually on confronting the addict with the immaturity of his past behavior and his need to learn responsible patterns of dealing with the world. Group therapy is emphasized, and the encounters can be extremely rough. It is part of the ethos, however, that the motives behind the encounters are concern and love rather than hostility.

Finally, the resident arrives at the re-entry phase. During this period, he begins to have a life outside the community again-he takes educational courses, spends weekends with his family, works, etc. When he has established a stable pattern outside the community and is considered responsible by the professional staff and/or peers, he may be discharged. (At Synanon, there is no re-entry phase. Family life, education, and work are all incorporated into the community. To Synanon community members, the straight world outside the community has not changed, and the pressures and problems that resulted in their addiction in the first place are still there. Return to the outside means return to heroin addiction, alcohol, or whatever drove them in.)

A major problem in evaluating therapeutic communities is the difficulty of ascertaining facts. Even a matter so rudimentary as the costs involved is a matter of dispute because of differences in calculating capital and operating costs, treatment of welfare expenditures that go to support the community, allocation of funds from different government agencies, appraisal of donated goods and services, and simple lack of records. Costs range anywhere from $3,000 to $10,000 per year per resident.

Even more difficult to assess is the result of the effort, since little careful evaluation has been done. One multimodal program analyzed the "split rate" from the TC component of its program. They found that, of 122 entrants, 40 per cent left within three weeks, 50 per cent within seven weeks, and 85 per cent within one year. A TC that appealed mainly to white, middle-class residents found that, during one year, almost 700 persons entered the program, 535 left voluntarily, and 23 were expelled. Of those who left, 175 came back. The program graduated 38 residents during the year. Of 113 graduates of the program over a four-year period, 13 had relapsed to drug abuse. Of the remaining 100 graduates, 25 were employed in the subject TC, 51 in other addiction programs, and 19 in the community at large; five were unknown .18 These are only fragments, because there is very little hard information on the results of TC's. In part this is because evaluation is expensive and difficult and many organizations do not have the money to spend on it. Also, some program operators oppose evaluation on philosophical grounds-they believe that what they are doing is humane and valuable and that their work is demeaned by attempts to judge it in quantitative terms. They may also believe that evaluation has negative effects on the program. If it shows many failures the residents will come to believe that they, too, will fail, and the prophecy will be self-fulfilling.

Finally, there are sound bureaucratic reasons for avoiding evaluation as much as possible. All the preliminary and anecdotal indications are that, while a few people are helped greatly by TC's, an overwhelming majority are not. In the hard competition for government drug-treatment money, evaluation might well hurt the TC's more than it would help them. The incentive to permit evaluation, let alone fund it, is minimal.

Looking at all the available evidence and the impressions of experts in the field, it is hard to escape the conclusion that TC's are, at best, good for a very limited number of drug addicts. As a rough guess, considering the initial rejection rates, the split rates, and the relapse rate, it would be surprising if careful evaluation showed that more than 5 per cent of those who come into contact with the program are enabled to lead a reasonably drugfree, socially productive life.

There is also a major question about the type of addict for whom the TC is the proper solution. Some experts believe that the TC works best for the sociopath who is tough enough to take the encounters but not for those with less serious psychological problems or those who are the least alienated. Other experts have different categorizations.

The TC's may have advantages in dealing with particular subgroups of addicts, however. Although exact population breakdowns are seldom available, it is generally recognized that the mean age of the residents is lower than that of either addicts in the methadone programs or the total addict population. This could mean that the TC is especially attractive to young addicts, but this is not certain; the same result would ensue if it were less attractive to older addicts. It may also be effective with multidru'g users or with young experimenters, but this has also been unproved.

In terms of any national program of treatment of heroin addicts, it is difficult to see a major role for the TC, simply because the success rate is too low and the cost too high to make an important impact on the problem. At the same time, most drug experts, when they discuss the necessary elements of a comprehensive drug-treatment program, include a therapeutic community, but whether this is based on a genuine belief in its utility, on the hope that utility might be demonstrated, or on simple politics is unclear. In the long run, it may turn out that the TC is much more interesting outside the drug context than within it. By setting itself the task of rehabilitating drug addicts-a notoriously hard group to rehdbilitate-the TC movement may have destined itself to look bad. The real contributions that such methods might make to improvements in the condition and functioning of more tractable populations are easily lost sight of by appraisers who are concerned with the drug problem.

OUTPATIENT ABSTINENCE

Many programs have a component that treats outpatients and attempts to get them to abstain from heroin use. Of 142 programs covered by an NIMH survey, only 23 were for inpatients only, and only 43 of the 142 engaged in methadone maintenance; therefore, at least 76 were operating some form of outpatient abstinence program.

These programs differ as much as or more than the therapeutic communities. The major components are community outreach to find people who need help; group and individual therapy of various types; vocational and social counseling; intervention with authorities, employers, or schools on behalf of the patient; vocational training and education; and family counseling. The programs emphasize these elements in varying degrees, of course, and most probably do not offer a complete range of services. Another variable is the intensity of the patient's involvement with the treatment center. Some are halfway houses, where the patient spends the whole day and goes home only at night. At the other extreme are agencies that have only one or two sessions with a patient or that are more or less social centers. Most programs are, of course, between these extremes."

This method of treatment is not based on any constant theoretical beliefs. Some people believe that addicts suffer from underlying character disorders and can be changed only through heavy involvement in therapy. Others believe that helping with the immediate problems of the patient will enable him to help himself. Still others are desperately trying to fend off the total catastrophe that may overwhelm the patient if he does not receive aid.

Very little evaluation of these programs has been done, and there are no reliable data on the results. Most observers believe that the attrition rates are very high, the number of patients who remain drug-free is small, and the impact on such areas as employment and criminal activity is minimal. Dr. Robert DuPont, Director of the Washington, D.C., Narcotic Treatment Agency, has found that only 15 per cent of the patients who selected NTA's abstinence program remained in it for six months, although those who did remain did well." A -D.C. Department of Corrections study of the performance of abstinence patients in NTA facilities (all of whom had been referred to NTA by the Department of Corrections) came out with somewhat better results: 50 per cent of 165 referees were failures after six months. If "escape" was removed as a category of failure, then the failure rate was only 25 per cent." Programs connected with the criminal-justice system usually have the spur of return to jail if the patient fails, of course.

The Office of Economic Opportunity enlisted a contractor to do a thorough evaluation of eight OEO-funded projects; but the data-collection problems were great, and it was impossible for the evaluators to reach any meaningful judgments." OEO is now trying again, but the results have not yet been published.

In general, the conclusions for these programs are about the same as for the therapeutic communities and the detoxification centers: They help a few people a great deal and more people to some degree, but the failure rates are very high. They have a considerable cost advantage over the therapeutic communities because they do not need extensive and expensive residential facilities. Their over-all, long-term contribution to the drug problem is in some doubt. The major imponderable is the extent to which changes in the addict population may invalidate pessimistic conclusions drawn from past experience. Addiction may have spread to people who are not so intractable as the groups on which these conclusions are based. They might become abstinent with the help that can be given by the outpatient facilities.

Most important is whether these programs have an impact on the juvenile who is dabbling in the drug scene but has not yet become a confirmed addict. This is the target population for many such programs and would seem to be the area in which they have the most to offer. At present, the answer is an enigma. Some of the conclusions reached and questions raised in 1969 by Judith Calof of New York's Community Service Society are still valid:

Voluntary treatment agencies have always emerged in response to the neglected needs of segments of the community. In the addiction field, there are still grave unmet needs. For one, the number of school-aged addicts has been growing, while voluntary and public agencies continue to concentrate on the older addict. Are special techniques needed for reaching and treating this young age group?...

A major unmet need is addiction prevention. Do voluntary treatment agencies have a major contribution to make in prevention? Could their coordinated efforts succeed in identifying and reaching those most vulnerable to this disease?

The limited success of the voluntary treatment agencies should not be interpreted as failure, but should be viewed in long-range terms. Pioneering means trial and error, with inevitable setbacks and frustrations, but it reveals the assessment of a situation. Voluntary treatment agencies have already demonstrated the enormity of the addiction problem and the immense difficulties in rehabilitating heroin addicts. The results of their dedicated efforts should serve as a learning against unrealistic expectations. Their experience can prevent catastrophe in a massive government program, and refusal of the public to allocate further funds for treatment .43

METHADONE MAINTENANCE

CHARACTERISTICS OF METHADONE

Methadone is a synthetic opiate. For purposes of understanding its use in the treatment of heroin addiction, its most important characteristics are as follows:

• It is a substitute for heroin, in that it will prevent an addict from having or feeling withdrawal symptoms if he replaces his usual drug with methadone.
• Unlike the heroin available in this country, it is effective when taken orally.
• If the dosage is sufficient (the exact level depending on the addict's level of tolerance to heroin), the methadone will block the action of heroin, so that the addict receives no euphoric effect if he tries heroin. At lower doses, methadone will not block this effect of heroin, but it will suppress the "narcotic hunger"-described by Dr. Jerome Jaffe as a "felt sense of physical abnormality"-that an addict feels without his drug.
• The effective action of methadone is about 24 hours, as opposed to about six hours for heroin. Thus, it needs to be taken only once a day.
• When taken orally in constant doses, methadone does not produce a euphoric effect.
• To date, no significant deleterious side effects have been reported.
  

THE PROGRAMS

Starting with a 1964 experimental project sponsored by the New York Health Research Council and conducted by Drs. Vincent Dole and Marie Nyswander, programs that maintain addicts on methadone have grown steadily. Despite some differences in theory and practice, in all maintenance programs an addict receives a dose of methadone every day, either at a clinic or, if he has proved himself, at home. He may also receive ancillary services-group or individual therapy, individual or family counseling, vocational rehabilitation, employment services, use of social center facilities, and medical and dental care. The extent and quality of these varies greatly, but almost all programs provide something.

There are wide variations in the modes of operation of methadone programs." For example, a study of 47 methadone programs found that 27 programs used ex-addicts on the staff, while the others did not; 6 had inpatients only, 19 had outpatients only, and the rest had both. Only 8 of the 47 provided chemotherapy without any group work.

Table 3-1 lists the types of service offered by the 47 programs in terms of the numbers of programs and the per cent of the total sample offering the service.

TABLE 3-1

TYPES OF SERVICE OFFERED BY METHADONE-MAINTENANCE PROGRAMS

a Drug-free detoxification is not a feature of the methadone program.

More detailed statements obtained from 25 of the methadone maintenance programs showed that 14 favored narcotic-free rehabilitation as the ultimate goal, and only 11 favored prolonged maintenance. Also, 18 preferred high-dose administration (50-180 mg.) and 7 preferred low-dose (20-40 mg.). Not surprisingly, there was a correlation between preference for narcotic free rehabilitation and preference for low doses.

The precise number of persons now in methadone-maintenance programs is not known. At the Third National Methadone Conference in November, 1970, Dr. Vincent Dole estimated that there were then about 9,000 people on methadone maintenance in the United States and Canada .4' This estimate was based on a
variety of inputs, including discussions with the manufacturer of methadone. It was in rough accord with the numbers of patients recorded in publications by the major projects and was probably fairly accurate.

Growth has been quite rapid, however. The NIMH treatment directory listed 44 methadone-maintenance programs as of 1968-69, and many of these had small patient populations. As of April, 1970, 64 programs had acquired or applied for Food and Drug Agency authority to use methadone for maintenance, although not all of them were in operation. At that time, the best estimates were that between 50 and 60 programs were actually operating." By June 1, 1971, the FDA had given permission to 257 sponsors representing 277 methadone-treatment programs, some of which included several clinics. Of these, 185 programs were in institutions and the other 92 were private. The number of programs now in actual operation is not known."

The FDA estimated, in June, 1971, that there were 20,000 to 30,000 people on methadone maintenance at that time. Dr. Bertram Brown Director of NIMH, testified at the same hearings that 20,000 was probably the best estimate." As of December, 1971, the FDA has doubled its estimate again. It now believes, according to Dr. Elmer Gardner, that there are between 40,000 and 50,000 patients on methadone maintenance.

Costs. Costs of methadone programs are hard to determine. Many figures are given, but it is never clear whether all costs (such as plant and equipment or the value of volunteer help, for example) are included. As a rough estimate, the cost of the programs is between $500 and $2,500 per patient per year, depending on a number of factors.

Methadone itself is not an important cost, since it can be procured for about $.05 per day per addict.

Controlling and administering the methadone is a significant cost, since it requires a staff.

Determination and preparation of individual doses are significant, since determination requires physician time, preparation requires careful work by a pharmacist, and keeping track of individual doses takes staff time. Whether individual doses are more effective therapeutically than standardized ones is an open question.

All programs use urinalysis to test the patients' use of heroin and other drugs. This costs $1 to $3 per test, depending on the frequency, the laboratory, and the number of samples tested. Obviously, this is a significant cost element: Testing three times a week at $3 per test would cost $468 per addict per year. There are some ways of avoiding these costs through random testing, which is effective for some purposes. There may also be cost-reduction possibilities for the tests themselves.

The method by which an addict is initially switched from heroin to methadone makes a large cost difference. If the addict is switched to methadone as an inpatient in a hospital (as was done for most of the patients in the Dole-Nyswander project, for example), each addict admitted may cause $200 to $1,400 for initial hospital expenses.

Physical plant and facilities obviously make a difference in costs.

Legal requirements are important. To the extent that jurisdictional law requires that elaborate information be obtained and records kept, the costs are increased.

Any research component adds expenses.

The level of ancillary services is important. An effort to supply group therapy, counseling, vocational or educational rehabilitation, and other services-all of which require high staff-to-patient ratios-will increase expenses substantially. Many of the public statements on costs regard this as the major variable involved. While most programs pay lip service to the need for these services, careful evaluation of the extent to which they influence the success or failure of the program is only beginning.

The rate of expansion of a program makes a significant difference in average cost. An addict will probably require more services and control in his first year than later, when he is stabilized in a new life-style, so that a new or expanding program should show higher average costs than a static one.

These variations account for the wide range of the basic cost estimate. At present, $500 per addict per year seems about the minimum for a program that uses standardized dosages, outpatient induction, fairly cheap urinalysis, and no services except those supplied by the addicts themselves. A reasonable estimate for a program with individual doses, some inpatient induction, frequent and expensive urinalysis, and many ancillary services is $2,000, although, of course, the cost for each patient stabilized in the program would be much lower." This figure could be raised almost without limit by the provision of more extras, of course, a phenomenon sometimes referred to by program operators as the danger of "Taj Mahalism"---providing very elaborate services to a few addicts rather than minimal effective services to many.

Population Characteristics. Because of regional differences the demographic characteristics of the over-all methadone population are hard to describe. The patient population of the Methadone Maintenance Treatment Program (MMTP) in New York City, for example, is about 40 per cent black, 19 per cent Puerto Rican, 40 per cent white, and I per cent Oriental. This breakdown compares with the ethnic breakdown of the New York City Narcotic Registry, which, as of December, 1969, was 47 per cent black, 27 per cent Puerto Rican, and 26 per cent white." The Santa Clara County (California) Methadone Program reports a patient population of 55 per cent Mexican American, 6 per cent black, and 39 per cent white." Other programs also exhibit ethnic breakdowns' indicating that methadone maintenance appeals to minority-group addicts. The Washington, D.C., program, for example, is 95 per cent black." The ethnic composition of any methadone project is probably not too dissimilar from that of the local addict population of comparable age, although it may be skewed slightly toward overrepresentation of white addicts.

Methadone has not had similar success in attracting younger addicts. Although the minimal age required for admission to most programs is 18, the mean age of the patient population is usually between 30 and 35. In addition, the average length of addiction for the patient population on methadone is 10 to 15 years, although most programs require only two years, and some now require only one. There are reports, however, that the mean and median ages and length of addiction are now falling." Unfortunately, no treatment method has been developed that attracts the majority of young addicts. Most members of this group do not seem to be sufficiently disenchanted with either the life-style or the effect of heroin to seek treatment of any type, or are as yet unconvinced that they are truly hooked.

Results. Most methadone programs have made an effort to evaluate their effect on the patients. The criteria employed usually follow those developed to evaluate the MMTP in New York -remaining in the program, employment, freedom from drug use, decrease in crime, and willingness to accept help for personal problems.

The New York program is not only the largest but also the best evaluated over time. Consistently, the evaluation committee, headed by Dr. Frances Gearing of Columbia University's School of Public Health and Administrative Medicine, has found the program successful with a large percentage of the addicts. The findings of the evaluation, as of October 31, 1970, are as follows: "

Population. Most of the patients had been selected under criteria that required them to be 20 years old, have a five-year history of addiction, display no serious psychiatric problems, and have no addiction to drugs other than heroin. Although in 1969 the requirements were reduced to age 18 and two years of addiction, this had little impact on the age distribution of the treatment population because of the waiting time. The mean age at admission remained about 33-higher than the 27.9 mean age of the addicts on the New York City Register. Whites had a mean age at admission of 31, blacks of 35, and Puerto Ricans of a year in between.

Retention. A total of 4,376 patients had been admitted since the inception of the program in 1964. Of this group, 3,485 (80 per cent) were still in treatment at the time of evaluation. The others had left voluntarily or had been discharged because of excessive use of other drugs or alcohol, death, incarceration, or antisocial or generally uncooperative behavior. Of the 2,424 originally inducted on an inpatient basis, 74 per cent were still enrolled. Of the 1,952 who had been admitted directly as outpatients, 88 per cent were still enrolled. (This group had not been in treatment as long as the others, since outpatient induction was started only in 1968. They were also a selected group.)

Special studies of three 500-patient cohorts have been done. One of those covered the cohort for 21 months, one for 33 months, and one for 48 months. About 23 per cent of each cohort had been discharged by 21 months after admission, 34 per cent of two cohorts by 33 months after admission, and 42 per cent of one cohort by 48 months after admission.

As is shown by the cohort studies, the commonly cited 80per-cent success rate is misleading. The statistic includes a large number of addicts who have been in the program for a relatively short period and does not fully reflect the attrition over time. For example, the total admissions, as of October 31, 1969, were 2,325. As of October 31, 1970, they were 4,376. Thus, the data for the latter date included 2,051 patients who had been in treatment for less than one year, and half or more of these may have been in for six months or less. (The cohort studies show that the attrition rate during the first six months is about 10 per cent, and over the first year it is about 16 per cent.) Maintenance of the over-all average of 20 per cent attrition is therefore dependent on continuing expansion of the program.

There is another side of this argument, however. MMTP has fairly strict standards for behavior and drops people for violation of those standards; a large proportion of those listed as failures were therefore dropped by the program (they themselves did not want to leave). A study of 138 terminations found the following causes: 55

Involuntary terminations 81.2%

Uncooperative behavior 17.4%

Antisocial behavior 7.2

Unreachable psychopathology 7.2

Drug abuse 8.7

Alcohol abuse 10.9

Arrested 15.2

Medical disability 2.2

Death 12.3

Voluntary terminations 15.9

Voluntary discharge 14.5

Loss of contact 1.4

Administrative terminations and unknown 2.9

Administrative .7

No information 2.2

One can question whether a methadone program should terminate patients for all of the causes given. Even if the patient has serious problems remaining, the program may have substantial beneficial effects. One can argue that the only patients who should be counted as failures are those who drop out voluntarily. If this criterion is applied to the 500-patient cohort that had a 42 per cent attrition rate over 48 months, and if we assume that only 15.9 per cent of these dropouts were voluntary, then only 34 of 210 dropouts would be counted as failures. By this standard, the MMTP may claim that it has a ' t least partial success with 93.2 per cent of all addicts who are admitted to the program.

Again, this is not totally satisfactory, for several reasons. For example, it is difficult to know how to categorize those who die or are discharged for medical disability. Some of the voluntary patients moved to programs in other cities. Some patients who were expelled might have dropped out voluntarily at a later time. Thus, 93.2 per cent may be unrealistically high. But it does show that a 42 per cent termination rate over four years probably understates the value of the program somewhat.

To sum up, if one adopts MMTP's own standards on the retaining power of methadone, the common figure of 80 per cent success errs on the high side. If, however, one argues that those standards are too stringent, excluding too many patients who are receiving worthwhile benefits from the program, the 80-percent figure may be too low. (it should be noted that the same problems exist in assessing the effects of nomnethadone programs. They are just more obvious in this context.)

Employment. For the group that stayed in the program, employment rose markedly. About 26 per cent of the men were employed when they entered. This figure rose sharply to about 57 per cent and 66 per cent for those in the program six and twelve months, respectively, and then rose more slowly to about 78 per cent for those in the program for 48 months. Because of attrition, this percentage rise represents a much smaller absolute rise in employment. Out of a cohort of 100 entrants, 26 would be employed. After four years, 58 members of the cohort would still be in the program, of whom 45 (78 per cent of the 58) would be employed. So, out of any group of 100 entrants, only 45 would be employed after four years.

Criminal Activity. For the group that stayed in the program, criminal activity apparently decreased. In the three years before admission to the program, the methadone patients had 120 arrests and 48 incarcerations for every 100 man-years. In the four years after admission, they had 4.5 arrests and 1.0 incarcerations.

A group of detoxification patients studied for purposes of comparison showed 131 arrests and 52 incarcerations per 100 person years in the three years prior to detoxification and 134 arrests and 63 incarcerations for the four years after detoxification. A separate study of 912 patients admitted over a four-and-a-half year period showed a 90-per-cent drop in criminal convictions."

Drug Use. While most patients test the methadone blockage a few times while on methadone, none had returned to regular heroin usage while still in the program. About 8 per cent have problems with chronic alcohol use and 10 per cent with continuing use of amphetamines, cocaine, and barbiturates.

Fate of Dischargees. A Gearing Committee study of 281 expatients six months after discharge had the following findings:

Left Discharged Total

voluntarily for cause discharge

Arrested or jailed 10% 26% 23%

Dead 2 2 2

Detoxification 13 20 19

Other R. program 11 4 7

Medical or psychiatric facility - 3 2

Private M.D. 2 2 2

Moved 7 1 1

Readmitted 33 6 11

No reports found 22 36 33

Total sample 100 (45) 100 (236) 100 (281)

Total N (90) (472) (562)

Two other studies have produced similar results.

Previous evaluations of MMTP have been criticized on the ground that the original selection criteria (since eased, as we have noted) picked only those addicts most amenable to treatment. Another criticism is that the ambulatory induction program has required that the applicant have either a job or a family. This may also select the strongest candidates. Finally, the fact that there is a waiting period may also operate to select patients who are most amenable to treatment. The Gearing evaluations through 1970 do not include any analysis of attrition rates from the waiting list or any comparison of those who enter treatment and those who drop off the list.

These criticisms seem at first glance to have weight. There are several compelling arguments that they do not, however. Dr. Carl Chambers, Research Director of the New York Narcotics Addiction Control Commission, headed a study that utilized single-factor analysis to compare patients who stayed in the program and patients who did not. He found that continuing in the program was not related in any statistically significant way to the patient's sex, marital status, multiple abuse of drugs, abuse of alcohol, ethnicity, education, age at onset of heroin use, or number of prior treatments. Continuing in treatment was marginally related to conviction history, in that there was a significant difference between those with three or more convictions and those with two or fewer. It was related to the length of abuse of narcotics, in that 90 per cent of those who had abused five or fewer years and only 77 per cent of those who had abused more than five years remained in treatment for two years. There was a relationship to the employment status of the patient at time of admission-88 per cent of those who were employed and 77 per cent of those who were not remained in treatment for at least two years. The item with the greatest predictive power was the number of convictions-the fewer the number, the greater the chance of remaining in treatment. Combinations of these characteristics do have some predictive value. For example, the Chambers study concluded that a patient with seven or more convictions who had no marketable employment skills was least likely to remain in treatment two years (55.6 per cent of these did remain), and that a patient with few convictions and no multiple drug or alcohol problems was most likely to remain in treatment (95.8 per cent)."

In short, the original admission criteria may exercise some influence on the success rate as measured by retention, but it seems to be minimal. Some admissions criteria, such as the four years of addiction, would operate against success. Others, such as freedom from severe psychiatric problems (which would probably result in a higher percentage of employed addicts than the number in the population at large), would operate in favor of success. But none seems to be very important.

Some special studies indicate that problem groups of patients do respond to methadone, although not quite so well as the normal groups. Of 269 patients on probation or parole-a group that would be especially difficult to work with-72 per cent remained in the program in good standing." Even more convincing is the fact that the Dole-Nyswander results have been replicated by reputable researchers in other places. At the National Methadone Conference, sponsored by NIMH and the National Association to Prevent Addiction to Narcotics, a succession of researchers from different parts of the country recited results comparable to, though usually not quite so good as, those achieved by the Dole Nyswander program. Results have been generally good no matter how few the restrictions placed on patient characteristics."

Interpreting these reports is complicated by the fact that, while the basic criteria remain fairly constant, there are variations in the exact methodology of evaluation-in the extent to which information from addicts is verified independently, in the frequency of urinalysis, in the relations between the police and the program (in some places, for example, the police may cooperate with methadone treatment by not prosecuting addicts in the program except for very serious crimes), in the sampling techniques used, and in the definition of retention. In addition, some programs use outside evaluation teams, and some rely on internal information systems or on special studies done by their own staff. At present, no two major programs have been thoroughly evaluated by the same team of outside experts, although the Columbia group that evaluated the MMTP will probably also evaluate the Narcotics Treatment Agency in Washington, D.C.

Nevertheless, the basic consistency of results is quite impressive. Although we may not yet know exactly how good methadone maintenance is, its essential efficacy is as well established as anything in this field can be. It is now generally acknowledged that methadone is medically safe, acceptable to many heroin addicts, effective, and administratively feasible for large-scale programs." Clearly, methadone should not be regarded as a miracle cure. The majority of program operators believe that most addicts on methadone try heroin a few times, partly out of curiosity as to whether the block works, partly because of the desire for euphoria. Judging a program in terms of whether an addict ever relapsed might well make it appear to be a failure. Methadone addiction avoids the large swings and demanding schedule of heroin addiction, thus making it easier for an addict to hold a job and support his family, but it is likely to take months for an addict to revamp his life-style into a new pattern. Underlying psychological problems remain, except for those caused by the demands of heroin addiction itself. Addicts tend to abuse some other drugs, such as amphetamines and alcohol, to about the same degree that they abused them while on heroin."

From society's point of view, the most important of all the evaluation criteria is remaining in the program. An addict who is using methadone is not continuing either extensive heroin use or heroin-seeking behavior, and his criminal behavior will probably be reduced because he does not need the money to purchase the drug. He is not spreading hepatitis contracted from infected needles by selling his blood to hospitals." He is not trying to sell heroin because he needs money for a fix. He is not hanging out in a shooting gallery or on the street serving as a role model for the neighborhood adolescents. And he is not helping to provide the mass market for heroin that makes investment in its importation and distribution economically attractive despite the risks. It should be emphasized, however, that the addict will still have the criminal skills he has learned and may choose to use them to support himself. In such case, the decrease in crime would be the difference between the amount needed to support the habit and the addict and that needed to support the addict alone. Some patients may continue to commit crimes at the same level as before, using the extra money to raise their standard of living or to build up a nest egg. Criminal activity, according to several experts, declines slowly, over a period of a year or more.

BASIS FOR THE SUCCESS OF METHADONE

The expansion of methadone maintenance has been based on empirical evidence of its utility, not upon any solid understanding of the pharmacological reasons for its success. While, obviously, this success is due to its nature as an opiate and long-acting substitute for heroin, an understanding of the nature of addiction itself is missing. It is not known whether methadone is more effective than other modalities because addiction has physiological components that only another opiate can offset or because of factors rooted in the psychology of addiction.

The issues concerning possible physiological components of addiction can be stated succinctly:

Are some persons physiologically vulnerable to heroin, in the sense that it causes physical changes in them that it does not cause in "normal" people?

Are there inherent physiological factors that make some people seek heroin-is there some pre-existing felt physical need that does not exist in most people?

Does taking heroin cause a permanent or long-term physiological change in the addict that makes him crave the drug after he becomes abstinent?

Does heroin addiction create a physiological change that makes an ex-addict particularly vulnerable to stress after he becomes abstinent?

There is no clear answer to any of these questions. Yet, most scientists would be inclined to think that the answers to at least the first two are "No." Dr. Vincent Dole, in the past, has hypothesized that narcotics addicts may have an inherent neurological vulnerability to the drug, but recently he seems to have modified his view." The second two questions are the subject of debate among experts. Dr. Dole does seem to think that opiate addiction causes a metabolic change in the addict that, in turn, causes drug hunger. Whether he thinks this change is permanent or only fairly long lasting (i.e., well beyond the period during which overt withdrawal symptoms are present) is, however, unclear." In either event, giving methadone to an addict, iti Dr. Dole's view, simply corrects the metabolic imbalance that has already been caused by his heroin addiction. In this sense, he believes the analogy between methadone for an addict and insulin for a diabetic is valid. Others are skeptical."

Dr. William Martin has hypothesized a more elaborate physiological model. In his view, an opiate such as heroin or methadone causes a metabolic change that makes the user more vulnerable to stress." An addict may become abstinent, but stress will trigger a physiological reaction that makes him crave the drug again. Furthermore, this effect may increase with continued or increased doses of opiates. Thus, when an addict is maintained on a methadone dosage higher than his prior heroin dosage, as is true in many programs, the underlying physical problem is aggravated. This, in turn, makes it even less likely that he will ever be able to become totally abstinent. Dr. Martin is uncertain whether the opiate-induced change is reversible.

Which, if any, of these theories are correct is obviously an important question. A finding that there is an inherent neurological vulnerability or that addiction causes an irreversible or long-term metabolic change that induces drug hunger, either inherently or as a response to stress, would have important consequences for law enforcement, treatment, education, and research.

To reiterate, the metabolic theories are far from proved at present. They may turn out to be wrong, or it may develop that there is a physiological change that is reversible over a period of months or years. Such a finding would pose very difficult public policy problems, because methadone might be prolonging and aggravating a physical condition that could be reversed if an addict could endure abstinence from opiates for some period that, in practice, most addicts cannot endure.

There are other hypotheses about the reasons for the success of methadone maintenance that are alternatives or supplements to the metabolic theory. Some of these are as follows:

To some extent, abstinence symptoms may be a conditioned response to environmental factors. In turn, self-administration of heroin is a conditioned response to the existence of these symptoms, in that for the addict it has been a successful way of eliminating them in the past. (There are reports, for example, of men who have been in prison and "clean" for years experiencing withdrawal symptoms upon return home.) By blocking the effect of heroin, methadone extinguishes the reinforcement for its self-administration .61

Heroin has a short duration of action and involves wide emotional swings, from euphoria after administration to the threshold of withdrawal six hours later. The rapidity of this cycle forces a totally drug-oriented existence on the addict. If he does not concentrate on procurement of the drug to the exclusion of virtually everything else, he is not going to have it when he needs it. Methadone, with its twenty-four-hour action and gentler swings, allows the addict the luxury of thinking about something besides drugs.

Methadone programs, with or without supporting services, gives the addict a good deal of psychological support. The staff is concerned with his well-being and is giving him a medicine in which they have obvious confidence. Medical practice has long known that this placebo effect is important.

Heroin addiction imposes a structure and purpose on the addict's life-getting the drug. Daily visits to the methadone clinic may provide comparable structure.

The life-style and personal associations of an addict provide great pressures to relapse after a period of abstinence. An abstinence program located where the addict will not live in the future (e.g., Lexington) does nothing about this problem, because the addict does not build up an alternative life-style and alternative associations and will probably return to the old ones after release. Methadone protects him from heroin while he builds new patterns of behavior and loses touch with the addict culture. In this view, after new patterns have been developed, it might be possible to withdraw the addict from methadone because his altered environment would not put pressure on him to relapse.

There is some evidence that a substantial number of addicts -perhaps as many as one-third-"mature out" of addiction when they reach their 30's and 40's. Some of the patients who do well on methadone may come from this group."

Studies have indicated that monitoring an ex-addict is an important factor in keeping him off drugs." The crucial ingredient of methadone treatment may be not the methadone per se but the urinalysis. Addiction to methadone is necessary only to force the patient to come to the program.

At present, one can do little but note these differences; one cannot know how these vary in validity for different addicts or groups, or, in some cases, even how they could be researched.

ISSUES CONCERNING METHADONE

Dosage Level. The first question about dosage levels is how much methadone should be given to an addict. Most people have a general preference for administering the least amount consistent with success. This is based partly on moral feelings that one should give as little of an opiate as possible and partly on a desire to minimize unknown side effects or metabolic disruption. The problem is to determine this minimum level.

The general rule of thumb is that a daily dose of 100 mg. will block any effect of heroin for almost all addicts. Most programs administer a maximum of 180 mg., although a few may go as high as 300 mg. in selected cases. A program that administers 80 mg. or more is probably aiming at a blockage dose. A lower dose will not block the effect of heroin-an addict can achieve euphoria if he tries. However, the lower dose will block the narcotic hunger and thus remove some of the pressure for heroin use. For most addicts, a dosage of 40 or 50 mg. is enough to eliminate this craving, but an even lower dose may be enough if the addict has a light habit.

In the early methadone programs, it was apparently assumed that any addict who found that he could break the block would do so, and that the higher, blocking doses were necessary. In the last few years, some experiments have been made comparing the efficacy of high and low doses. Dr. Avram. Goldstein, at the Santa Clara County Program, maintained three groups of randomly chosen addicts on blind doses of 30, 50, and 100 mg., respectively. (Blind dosage is not discussed with the patient, who is not aware of how much he is receiving.) The addicts receiving the lower doses did tend to use heroin more often during the first month, but by the third month in treatment there was no significant difference among the groups in either heroin use or retention in the program." Dr. Jerome Jaffe, of the Illinois Drug Abuse Program, has done similar research with roughly equivalent results. For the first month or so, the highdose group has a higher retention rate; thereafter, the two groups do about the same in terms of retention, employment, and arrest rates. Dr. William Weiland came to the same con clusions after similar experiments in Philadelphia with groups of 52 patients on 50 mg. of methadone and 52 on 100 mg. for a period of 60 days." There are few dose-related side effects.

These results suggest that suppression of the narcotics hunger may be more important than the blockage effect, at least for motivated addicts. The results are only suggestive, however, because the time spans involved in these experiments are limited, and it is not known what the results of a more extended experiment might be. The results might also be different if the populations involved were younger or less motivated. Drs. Dole and Goldstein, among others, regard these experiments as very interesting. The low dose does mean that some addicts will drop out in the initial stages who might have been retained with a higher dose. In addition, it exposes the patient to the medical risk of relapse. Given these known costs and risks, and given the lack of any solid reason to believe that a 100-mg. dose is in some way more harmful than 50 mg., some doctors are reluctant to use a low dose. The major reason for doing so is that it minimizes leakage into the community from patients who take their methadone home, minimizes side effects, and safeguards somewhat against unknown side effects or long-term effects.

Some programs use doses even smaller than those described above, but none has been scientifically evaluated. Colonel Hassan Jeru Ahmed, of the Blackman's Development Center in Washington, D.C., claims to give a number of addicts as little as 5 mg. per day with good success. Without controlled experiments, it is hard to know whether his opinion is accurate. Theoretically, such a dose might suppress the hunger in an addict with a very low habit, or there might be some placebo effect involved. Since Colonel Hassan's aim is abstinence rather than maintenance, this might also be a method of slow detoxification.

A second issue about dosage involves expense. Most programs have assumed that the specific dose should be tailored to the individual addict and therefore give doses of anywhere from 25 mg. to 180 mg., depending on the individual. From the standpoint of administrative efficiency, this is costly. To work with a few standardized doses would allow programs to treat more addicts with the same expenditure. Dr. Goldstein has done an experiment to determine whether the individualized dose is really more effective and has concluded that it is not." To test this, he used a blind dosage procedure. (This procedure not only is necessary for research on dosage but also has substantive benefits as well. The most important of these may be that the "dosage game" is part of the addict's life style of "conning," and eliminating it contributes to over-all rehabilitation.) An initial dose of 30 mg., increased by 10 mg. a day until final stabilization at 100 mg., was equally effective for all patients.

Ancillary Services. Most program operators declare that ancillary services are a vital part of methadone treatment. Group and individual therapy, job training, job placement, family counseling, medical and dental care, and education are all regarded as crucial to the process of helping addicts make the adjustment to a new life-style once they have broken the heroin habit. MMTP, for example, provides extensive services, which is one reason the total cost is estimated at about $2,000 per year per patient. (The cost for each patient who has finished the induction stage is about $1,000 per year.) In its evaluation reports on MMTP, the Gearing Committee always emphasizes the importance of services." Dr. Jaffe, whose Illinois Drug Abuse Program also offers services, agrees. In particular, he believes that the techniques and group procedures developed in therapeutic communities are helpful in stabilizing addicts on methadone because they create an environment in which patients not only can be relieved of narcotics hunger but also can begin to develop attitudes that may be useful to them in achieving social rehabilitation.

There are some programs that operate with a minimum of extras, however, and their success rate does not seem markedly lower than the others'. In New Orleans, most addicts are treated in private clinics and pay about $10 per week." The program has limited ability to finance additional facilities. The Santa Clara County Program, which also operates at a cost of about $10 per addict per week, is equally limited in its services." About 10 per cent of the patients receive psychiatric help outside the program, and there is some vocational counseling. There is also some group work by the patients themselves without professional involvement. Since the initial retention rate of the Santa Clara County Program is relatively close to that of the MMTP, additional ancillary services might contribute little as compared with their costs. (An important aim of the program has been to study this question.) The Santa Clara Program did include a vocational counselor, which many observers feel is the most important single service that can be offered. It also emphasizes peer-group therapy as a key to rehabilitation." Drs. Jaffe and Dole have experimented with giving methadone without services to people on waiting lists. Preliminary results from MMTP are good."

Although one could easily find widespread agreement that ancillary services would be clearly desirable if they were free, one seldom finds any explicit analysis of the cost/benefit aspects of the issue. The key fact is that, as long as the supply of addicts holds out, a minimal program can treat many more patients than an elaborate one at any given level of expenditure. A program costing $500 per year per addict, with a retention rate of only 50 per cent, can treat more people than a program costing $2,000, with an 85-per-cent success rate. With $1 million, for example, the cheaper program could treat 2,000 addicts for a year and would retain half of them. The more expensive one could treat only 500 addicts, even though it would retain 425 of them. The economic advantages of the cheaper program are even greater when the comparative outputs are analyzed over time. Still, assuming a limited budget and an unlimited supply of addicts (and, at present, almost all methadone programs have waiting lists) , each type of program will be losing its failures and retaining its successes. After some period, each would have a success rate of 100 per cent, because only the successes would remain; but the $500 program would be maintaining four times as many addicts for the same amount of money.

This analysis holds even for gross differences in success rates. Since, as New Orleans and Santa Clara show, the actual differences may be limited, or even nonexistent, the case for the cheaper program is even stronger. Any city with a large addiction problem and limited funds should probably choose a methadone program with minimal services rather than full ones. The principal argument against this conclusion is that services might make a crucial difference for the hard-core addicts, and that this is the population that causes most of the crime. But, while it is true that addicts with long criminal records are less successful on methadone than are others, it has not yet been proved that the services make a crucial difference for this group. In addition, the proposition that society should condemn four treatable people to addiction in order to treat one other addict who is causing more trouble is a hard moral position to defend. It might be better to put the hard-core addict on heroin maintenance and treat the others with methadone.

Another argument sometimes used in support of extensive services is that society should spend the money necessary to give full treatment to all addicts, thus obviating the whole question and avoiding the need for moral choices. In the practical world, however, everyone knows that the cities are in financial trouble and have tremendous demands on their limited resources. It is neither possible nor desirable to give narcotics addicts a prior claim to limited public resources that might otherwise be spent on education, health, welfare, or countless other pressing areas. The best model may be one in which the patients are encouraged to develop their own services, with the expensive ancillary services targeted on the hard-core.

Outpatient Induction. The MMTP originally inducted patients into the methadone program by putting them in the hospital for a week or two during the transition from heroin to methadone. Because this is expensive, and because the limited number of available hospital beds imposes a constraint on the number admitted to the program, there has been much interest in ambulatory induction. Starting in 1968, MMTP has adopted such a program for some of its patients. As of 1971, about 1,952 of its 4,376 patients had been admitted in this fashion. Preliminary data indicate that rates of attrition are almost identical whether patients are inducted as inpatients or outpatients. After 24 months, about 72 per cent of each group remains." This figure is not entirely valid because of the special characteristics of the ambulatory group. Having a job or family was a requirement for admission to the ambulatory component, and 79 per cent of admittees were employed or in school. Whether a patient is employed, as we have seen, is a statistically significant predictor of whether he will remain in treatment.

Other programs have also used ambulatory admission with consistently good results, and the effectiveness of this method is no longer in doubt."

Withdrawal. Eventual withdrawal from methadone rather than perpetual maintenance is regarded as a goal by drug experts -in part because of a moral feeling that people should not and do not need to be drug-dependent; in part because of a desire to free the addict from his ties to the clinic; in part because of the wish to minimize any unknown long-term effects of opiates on the human body.

At present, it is uncertain whether withdrawal is possible. In a study of 350 patients who withdrew from the MMTP, Dr. Dole found that "narcotics hunger" returned in almost all individuals immediately after they ceased taking the methadone, whether their withdrawal was voluntary or involuntary. Since this is a somewhat special populations high proportion were treatment failures-the results are not conclusive, although they are suggestive that withdrawal may be difficult. Dr. Dole has also found in blind experiments that a patient stabilized on methadone and free from drug hunger may have a return of drug dreams if his medication is withdrawn. He believes that, for most addicts, maintenance has to be a permanent way of life. It is important to note, however, that the return of "narcotics hunger" does not automatically mean a return to heroin use; some individuals are able to live with the hunger without returning to drugs. But hunger does make successful abstinence substantially more difficult."'

Dr. Jaffe believes that withdrawal from methadone can be successfully accomplished, although his work in this area has not yet been extensive. In a study of 53 patients in active treatment, he found that 29 per cent had voluntarily withdrawn from methadone but remained affiliated with the methadone units, either participating in group therapy or transferring to therapeutic communities or aftercare systems. Not all those observed on withdrawal remained abstinent, although some patients observed after six months had been able to do so. Dr. Jaffe seems to feel that continued therapy techniques are helpful in maintaining abstinence."

Dr. Avram Goldstein has done experiments showing that the methadone dosage can be reduced without discomfort to the patient if it is done slowly at a weekly reduction rate of no more than 10 per cent. Withdrawal from a moderate methadone stabilization program would then require about six months." But follow-up results are not yet in.

Although the results to date are ambiguous, it seems certain that substantial experimentation with withdrawal from methadone will be undertaken. Some black activists, in particular, are strongly opposed to the concept of permanent maintenance and will accept methadone programs in their communities only if they are seen as intermediate-term therapies with the ultimate goal of abstinence. Dr. Beny Primm, of Addiction Research Treatment Corporation in New York City, for example, told us that his explicit goal is to get everyone off methadone and into a drug-free state. Dr. Goldstein has also suggested that methadone treatment should be thought of as "methadone temporary support rather than methadone maintenance, with its implication of life-long medication." An addict could join the program, become stabilized on methadone, eventually taper off slowly and become drug-free, but be able to return to methadone if the urge to take heroin became overwhelming." Ultimate determination of the possibilities of withdrawal must await determination of the metabolic-change issue. Meanwhile, the only way to find out if withdrawal is possible is to try it. Since we do not know why methadone works, there is no way of telling a priori. Some programs have reported an unexpected phenomenon that might be called "the 20-mg. barrier." The patient undergoing withdrawal does well until the dose is reduced to about 20 mg. At this level, there is a sudden increase in physical complaints and heroin usage." What this means for permanent withdrawal is a question that needs study.

Benefits to the Addict. Methadone maintenance is sometimes criticized on the ground that it is society's way of dealing with the addict crime problem without regard to the addict himself. This view is especially strong among so-called militant black groups. On the whole, however, the idea that methadone sacrifices the addict for the sake of society does not seem valid. Although many communities adopt methadone programs in an attempt to solve their crime problem, the program results showing increased productivity and family stability of the patients suggest that they themselves benefit from the changed life-style and reduced crime as much as or more than the community at large. Since most programs operate primarily on a voluntary basis, the patients themselves must prefer methadone to the addicted life. Even when an addict is coerced into treatment by law enforcement, simply staying in treatment is a vote against the former life-style.

Finally, even if one were to concede the truth of the criticism, the logical rejoinder would be "So what?" There is no good reason for society to tolerate crime simply because the criminal is a heroin addict when it can eliminate the crime by forcing him to switch to being a methadone addict. It is not as if one could choose between methadone and an equally effective but more expensive alternative: The other alternatives do not appear to work so well. Even if they did, it would be difficult to argue that addicts deserve priority in allocating scarce public resources that could be devoted to the general welfare of the groups in society that furnish most of the addicts. In general, to the extent that the criticism represents the truth of the situation, its use as a criticism seems based on wishful thinking rather than sound analysis. Its proponents wish there were another, equally effective treatment method or wish that public resources were unlimited.

If the metabolic theories of addiction should prove accurate, the issue will become more acute. Dr. William Martin, for example, poses the issue as the "medical dilemma of methadone maintenance, namely, the creation or continuance of a serious medical disorder, physical dependence, in order to decrease antisocial behavior."" If this dilemma is a real one, all the choices would be unpleasant. The nation could legalize heroin or move to a massive system of heroin maintenance, but this would pose exactly the same moral problems as administering methadone. It could continue to keep heroin illegal and prosecute addicts for crimes committed to obtain it while refusing them methadone, but this seems both morally wrong and politically impossible. It could declare that addicts are not responsible for crimes committed to obtain heroin because of the physical duress involved. This would necessitate either heroin or methadone maintenance, however, since no one can be given such a license to steal without some counteraction by society. Despite the problems stated by Dr. Martin, methadone seems the best choice.

Methadone and the Law-Enforcement System. Some program operators are strongly opposed to the development of close relations between methadone maintenance and the law-enforcement system. In their view, a coercive system that forces an addict to accept methadone as a condition for probation or parole is an intolerable violation of civil liberties. Others, with equally strong opinions, disagree. They believe that the realistic choice lies between having the addict on methadone and having him in jail, and that the authorities will not often impose a methadone requirement on a man who would otherwise have been released. In this view, accepting treatment set by courts or parole boards gives addicts an option that would not have been available otherwise. All agree that participants in the methadone program should avoid becoming informers for the law-enforcement system. Because of the need to maintain the confidential doctor-patient relationship, patients should not be reported by the treatment agency for violations of probation or parole.

Methadone and Causes of Addiction. Addiction is often seen as a sociopsychological disorder, stemming from basic personality defects. In this view, it is useless and wrong to treat addiction by administering methadone without, at the same time, treating the underlying disorder. A better way to approach the problem is to deal with the basic pathology; when this is done, freedom from drug use will follow naturally. As stated by a Manhattan probation officer:

My objection to the methadone program . . . is predicated on the observation that while the drug methadone removes the physical craving for the other opiates it nevertheless fails to combat in any way or deal with the various emotional or other difficulties that permitted the individual to initially become and remain involved with drugs. Since the drug problem has, so to speak, been eliminated, that basic problem has not been dealt with; that of the inadequate, ineffective person unable to cope with the reality of his situation. In essence, an aspect, the symptom, has been treated not the entire individual, with the result that they then frequently resort to other avenues of escape including amphetamines, barbiturates, wines, and liquor, or they begin to manifest serious forms of instability.88

Most proponents of methadone would readily agree that methadone per se does not cure any personality disorders that might cause addiction. (Not all would; it is entirely possible that the opiates constitute an effective treatment for certain as yet undefined psychic states.") Those who do agree would respond to the basic criticism as follows:

No consistent pathology has been found. No psychiatric diagnosis can be shown to apply to all heroin addicts or even to a majority of them. Thus, while addicts tend to be depressive, they are not so depressive as neurotic nonaddicts. While some addicts are schizophrenic, 80 per cent to 90 per cent are not. Some are psychopathic, but the great majority are not. In short, no satisfactory explanation of the psychological roots of addiction has been found, much less developed to the point where it is operationally useful for treatment purposes's

The view that an underlying pathology is responsible is an assumption rather than a proved fact. One can construct equally plausible theories that experimentation is caused by exposure and normal psychological processes, and addiction is caused by physiological factors. Dr. Dole, for example, believes that the observed common characteristics of addicts are simply those forced on them by the nature of the life-style required to maintain a heroin habit. Other experts also believe that, even for addicts with marked problems, it is the addiction that causes the problems rather than vice versa.

Even granting the argument that pathology is at the root of addiction, it is easier to work on underlying causes with an addict who is on methadone and free of drug hunger and the heroin life-style.

Again granting the argument that pathology is at the root of addiction, the success rates in attempting to cure such pathologies-especially among the socioeconomic groups that furnish most of the addicts-are not very high. Thus, one has no realistic choice except to accept the second best solution of methadone maintenance, which has very great benefits for society and for the addict, even though it is not a complete cure.

Perhaps the best summary has been given by Dr. John Kramer, discussing the psychopathology of addiction generally, not just methadone:

It is generally conceded that traditional psychiatric techniques have not been useful in the management of opiate dependence. In a psychoanalytic frame of reference symptoms are considered to be the behavioral or somatic representations of an underlying intrapsychic conflict. Once the conflict is resolved or reduced to manageable proportions, the symptoms will diminish or disappear.

This conceptual model fails to account for two different issues, either or both of which may play a role in people who abuse drugs. First, though intrapsychic determinants may play a part in whether a person uses drugs, other circumstances such as drug availability, subgroup attitudes, peer pressures, and plain chance are very often more important. In other words, in some individuals, there may be no serious underlying conflicts, though there may be considerable conflict with the community. Second, whatever the original determinants of drug use may be, the symptom, dependency on drugs, can become so central an issue 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 analogy may be drawn with a depressed person who in an attempt at suicide breaks his neck and becomes paraplegic. Psychotherapy may relieve his depression but will 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 intrapsychic events which cause, or contribute to it, are of equal magnitude. Hence the view, that since drug use potentially subjects the person to such serious consequences, the psychological problem he has must be equally big. Experience with drug users does not validate this view. Some do indeed have clearly definable psychiatric problems, but many do not. Where it is sought, some subtle psychiatric defect can always be found, as has been the case with addicts. Further investigation may clarify this question. In the meantime a functional approach, handling the symptoms, educating and giving practical assistance as well as offering psychotherapy in selected instances seem desirable.91

Multiple Drug Use. If a heroin addict is involved in the use of other drugs, methadone will do nothing about that use. There is evidence, however, that methadone patients do not increase their use of other drugs-a charge that has been made-although they do tend to maintain it at about the same level. The Santa Clara County Program found that, both before and after going on methadone, about 20 per cent of the patients overused alcohol, 5 to 10 per cent used amphetamines, 45 per cent used marijuana, and 30 per cent used nothing. The only significant difference was that 20 per cent abused barbiturates before going on methadone, and only 6 per cent did so afterwards." Since barbiturates create a dangerous addiction if used too much, this is an important shift.

We know of no other before-and-after study of drug use by patients on methadone. A recent study of multiple drug use by heroin users, however," supports Dr. Goldstein's conclusion that the use of other drugs does not increase. A sample of 422 heroin users were asked whether they had used certain drugs more than six times. The per cent who had done so were: marijuana-86 per cent; cocaine-47 per cent; barbiturates-34 per cent; and amphetamines-33 per cent. (They were also questioned about other drugs, not recounted here.) In general, it had not been thought that multiple use among heroin addicts was as high as this, and there may have been some tendency to assume that multiple use among methadone patients was a new pattern for them rather than the continuation of an old one.

Leakage of Methadone. As more large methadone projects come into existence, it is reasonable to anticipate that some of them will be lax in their control of methadone, permitting leakage into the community at large. Several possible consequences of such a development cause concern. First, there is a fear that the drug will become available in an injectable form that is an acceptable, if not a totally satisfactory, euphoric substitute for heroin. Secondly, the availability of even oral methadone will create a new group of addicts. Thirdly, nonaddicts, particularly children, may take methadone and die.

These fears have a sound factual basis. Indeed, methadone can already be bought on the street in any major city, although it is unclear whether the source is diversion from the programs or independent manufacture. The major concern is injectable methadone. Many addicts regard it as a very good drug, and it could result in a substantial addition to the present addiction problem. This is probably a controllable problem, however. Methadone can be mixed with Tang or some other substance before dispensation (as is true in almost all programs at present), so that it is suitable for oral administration only. More important, the drug companies have developed a methadone disk that requires a large volume of water for it to dissolve. This makes it difficult, although not impossible, to inject."

The second concern, the leakage of oral methadone, is more crucial. The rapid expansion of methadone programs is highly probable. With this will inevitably come carelessness about staff and about control of methadone. If there is a market for the drug, there will also be some corruption. It will be surprising if there are not some major scandals involving the diversion of methadone from treatment programs.

In some ways, leakage may not be very important. While there are some methadone addicts who are not involved in treatment programs, oral methadone is not so euphoric as heroin, and few current heroin addicts would prefer it to heroin as a euphorogenic.

There is no reason to believe that methadone addiction is physically more harmful than heroin addiction, and, if the methadone is pure, there is good reason to think it less harmful. There is substantial evidence to the effect that methadone addiction is psychologically less harmful than heroin addiction. In general, while a few addicts might make oral methadone their drug of choice, it is probable that the major market for illegal methadone will consist of addicts who are on do-it-yourself methadone maintenance, who tide themselves over with methadone when they cannot get heroin, or who want the euphoric effects of heroin only occasionally. In these cases, both society and the addict are better off if they can get methadone to substitute for heroin.

There is some possibility that methadone will make addicts of persons who would not otherwise have become addicted. Heroin has two major defects that may exert some deterrent effect on potential experimenters: It often contains dangerous impurities; and it is not effective when taken orally. On the whole, however, it seems unlikely that these factors are very influential. For those who might not like to inject a drug, heroin can also be snorted. (This is, in fact, the usual method by which neophytes take the drug.) The impurities point might be valid, but it is difficult to believe that anyone willing to get into the general life-style of addiction is going to be deterred by the marginal additional disadvantage of impure drugs. It does seem likely, however, that, as methadone becomes increasingly available, it will be used as the drug of initiation by persons who would otherwise have tried heroin.

More difficult to accept are the overdose deaths that are already starting to occur-most poignantly, among children who find and drink methadone-laden Tang. Recurrences could be prevented by insisting that methadone patients keep methadone in a locked box outside the refrigerator. The drug will keep a week without refrigeration, so that this is perfectly feasible." Noninjectible methadone could also be given in a tablet form that is too large and bitter for children.

Other deaths occur among people who use methadone to achieve euphoria. Because methadone is slower-acting and longer lasting than intravenous heroin, even a veteran heroin addict may take methadone, decide that the drug is not having an adequate effect, take more, and overdose when the peak comes two or three hours later. Self-education within the drug subculture might keep such incidents to a minimum. But some deaths will occur, and it is reasonable to expect that the more methadone available, the more deaths it will cause.

The only effective answer to this argument is to point to the large number of heroin deaths caused by overdose, disease, and infection and to the other deaths caused by addict-committed crime and by such practices as the sale of infected blood by addicts. Almost certainly there will be an over-all decrease in opiate-related deaths as methadone replaces heroin in the community.

Side Effects." A number of possibly undesirable side effects of methadone have been hypothesized, ranging from impotence to damage to the bones and teeth. So far, clinical studies have found no evidence of birth defects and no indication of physical damage. Drowsiness is a frequent complaint of program initiates, but this is a natural consequence of an increase in the opiate dose and disappears as the addict develops tolerance for the new level. Some addicts continue to complain of the loss of libido, but the best evidence is that, for most, sexual performance is better when they are on methadone than when they are on heroin. In short, although it cannot be stated categorically that there are no serious side effects, clinical investigation so far has failed to find any. To date, however, research has concentrated on possible physical effects; there do not seem to be detailed studies of the effects of methadone on intellectual or motor functioning, and we do not know how methadone affects a wide range of important functions, from problem-solving ability to the ability to operate a car or often complex machinery. Since methadone is a powerful tranquilizer, it may well have effects in these areas. It is also possible that tolerance to tranquilization develops, as may be indicated by the disappearance of excessive drowsiness.

THE FUTURE OF METHADONE

It is virtually certain that methadone maintenance will increase rapidly in the next few years. While many observers have reservations, the cost/benefit and cost/effectiveness advantages of methadone have become obvious. Since the relationship between addiction and crime has been widely publicized, political pressures to do something about crime are great enough so that the government will probably support methadone, and vigorously.

While the federal subbureaucracies involved-the National Institute of Mental Health, the Bureau of Narcotics and Dangerous Drugs, and the Food and Drug Administration-have never been fond of methadone maintenance, its social and political advantages should now be obvious enough to induce large scale federal funding in the near future. Most informed observers regard the Administration's proposal to create a Special Action Office on Drug Abuse Prevention and to increase funding dramatically as confirmation of this. At this writing, the Food and Drug Administration is on the verge of liberalizing the rules under which methadone is approved for use.

As the programs expand, several issues in addition to those already discussed will become important:

Administrative Problems. There are clear differences between operating small, experimental programs and operating mass programs. Such issues as the extent to which ancillary services should be supplied, the extent of monitoring through urinalysis, high doses versus low doses, standardized doses versus individual ones, and control of leakage will arise over and over. In addition, there will be the problems of recruiting and training staff common to any expanding area. At present, there are not enough people experienced in methadone programs to double or triple current programs. One can expect a period of raiding of existing programs (with a consequent decline in their effectiveness) and increasing use of less qualified and less dedicated people. The difficulties of hiring good staff will compound the leakage problem. It will also create pressures to use the cheapest methods available. Most of the higher costs of the more expensive programs are caused by the increased staff required for added services; if the trained staff to provide these services is simply not available, they either will not be provided or will be done poorly. Analysis of the impact of these services is therefore urgent.

Community Problems. As noted, some black militants are opposed to methadone maintenance because they regard it as a device to keep the black community "drugged and enslaved." Many of the rumors of side effects are also believed. These fears can be countered as long as there appears to be a possibility that methadone maintenance leads to abstinence; but, if experiments indicate that this is not a reasonable hope, the situation may become more difficult. This is not the type of problem that is amenable to rational solution, or even advice. Methadone-program operators, however, can do at least three things to meet the challenge:

1. Maintain close contact with various elements of the community, to explain what they are doing and why it is good for the addict and the community.

2. Provide facilities to ensure that any methadone patient who wants to try to become totally drug-free will receive the best possible support for his effort.

3. Involve the community in the staffing and administration of the project.

Since these are all good policies irrespective of any militant reaction against methadone, programs should follow them whether or not they foresee any problem. Some program operators believe that the fear of adverse community reaction is exaggerated and is likely to decrease over time. The area in which the addict lives, after all, bears the crime costs and the risk of a spread in addiction. As a methadone program becomes operational, the surrounding community comes to appreciate it, and strong opposition dissolves. Dr. Robert DuPont, of Washington's Narcotic Treatment Agency, has told us that methadone patients become the best missionaries in the community.

Long-acting Methadone. The effect of the methadone used at present lasts only about 24 hours. Drug companies have been experimenting with a drug (acetylmethadol) that will last up to three days, and it is expected that this will become generally available soon." This will have several significant effects on methadone maintenance. It will cut costs by reducing the expense of preparing and administering the drug. It will also make it more difficult for the patient to skip his dose and try heroin. Another effect may be to allow the patient greater mobility and weaken the ties between the patient and the program. In the view of some, this will be a good thing because it will enable the patients to lead a more nearly normal life. Others speculate that it will be counterproductive, in that the routine daily visit provides an important element of structure in the patient's life and has positive therapeutic benefits. There is no way of resolving this dispute a priori.

Changing Patterns of Addiction. There is consensus that the primary reason addicts volunteer for methadone programs, or stay in them once assigned by the law-enforcement system, is that they are tired of the life-style of an addict, with the constant need to make a connection, the strains of criminality, the jail time, and the risk of infection and death. Participation in a methadone program and abstinence from heroin become a more attractive choice. Whether he procures methadone on the street or through a clinic, as long as it is cheap he can maintain his opiate habit at low cost and then occasionally obtain the desired euphoria by skipping the methadone and using large amounts of heroin. Since the data from existing programs indicate that many addicts do use heroin occasionally-anywhere from 10 to 50 per cent, depending on the program and length of time in treatment-this may already be a common pattern.

This problem presents a difficult choice to program operators. To eliminate this last increment of drug use might require expulsion of addicts for occasional heroin use. This would certainly return some patients to the addicted life, with all the social and personal costs involved. If an addict is adjusting well in other ways, this cost is not justifiable. Eliminating the last vestige of heroin use in such a case is essentially a meaningless concession to moralism.

There is a more serious question involved, however. There is no way of knowing the extent to which the negative aspects of the addicted life have a general deterrent effect that keeps people from experimenting with heroin. Clearly, almost anyone exposed to heroin is also exposed to the addict community generally and knows the risks involved in becoming addicted. It -is possible that the existence of large methadone programs would indicate to some portion of the nonaddict population that they could attain the euphoria of heroin without having to adopt the life-style as a whole, and they might find this option more attractive than either abstinence or full-scale heroin addiction. Present evidence indicates that there may be a curious gap of belief in people who become addicted to heroin. They know full well that the drug is addicting and that the life-style is terrible, but they do not doubt their own ability to handle the drug without becoming addicted. For all we know, the unattractiveness of the life-style may be exercising a potent deterrent effect on others who are curious but more realistic about the danger of becoming addicted. Opening up the methadone choice might make these people more willing to run the risk. Since we know little about the causes of addiction and even less about deterrent effects, we do not know whether this is a matter for real concern. If it turns out to be an important phenomenon, it will create some painful public-policy choices.

Total Size of Methadone Programs. A final question concerns the portion of the addict population that is amenable to successful methadone treatment. Any figure is only an educated guess based upon the observer's estimate of the total number of addicts, observations about the results of existing methadone programs, and judgments about the criteria of success.

Official U.S. Government calculations seem to agree that 25 to 33 per cent of the addicted population will be helped by methadone." This estimate may well be too low; some program operators have estimated that their methadone programs drew almost 50 per cent of the addicts in an area within a year or so after beginning operations."' Considering that many addicts believe street rumors adverse to methadone, and that one would not expect any program to reach its full potential right away, an estimate of 50 per cent probably represents a more realistic, but still conservative, figure, if one assumes that "success" means "derives substantial benefit from methadone maintenance."

ANTAGONISTS

Antagonists are drugs that prevent opiates from having any effect if the antagonists are administered before opiate injection and that precipitate withdrawal if administered after injection. The possibility of using these drugs as a major treatment modality has intrigued researchers for the last six years, but at present the antagonists remain experimental."'

There are two basic antagonists currently in use for the treatment of heroin addicts, cyclazocine and naloxone, but an excellent survey by New York's Health Services Administration noted that there might be several hundred others already in existence, as yet untested."' The most important characteristics of these drugs are as follows:

Cyclazocine produces unpleasant side effects, such as nausea sweating, a drunken feeling, anxiety, and hallucinations, but tolerance to these effects does develop. Naloxone does not appear to have significant side effects. Cyclazocine is effective when taken orally and has a duration of action of 12 to 24 hours. Naloxone is effective when taken intravenously but is relatively ineffective when taken orally. There does not appear to be any information on subcutaneous administration, though presumably it would be less effective than intravenous but more effective than oral administration. Small doses of an antagonist are effective. Thus, 4 mg. of cyclazocine will block the effects of 15 to 25 mg. of heroin for one day. Naloxone is even more powerful if used intravenously: 1 mg. will block the effects of 25 mg. of heroin for ten hours. (Taken orally, it requires 200 mg. to block the effects of 25 mg. of heroin for six hours.) Cyclazocine has addictive qualities, in that an abstinent user will show some withdrawal symptoms. Users do not crave the drug even when they are in withdrawal, however. Naloxone does not have addictive properties. The antagonists do not reduce the "drug hunger" felt by the opiate addict.

Most experimentation to date has been done with cyclazocine, largely because the short duration and ineffectiveness of oral naloxone makes it an unsuitable candidate for mass treatment.

The NIMH Addiction Research Center is now experimenting with a new antagonist, EN-1639A. It is two to three times more potent than the other two, is effective orally, and has a longer duration of action than naloxone .103

Besides the mechanical problems of dosage and delivery, there are several major problems in using the antagonists as a treatment modality. Because they do not eliminate the "drug hunger," the patient is constantly tempted to miss his dose and take heroin. As the HSA paper points out, the fact that addiction to the antagonist itself is minimal means that it is possible for him to do this. A methadone patient is tied to the program by his addiction; an antagonist patient is not. Because of this problem, and also because of the short duration of action of many possible antagonists, a major search is under way for a capsule that could be implanted in the patient to release the drug slowly over an extended period. It is likely to be some time before success is achieved, however."' The civil-liberties questions involved are also substantial.

Two apparent disadvantages may be due to the experimental nature of the programs. So far, the costs have been high ($3,000 to $5,000 per addict per year), partly because of the need for inpatient care common to all experimental programs and partly because of the scarcity and high price of some of the drugs. The success rate so far is hard to calculate, but, at best, it has been about 40 per cent over all, judged by the criterion of remaining in the program."' However, some of the failures may reflect the fact that dosages had to be worked out and supportive services developed. Future experiments may do better. One can, of course, argue the opposite-that future, larger projects will be less successful because the Hawthorne effect of participating in a new experimental program will be gone. In addition, there is some evidence that the success rate for outpatients may be considerably lower than for inpatients.

It is as yet unproved that the antagonists will ever be a useful treatment modality. Nor is there any reason at present to believe that the side effects of any antagonists would be less adverse than those of methadone. It could easily turn out to be the reverse, with the antagonists having more serious adverse effects. If an addict is going to be dependent upon long-term chemotherapy, there appears to be no reason at present for preferring that he be dependent on an antagonist rather than on methadone.

Under some theories of addiction, the antagonists could be useful adjuncts to treatment. If one takes the view that it is important to extinguish reinforcement of the desire to use opiates, the antagonists may turn out to be successful. One can also argue that the use of an antagonist, combined with supportive services, would force the addict from the addicted life-style and give him an opportunity to forge a new one. Finally, and probably most important, is the possibility that use of an antagonist might turn out to be the only practical way an addict on methadone can become abstinent. If research should ultimately show that opiate use does create a drug hunger that persists for a long period after obvious withdrawal is complete, then antagonists might be developed that would help the addict survive this period without readdiction. Dr. William Martin has found that secondary withdrawal symptoms persist in animals for at least six months after withdrawal from opiates. If the drug hunger is such a symptom, and if it persists in humans in similar fashion, there is at present no way for an addict to leave a methadone program without enduring six months of craving opiates. As is obvious from the failure rates for abstinence programs, few manage to do this. If an antagonist could prevent relapses from leading to readdiction during this period, it would be valuable."'

Dr. Martin is cautious about the antagonists. He states only that, if the research goals are achieved, "I believe that certain motivated addicts can be benefitted by this approach. . . . [They] may find a role in the treatment of the juvenile experiment. Others are more enthusiastic, and suggestions of mass inoculations are occasionally heard. The wisdom of such ideas is questionable.

MULTIMODAL PROGRAMS

Several programs now contain components of all the different modalities. The Illinois Drug Abuse Project (IDAP), in Chicago, the Narcotics Treatment Administration, in Washington, D.C., and the New Haven Mental Health Center, for example, include methadone, therapeutic communities, detoxification, abstinence, and supportive services for all types of patients. The Community Mental Health Center'in New Haven has an experimental naloxone group as well, and IDAP at one time tried cyclazocine on some patients. While the approach is promising, rigorous comparison of multimodal and unimodal programs has not yet been done, and one can only set forth the present arguments for and against the multimodal approach.

The arguments in favor run along the following lines:

Most observers believe that different programs work best for different addicts, although the typologies are not worked out and no tool has predictive value at present. If a program has several modalities, an addict can readily transfer from one to another if he or the staff feels that his performance could be improved by the change. In addition, failure in one modality does not mean total failure, because the addict can try another with minimal delay.

Different modalities attract different types of addicts. Therapeutic communities, for example, may have more appeal to younger addicts; methadone, to older. Differences in age, education, employment, or criminality may also be significant. But the modality that attracts an addict may not be the one in which he will ultimately do best. Combining the modalities makes one an intake center for each of the others, to the benefit of all.

In some cases, the modality to which an addict applies is an accident of geography and personal contacts. Centralized administration can make this choice more rational and productive.

Each modality has something to contribute to the others. The group-therapy techniques and intense environment of the therapeutic community may help methadone patients by encouraging them to become abstinent or by improving their understanding of the factors that led them to addiction. They may also have an impact on abuse of other drugs by methadone patients. Conversely, TC residents and other abstinent patients may benefit from knowing that there is a back-up program if they do not succeed in remaining abstinent.

A multimodal program will find it easier to develop new strategies for the treatment of addiction. For example, it may be possible to have patients who are basically abstinent but receive low doses of methadone if they feel the craving for drugs is about to overwhelm them. This could be a particularly important technique for teenagers. It would be difficult to operate such a program in connection with any single modality, because both the administrative structure and the ambience would be against the experiment.

Politically, it is advantageous to combine the modalities, so that they will stop fighting each other and unite to get more support from the government.

The primary arguments against multimodal programs are as follows:

Most of the benefits to be gained from eliminating accidental assignment, allowing rapid reassignment, and experimenting with new programs may be achieved just as well by better administration and coordination of separate modalities.

Multimodal programs have the basic problem that they transmit contradictory messages to the patients. The ethos of most such programs is that abstinence is superior and that methadone patients, while not so bad as heroin addicts, are definitely second-class. This lack of psychological support makes it more likely that the methadone patient will fail. It may also make it difficult for a patient who is not doing well on an abstinence program to change to methadone-he may leave treatment entirely rather than accept what be and his peers view as a demotion. If such an attitude does not pervade the project, the reverse problem may occur: The abstinent patient may not see why he should endure drug hunger while others are receiving methadone.

In this view, faith is a very important part of every modality. The evangelical nature of the TC has been discussed, for example, and it may be a necessary part of the therapy. Part of the success with methadone may be due to the fact that patients come to believe that they have a metabolic disease and are going to receive a medicine that will help them. In short, mixing different modalities may undermine all of them by confusing the patient about the expectations and possibilities of the program.

Resolution of this issue must await further research that explicitly compares the success of the different components of multimodal programs with that of comparable techniques used alone.

Since multimodality is a growing trend, such evaluations should be performed soon.

HEROIN MAINTENANCE

One treatment modality that is not used in the United States at present is maintenance of addicts on heroin or morphine. While many, perhaps most, observers react negatively to the idea, there are good reasons for trying it on an experimental basis. The major argument in favor is that heroin maintenance might attract two important groups of addicts: those who do not succeed on methadone maintenance and those who do not volunteer for it in the first place. If this were the result, addiction-related crime would be decreased, because the costs of the heroin habit would be eliminated and, as a benefit to the addict, the chances of infection, overdose, and imprisonment would be lessened. In addition, since remarkably little is known about the etiology of addiction or the effects of heroin, controlled clinical experimentation with heroin maintenance would allow some important questions to be studied. It is also possible that heroin maintenance would break the market for heroin and remove the impetus for expansion caused by the high profits of illegal distribution. (The English experience, described by Edgar May in Staff Paper 7, is, of course, instructive.)

The most important objections to heroin maintenance are as follows:

The administrative expenses would be high. If the drug were administered in clinics, it would have to be made available about four times a day. Also, because heroin is relatively ineffective orally, medical personnel might be required to give injections to ensure a sterilized procedure. Both factors would increase expenses. If the English system were adopted and the heroin were dispensed from pharmacies on prescription, it would be difficult to control the dosages, track the patients, secure the heroin, and avoid infection and disease. Because of heroin's sharp peaks and short duration of action, it may be a difficult drug on which to find and maintain a constant dosage even if the patient desires stabilization. There is always physical pressure on the patient to increase his dosage. To make this problem worse, a maintenance program would draw addicts who were not willing to give up the effort to attain the euphoria of heroin. Thus, they might take their maintenance dose, buy more on the street, and then demand that the clinics maintain the new, higher dosage. While there may be a pharmacological ceiling beyond which the drug has no additional euphoric effects, this is not definitely known. Addicts on heroin maintenance might quickly reach levels of 100 to 200 mg. of heroin per day, a dose higher than that of almost all present addicts. The physical effects of this dosage are not known. Many members of the black community would oppose heroin maintenance, interpreting it as a scheme to keep the black community tranquilized and quiet or as an indication that society is concerned only with the crime caused by addiction, not with the addicts themselves. Still others, who believe that continuing use of heroin causes long-term organic damage, might regard heroin maintenance as a form of mass murder.

The high doses that would tend to prevail in such a program would tranquilize addicts and make them function ineffectively. This would make rehabilitation efforts impossible.

Heroin maintenance might draw patients away from methadone, thus transferring them from a program with proved effectiveness for rehabilitation to one that is probably counterproductive in terms of reformation of the addict's life-style.

The existence of heroin maintenance would remove an important deterrent to experimentation with heroin-the obvious degradation of the addicted life.

These objections have force. It seems doubtful that society would wish to move to a large-scale heroin-maintenance program at the present time, especially if doing so would undercut methadone. However, there are limitations on the effectiveness of methadone and on the extent to which it can eliminate the addiction problem. If, for example, only 50 per cent of the addicts are helped by methadone, the country may be left with a sizable addiction problem even after methadone has reached its full potential. Despite the problems, it is likely that heroin maintenance will begin to receive serious consideration. It would be wise to start accumulating solid knowledge on its workings and effects, and on the validity of the objections to it, before proposals for large scale programs make the matter urgent. There will not be time to do so afterwards. Careful experimentation is desirable.

TREATMENT OF USERS OF NONOPIATES

Treatment of users of the amphetamines, barbiturates, hallucinogens, and cannabinols has two distinct aspects. The first is (,crisis intervention"-emergency assistance to those who are suffering from adverse effects of drugs. The second consists of longterm programs designed to prevent future drug use.

CRISIS INTERVENTION

Overdoses of opiates and barbiturates constitute a medical emergency, and death results unless steps are taken quickly."' For other drugs, the adverse effects are more psychological than physical-usually the user is having a severe mental disturbance as a result of the drug and needs psychological support until the body clears the drug from the system."'

Until recently, users of nonopiates suffering from adverse effects of drug taking had nowhere to go except hospital emergency rooms. Most users were reluctant to do this, both because hospitals often felt compelled to report the illegal drug user to the authorities, and because emergency-room personnel treated them demeaningly. In addition, drug users came to believe that the treatment received in hospitals was not very helpful. In fact, the reaction of the medical personnel tended to intensify and prolong the user's own panic. In the words of one observer, "Modern medical science can keep a panic reaction going for about five days." The hospital use of strong tranquilizers is regarded by experienced drug users and drug-treatment doctors as unnecessary and possibly damaging. Chlorpromazine, the usual drug given, has strong side effects... and is unpleasant in its psychoactive characteristics."'

Free clinics, manned by interested professionals, experienced youths, and volunteer doctors, have sprung up in many cities. The Haight-Ashbury Clinic in San Francisco seems to have been the prototype. The Langly Porter Youth Drug Unit at the University of California is another. It is not known how many there now are, but it is probable that every large city has at least one, some have several, and the movement is spreading rapidly to suburban communities.

The treatment provided to drug users on a "bad trip" consists primarily of "talking down" the patient, which can be done by peers who have had similar experiences. "Quiet rooms" for such "talk downs" have been recommended as a component for all emergency medical centers that treat youthful drug users. The patient is not left alone and is constantly reassured about who he is and where he is. Establishment of verbal contact with the patient is recommended, and there is little or no use of tranquilizers. When tranquilizers are used, chlorpromazine is the most common, given either orally or, preferably, intramuscularly, which avoids adverse gastrointestinal symptoms. Experimentation is going on using short-term barbiturates instead. As of 1970, the Berkeley Free Clinic claimed to have given only three tranquilizing injections to "freakouts" since the clinic began; the rest were talked down.

Heavy amphetamine users and barbiturate addicts present different detoxification problems. The barbiturate addict needs to be withdrawn from his addiction under a carefully supervised medical regimen in an inpatient hospital setting, for the withdrawal process itself is life-threatening."' Heavy amphetamine users are apt to suffer from paranoia, sometimes leading to violence; they need a quiet recovery room away from strangers whom they may consider enemies. They often shy away from hospitalization for fear of arrest.

Treating soft-drug users for adverse reactions is an important health measure to prevent possible deaths, suicides, or bizarre and self-destructive behavior. Since most facilities that perform this service do not have a follow-up capacity, there is no way of telling how many patients return to drug use and how many abandon it after experiencing adverse reactions. The treatment process itself is not concerned with abstinence but with the immediate problem. Many of the patients seen in these clinics are only occasional experimenters or sporadic-users.

Before the drug legislation of 1970, there was no basis for federal funding of these crisis clinics. The law now provides that HEW can make grants for such partial services to drug users. Some of the clinics are not enthusiastic about federal backing, fearing that it will lead to greater conformity in approach and a decreased ability to utilize ex-drug users in new roles. Federal or state governments might also impose bureaucratic standards on staff training and facilities without contributing enough money to meet the costs of these requirements. There is also a fear that government backing will turn away some clients.

LONG-TERM THERAPY

While the crisis centers provide necessary emergency services, it is unlikely that they have much permanent impact on drug users. There is therefore a movement to expand the centers to include programs that will have some effect on the drug-using behavior of patients. As a result, the crisis centers are beginning to offer long-term therapeutic help as well as emergency services.

This expansion is not limited to the treatment of drug users. Most clinic staff members view drug problems as only one aspect -and not always the most serious-of human malfunctioning for which help should be provided. For example, the Center for Special Social and Health Problems in San Francisco, according to its descriptive materials, is concerned with drug abuse, sexual problems, violence and hatred, compulsive gambling, suicide, management of death and dying, crime and delinquency, inability to manage finances, obesity, and insomnia. While this list is more ambitious than most, it illustrates the general trend toward, broadening the scope of the crisis clinic. In a way, these organizations are becoming privately run community mental-health centers.

The techniques and operations of these programs are about the same as those of the therapeutic communities and outpatient abstinence programs. Since, at present, there is no chemotherapy for soft-drug use, no treatment comparable to the methadone movement is possible. The basic problem with nonaddictive soft drugs is that continued use reflects the user's desire to keep taking them or a psychological dependence on them, which can be even more difficult to deal with than a physical craving. As one study points out, "Student drug users are, as a group, knowledgeable about the undesirable effects of drug abuse. In general, it is not difficult for most student drug abusers to stop. The issue is to get them to want to Stop.11113

While some soft-drug users are in TC's, the majority of those receiving help are in some form of outpatient program, usually the same programs described in the section on outpatient abstinence for opiate users. Often, the patients themselves are the same. A number of heroin addicts use other drugs as well, and youthful drug users are increasingly experimenting with heroin as one of several drugs they try. Whether it is possible to sustain a pattern of sporadic heroin use without becoming addicted is as yet uncertain. The "speed culture" in the Haight-Ashbury section of San Francisco has produced some evidence that speed users, who first use barbiturates to ease the "crash," soon learn that heroin is an even smoother way to achieve this purpose. Eventually they may abandon speed entirely and become heroin addicts. It is possible that a pattern of multiple drug use that includes heroin is an intermediate step toward full addiction."' It is even more difficult to determine the success of these programs with soft-drug users than with narcotics addicts, in part because most experts believe that youths who become heavily involved with cannabis and hallucinogens do not usually stay involved for a long period of time."' This fact, of course, increases the difficulty of evaluating the impact of any drug program, because abstinence is a poor indication of the program's effect.

Some work is going on in the area of chemotherapy. An effort is now being made to find antagonists to some of the more common drugs. Researchers tentatively claim to have found a drug that is an antagonist to amphetamines, although it has not yet been fully tested, and some work is being done on antagonists to LSD. However, it is not clear whether these drugs, when and if they are perfected, will have a significant impact on drug use, since soft drugs are taken without the spur of physical necessity. Unless a policy of forced implantation is followed, the drug user will always have a choice about taking the antagonist, and in most cases the choice would probably be to continue drug use.

There are, however, two hypotheses under which the antagonists might be useful. The amphetamines appear to be physically addictive to a limited extent, and this could exert some pressure on the amphetamine user to continue his use."' An antagonist might prevent the constant renewal of this physical dependence and give the user's body a chance to become free of it. Secondly, if one adopts a conditioning theory of drug use, an antagonist would eliminate the reinforcing effect of gratification from drug use and might in time extinguish the conditioned response of taking drugs.

One of the most carefully evaluated methods of decreasing soft drug use is transcendental meditation. A Harvard Medical School Study gave questionnaires to 1,950 subjects who had been practicing transcendental meditation for three months or more. Of these, 1,862 completed the questionnaire. The decrease in drug use was quite striking. The study says:

Following the start of the practice of transcendental meditation, there was a marked decrease in the number of drug abusers for all drug categories. . . . As the practice of meditation continued, the subjects progressively decreased their drug abuse until after practicing 21 months of meditation most subjects had completely stopped abusing drugs. For example, in the 6-month period before starting the practice of meditation, about 80 percent of the subjects used marijuana and of those about 28 percent were heavy users. Aftel practicing transcendental meditation 6 months, 37 percent used marijuana and of those only 6.5 percent were heavy users. After 21 months of the practice, only 12 percent continued to use marijuana and of those most were light users; only one individual was a heavy user. The decrease in abuse of LSD was even more marked. Before starting the practice of transcendental meditation, 48 percent of the subjects had used LSD, and of these subjects about 14 percent were heavy users. In the 3 months following the start of the practice of meditation, 1 1 percent of the subjects took LSD while after 21 months of the practice only 3 percent took LSD. The increase in the number of non-users after starting the practice of meditation was similar for the other drugs: non-users of the other hallucinogens after 21 months of the practice rose from 61 to 96 percent; for the narcotics, from 83 to 99 percent; for the amphetamines, from 70 to 99 percent; and for the barbiturates, from 83 to 99 percent.117

As the researchers point out, these correlations are not proof of causation. "Involvement in other kinds of self-improvement activities may also lead to decreased drug abuse. The motivation to start meditation may have influenced the subjects to stop drug abuse. The subjects in the present study may have spontaneously stopped, continued, or increased taking drugs independently of transcendental meditation.""'

Despite these necessary caveats, the results are striking, especially in an area in which, as the study delicately points out, "Existing programs for the alleviation of [non-narcotic] drug abuse usually involve education as to the dangers of the effects of drugs and sometimes provide personal counseling or psychiatric care. The efficiency of these programs has yet to be established."' (Staff Paper 6, by Dr. Andrew Weil, deals with meditation and other nonchernical means of achieving altered stages of consciousness.)

CONCLUSION

Few solid conclusions emerge from this morass of conflicting information. It is clear that methadone is a helpful treatment modality, but just how helpful is not yet known. It is equally clear that its almost inevitable expansion will create new problems, some of them predictable and some of them totally unexpected. Not much can be said about the other treatment modalities and concepts. Those who favor them have not yet proved their case, but neither have those who are skeptical. On the whole, it seems probable that they will turn out to have only marginal effectiveness as drug-treatment methods, although they may have possibilities as a part of the more general human-potential movement. The basic problem is that we lack any solid theory or understanding of the nature and causes of addiction. As researchers have repeatedly pointed out, for most drug users the drugs are functional and adaptive mechanisms. Society cannot make long-term progress toward developing more effective treatment mechanisms without grasping and accepting this fact. At present, however, we have little choice but to proceed empirically.

NOTES

1. Alfred Lindesmith, The Addict and the Law (New York: Vintage ed., 1967), pp. 105-6, 124. (Hereafter cited as Lindesmith.)

2. Charles Terry and Mildred Pellens, The Opium Problem (Bureau of Social Hygiene, 1928), p. 627. (Hereafter cited as Terry and Pellens.)

3. Ibid., pp. 137-65.

4. Troy Duster, The Legislation of Morality (New York: Free Press, 1970),

p. 15.

5. Terry and Pellens, pp. 30-32. These authors are skeptical and believe that physicians would have reported only addicts under curative treatment. 6. Rufus King, The Drug Hang-up-America's Fifty Year Folly (in press), MS. pp. 76-77.

7. Terry and Pellens, p. 866.

8. King, op. cit., note 6, MS. p. 57.

9. Norman Zinberg and John Robertson, Drugs and the Public (in press),

MS. p. 40.

10. Lindesmith, pp. 99-134. For a brief review of relevant population estimates, see Arthur D. Little, Inc., Drug Abuse and Law Enforcement (A Report to the President's Commission on Law Enforcement and Administration of Justice: 1967), "Appendix C: History of the U.S. Addict Population." This report argues that "what is apparent is not the constancy of the addict and his habit, but rather that the addict deserts his habit quite easily" (pp. C-4 and C-5). It points to sources showing a decline from about 246,000 in 1890 to 100,000 in 1926. These sources are criticized in the cited portion of Lindesmith.

11. Frances Gearing, "Methadone Maintenance Treatment Program:

Progress Report of Evaluation Through March 31, 1970" (mimeograph, 1970), p. 1 1. (Hereafter cited as Gearing, 1970.)

12. The studies are summarized in John O'Donnell, The Relapse Rate in Narcotic Addiction: A Critique of Follow-up Studies (New York State, Narcotic Addiction Control Commission Reprints, 1968) (originally published in 1965).

13. William Martin, Statement in Narcotics Research, Rehabilitation, and Treatment, Hearings before the Select Committee on Crime, House of Representatives, 92d Cong., Ist sess., April 26-28 and June 24, 23, 1971 (GPO, 1971), Part 2, pp. 437-38. (A number of statements at these hearings are cited hereafter. They are footnoted as Hrgs.

14. These summary statements are drawn from a large number of published sources and interviews. Some of them are discussed at greater length later in the paper, particularly in the methadone section. For development and discussion of psychological characteristics, see Isador Chein, Donald Gerard, Robert Lee, and Eva Rosenfeld, The Road to H (New York: Basic Books, 1964), a book that equals The Opium Problem as a classic in the field.

15. David Smith, George Gay, and Barry Ramer, "Adolescent Heroin Abuse in San Francisco," Proceedings Third National Conference on Methadone Treatment, November 14-16, 1970 (GPO, 1971), pp. 89, 90. (These proceedings are hereafter cited as Third Meth. Conf.)

16. Howard Jones, Hrgs., p. 588.

17. George Gay, Alan Matzger, William Bathurst, and David Smith, "Short-Term Heroin Detoxification on an Outpatient Basis," International journal of the Addictions, VI, No. 2 (June, 1971), 241, 259-60.

18. Kramer, Hrgs., p. 668.

19. U.S. Comptroller General, Limited Use of Federal Programs to Commit Narcotic Addicts for Treatment and Rehabilitation (September 20, 1971), p. 6; Jonathan Cole, "Report on the Treatment of Drug Addiction," in President's Commission on Law Enforcement and Administration of Justice, Task Force Reports: Narcotics and Drug Abuse (GPO, 1967), pp. 135,140-41.

20. O'Donnell, op. cit., note 12.

21. These are reviewed in Cole, op. cit., note 19, pp. 135-36.

22. Duster, op. cit., note 4, p. 134. The description and statistics that follow are taken from Duster and from John Kramer, Richard Bass, and John Berechochea, "Civil Commitment for Addicts: The California Program," American Journal of Psychiatry, CXXV (1968), 816.

23. Kramer, Hrgs., p. 654.

24. Compare the descriptions of the two programs in National Institute of Mental Health, National Clearinghouse for Mental Health Information, Directory of Narcotic Addiction Treatment Agencies in the United States, 1968-69 (GPO, 1970), pp. 5-6. (Hereafter cited as NIMH Directory.) 25. Jones, Hrgs., pp. 565, 584. The budget estimate is calculated from the budget numbers given. It is not a statement of the Commissioner.

26. For a thoughtful critique based on observation of five centers, see Community Service Society of New York, Committee on Youth and Correction, Observation on Five Residential Facilities of the Narcotic Addiction Control Commission (1971), pp. 89-101.

27. New York Times, October 4, 1970. See, also, the statement of the Health Policy Advisory Center:

The program promises to return the addict to a useful life "through extended periods of treatment in a controlled environment followed by supervision in an after-care program." The emphasis is on "controlled." The addict receives about as much rehabilitation as the criminal prisoner with about as much result-the recidivist rate for addicts is much higher than for criminals. Moreover the rehabilitation centers are run like prisons. There are guards, most of whom receive training for prison work-one guard for every two inmates, recalcitrant addicts are beaten and placed in isolation on reduced diets; inmates are sexually abused; there is no separation of the young from the old. The few rehabilitation programs that do exist are staffed by instructors and therapists who have received little or no training. For the 5,000 or so inmates in the 14 separate institutions there are only 4 psychiatrists, 16 psychologists, and 78 teachers and vocational instructors. The prison-like atmosphere has caused a large percentage of the addicts to try to escape. [Health Policy Advisory Council, Health/PAC Bulletin, June, 1970, pp. 16-17.]

28. Carl Chambers, Hrgs., p. 566.

29. U.S. Comptroller General, op. cit., note 19, pp. 12-17.

30. Information furnished by the Bureau of Prisons.

31. The information on 1969 was furnished by NIMH. The 1971 information is from Bertram Brown, Hrgs., p. 470.

32. Brown, Hrgs., p. 433.

33. U.S. Bureau of Prisons, "Narcotic Addict Rehabilitation Act: Progress Report" (mimeograph), February 22, 197 1.

34. These are difficult numbers to pin down. According to the NIMH Directory (p. 144), 40 programs listed themselves as therapeutic communities as of about 1968. It is not clear how stringent the standards for inclusion were, however, and this may include some programs that are essentially outpatient abstinence with group work. At the other end, it misses some of the newer therapeutic communities.

The population figure is also an educated guess. Most TC's are in New York, and knowledgeable sources estimate that the Phoenix Houses (the city's TC program) had about 1,000 residents and private TC's about 1,400 in 1970. Synanon had about 1,400 residents (NIMH Directory, p. 32). These places account for the largest number of TC residents, but there are many others with 10 to 100 residents scattered throughout the country. The estimate of 5,000 residents is probably an upper limit.

35. A description of four of the New York City projects is given in Community Service Society of New York, Committee on Youth and Corrections, The Long Road Back from a Living Death: A Study of Four Voluntary Treatment and Rehabilitation Programs for New York City's Narcotics Addicts (Part 1) (1967).

36. Kramer, Hrgs., p. 667.

37. Ibid.

38. This study was given to us on a no-attribution basis.

39. NIMH Directory, passim. For a detailed description of two projects, see Community Service Society of New York, Committee on Youth and Corrections, Lifeline to Tomorrow: A Study of Voluntary Treatment Programs for Narcotic Addicts (Part 11) (1 969).

40. Robert DuPont, Hrgs., p. 144.

41. D.C. Department of Corrections, "Performance of Corrections Referrals Under Three Narcotic-Addiction Treatment Modalities" (Research Report No. 42: mimeograph, July, 1971).

42. Friends of Psychiatric Research, Inc., Uniform Evaluation of Programs to Combat Narcotic Addiction (Baltimore, 1970).

43. Op. cit., note 39, pp. 93-94.

44. The data that follow are from S. B. Sells and Deena Watson, "A Spectrum of Approaches in Methadone Treatment: Relation to Program Evaluation," Third Meth. Conf., p. 17.

45. Vincent Dole, "Planning for the Treatment of 25,000 Heroin Addicts," Third Meth. Conf., P. I 1 1.

46. NIMH Directory, p. 144; Second National Methadone Maintenance Conference, New York, October 26-27, 1969, published in the International journal of the Addictions, V, No. 3 (September, 1970) (hereafter cited as.Second Meth. Conf.); Third Meth. Conf.

47. Charles Edwards, Hrgs., p. 395.

48. Elmer Gardner, Hrgs., p. 397; Brown, Hrgs., p. 440.

49. Avram Goldstein, "Blind Controlled Dosage Comparisons with Metha-

done in Two Hundred Patients," Third Meth. Conf. (hereafter cited as Goldstein, 1970); Ray Trussell, "Treatment of Narcotics Addicts in New York," Second Meth. Conf., pp. 347, 352; Lynwood Holton, Hrgs., pp. 600601. Governor Holton's statement is particularly interesting because it makes budget estimates within the context of a comprehensive state treatment program.

50. Gearing Report 1970 and "Successes and Failures in Methadone Maintenance Treatment of Heroin Addiction in New York City," Third Meth. Conf., p. 2.

51. Goldstein 1970, p. 31.

52. DuPont, Hrgs., p. 173.

53. See, e.g., Gordon Stewart, "A Survey of Patients Attending Different Clinics in New Orleans," Third Meth. Conf., p. 27.

54. The information on MMTP is drawn, except where otherwise indicated, from three sources; the Gearing Report, 1970; the 1969 edition of the same report; and the paper presented at the methadone conference, cited in note 50.

55. Carl Chamber and Dean Babst, "Characteristics Predicting Long-Term Retention in a Methodone Maintenance Program," Third Meth. Conf., p. 140. 56. Herman Joseph and Vincent Dole, "Methadone Patients on Probation and Parole" (mimeograph) (New York: Rockefeller University Press, 1970), P. 9.

57. Chambers and Babst, op. cit., note 67.

58. Joseph and Dole, op. cit., note 56.

59. The Second National Methadone Maintenance Conference had reports from New York, Chicago, Minneapolis, St. Louis, Baltimore, New Haven, Vancouver, New Orleans, and Miami. The Third National Methadone Treatment Conference had reports from New York, Brooklyn, Chicago, New Orleans, Santa Clara, Philadelphia, Vancouver, Baltimore, Denver, and Washington as well as from Sweden.

60. Henry Brill, "Methadone Maintenance: A Problem in Delivery of Service," Journal of the American Medical Association, CCXV, No. 7 (February 15,1971), 1148-50.

61. Goldstein 1970, p. 37.

62. The incidence of hepatitis among addicts has been described as "unbelievable." Some experts think the sale of blood by these addicts is creating a major public-health problem. See Stewart, op. cit., note 53.

63. For a more detailed discussion, see Staff Paper 1.

64. Vincent Dole and Marie Nyswander, "Methadone Maintenance and Its Implication for Theories of Narcotic Addiction," in Abraham Wikler, ed., The Addictive States (Baltimore, Md.: Williams & Wilkins Co., 1968), p. 359, postulates an inherent neurological vulnerability. But, at the Second National Methadone Maintenance Conference, Dr. Dole was asked: "Apart from any psychological factors or emotional factors, is there a metabolic irregularity which causes a craving for drugs in the first place or does the metabolic irregularity come after the use of drugs or both?" His response was: "This is a very important question for which I have no adequate answer. I can only guess. My opinion is that a heavy exposure to heroin induces the metabolic changes. According to this theory, the abnormal drug craving in man, like the induced drug seeking behavior in animals, is a result of exposure to narcotic drugs and not the original cause of the addiction." Second Meth. Conf., pp. 359, 370.

65. Dr. Dole seems to lean toward the idea that the metabolic change is permanent. He has stated: "I believe one has to reckon with the fact that heroin hunger is probably a symptom of a pharmacological imprint that may last for a man's life." Vincent Dole, "Research on Methadone Maintenance Treatment," Second Meth. Conf., pp. 359, 370.

66. See, e.g., Avram Goldstein, "Blind Dosage Comparisons and Other Studies in a Large Methadone Program" (paper presented at the National Heroin Symposium, June 20, 1971, pp. 12-13; to be published in the Journal of Psychedelic Drugs). (Hereafter cited as Goldstein 1971.)

67. William Martin, "Pathophysiology of Narcotic Addiction: Possible Roles of Protracted Abstinence in Relapse" (unpublished paper, 1970), pp. 6-7, and private communications.

68. Abraham Wikler, "Interaction of Physical Dependence and Classical and Operant Conditioning in the Genesis of Relapse," in Wikler, ed., The Addictive States, op. cit., note 76. The views of Wikler and Martin can be merged into one coherent psycho-physical theory. See Max Fink, "Narcotic Antagonists in Opiate Dependence," Science, CLXIX (September 4, 1970), 1005.

69. The maturation hypothesis was first proposed by Charles Winick in "Maturing Out of Narcotic Addiction," Bulletin on Narcotics, XIV, No. 1 (1962). Since then a number of researchers have looked at particular groups of addicts to determine whether they do, in fact, mature out. The onethird figure is based on a number of these works as well as on interviews.

70. See Cole, op. cit., note 19.

71. Goldstein 1970, p. 35.

72. Jerome Jaffe, "Methadone Maintenance: Variation in Outcome Criteria as a Function of Dose," Third Meth. Conf., p. 37.

73. William Weiland and Arthur Moffett, "Results of Low Dosage Methadone Treatment," Third Meth. Conf., p. 48. See also Hugh Williams, "Low and High Methadone Maintenance in the Out-patient Treatment of the Hard Core Heroin Addict," Second Meth. Conf., p. 439.

74. Goldstein 1970, p. 24.

75. See, e.g., Gearing Report 1970, pp. 8-9.

76. Stewart, op. cit., note 64.

77. Goldstein 1970, p. 32.

78. Goldstein 1971, pp. 2-3.

79. Gearing Report 1971.

80. Gearing, op. cit., note 50.

81. For a general review of ambulatory induction, see the material from the different cities contained in Second Meth. Conf. and Third Meth. Conf.

82. Dole, op. cit., note 65, pp. 364, 370, 386.

83. Jerome Jaffe, "Further Experience with Methadone in the Treatment of Narcotics Users," Second Meth. Conf., pp. 375, 383-84, 386.

84. Goldstein 197 1, pp. 13-14.

85. Goldstein 1971, pp. 14-15.

86. Ibid., P. 14. William Vandervort, "Treatment of Drug Abuse in Adolescents," Third Meth. Conf., P. 87.

87. William Martin, "Commentary on the Second National Conference on Methadone Treatment," Second Meth. Conf., P. 545.

88. Quoted in Joseph and Dole, op. cit., note 56, pp. 14-15.

89. See Gerald Davidson, Hrgs., pp. 326-27.

90. See material in Second Meth. Conf. and Third Meth. Conf., which includes several papers on possible psychopathology. See also John Kramer, "Methadone Maintenance for Opiate Dependence," California Medicine, CXIII, No. 6 (December, 1970), 6, 9.

9 1. Kramer, Hrgs., pp. 668-69.

92. Goldstein 1970, p. 35.

93. John Langrod, "Secondary Drug Use Among Heroin Users," International journal of the Addictions, V, No. 4 (December, 1970), 61 1. 94. Ivan Bennett, "Development of a Newly Formulated Tablet for Methadone Maintenance Programs," Third Meth. Conf., p. 143. 95. This statement was made by Dr. Goldstein at the Third Methadone Conference. It was not included in the printed version.

96. See the papers presented at the Second and Third Methadone Conferences. Many of them are directed specifically at side effects. This section summarizes what seems to be the general experience of the programs.

97. Edwards, Hrgs., pp. 393-430; Washington Post, November 2, 1971. For a discussion of some of the problems, see "Oral Methadone Maintenance Techniques in the Management of Morphine-type Dependence"; Combined Statement of the Council on Mental Health and Its Committee on Alcoholism and Drug Dependence, American Medical Association; and the Committee on Problems of Drug Dependence, National Research Council, March 169 1971.

98. Jaffe, Hrgs., p. 2 1 0.

99. Brown, Hrgs., p. 455.

100. Stewart, op. cit., note 53; Goldstein 197 1) p. 5.

101. The antagonists were introduced as an experimental addiction treatment modality in 1965. Max Fink, "Narcotic Antagonists in Opiate Dependence," Science, CLXIX (September 4, 1970), 1005. For a review of the pharmacology, see Jerome Jaffe, "Narcotic Analgesics," in Louis Goodman and Alfred Gilman, The Pharmacological Basis of Therapeutics, 4th ed., (New York: Macmillan, 1970), pp. 237,264-71.

102. City of New York, Health Services Administration, Narcotics Antagonists Research Program: The Current State of Knowledge of Drug Antagonists for Heroin Addiction (mimeographed staff paper: 1971), p. 7. (Hereafter cited as HSA.) We have found that this is the best source written in a form comprehensible to laymen.

103. Martin, Hrgs., pp. 435-36.

104. HSA, pp. 3, 8-9. HSA said that the consensus of researchers is that it would take three to five years for a long-lasting antagonist or long-lasting depot vehicle to be ready for use, and, in any event, there is no guarantee of success. Other people we have talked to are skeptical about the feasibility of the whole idea, and raise both pharmacological and social objections.

105. Fink, op. cit., note 101, says that, since 1968, 40 per cent of more than 450 adult male addicts have remained in cyclazocine treatment.

106. Martin, Hrgs., p. 435.

107. Ibid., p. 436.

108. Treatment for an opioid overdose consists of immediate administration of an antagonist to prevent death from respiratory depression. See Jerome Jaffe, op. cit., note 101, pp. 237, 268. The treatment of barbiturate poisoning is considerably more complicated and requires more elaborate medical facilities. See Seth Sharpless, "Hypnotics and Sedatives: 1. The Barbiturates," in Goodman and Gilman, pp. 97, 117-18.

109. There are variations, of course. The user who has taken an excess of hallucinogen or cannabinol is not dangerous. He requires support but rarely restraint. The user who has taken too much metharnphetarnine may have paranoid delusions, and considerably more caution is indicated.

1 10. Side effects are not always encountered, but those that are, are (I many, varied, and can be quite severe." They usually occur only with continued use, however. See Charles Solow, "Drug Therapy of Mental Illness: Tranquilizers and Other Depressant Drugs," in Richard Rech and Kenneth Moore, eds., An Introduction to Psychopharmacology (New York: RavenPress, 1970), pp. 289, 299-301.

111. Chlorprornazine, although a powerful tranquilizer, is not a drug of abuse. See Staff Paper 1.

112. David Smith and Donald Wesson, "Phenobarbital Technique for Treatment of Barbiturate Dependence," Archives of General Psychiatry XXIV (January, 1971), 56-57.

113. Herbert Benson and R. K. Wallace, "Decreased Drug Abuse with Transcendental Meditation: A Study of 1,862 Subjects," in Hrgs., pp. 682, 684.

114. Smith, Gay, and Ramer, op. cit., note 15.

115. William McGlothlin, "Policies Concerning Hallucinogenic Drugs," in Hudson Institute, Policy Concerning Drug Abuse in New York State, 11 (Hudson Institute, 1970), 27, 31-32.

116. See John Kramer, "An Introduction to Amphetamine Abuse," journal of Psychedelic Drugs, 11, No. 2 (1969), 1, 13. Dr. Kramer, commenting on treatment, states that ". . . abstinence is probably the most important therapeutic device, and that may be difficult to attain. Many users who attempt abstinence find it difficult because of the fatigue which results, extreme at first, gradually diminishing, but persistent, perhaps for months."

117. Benson and Wallace, op. cit., note 113, pp. 683-84.

118. Ibid., p. 685.

1. Ibid., p. 682.
   
   

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