Rehabilitation, from Nothing to NARA

The Drug Hang Up, America's Fifty-Year Folly

by Rufus King

Chapter 24

A SOURCE of confusion which has long served only oppressing forces is the lumping together of drug categories like the opiates, which are truly and powerfully addicting, with substances like cocaine and cannabis, which do not have true addictive properties. The confusion has been compounded recently by adding barbiturates (fearfully addicting) and amphetamines and hallucinogens (nonaddicting). Alcohol, at least in its hold and effects on alcoholics, is worst of all, while tobacco smoke likely the most toxic substance mentioned in this paragraph-falls on the borderline and probably should be classified as only strongly habituating.

Periodic efforts by authoritative bodies like the World Health Organization-and by White House publicists and congressional phrasemakers-to alter traditional definitions and fabricate new concepts tend only to make the situation worse. In order to get away from the three classic elements of drug addiction (compulsion, tolerance, and withdrawal symptoms), WHO, responding partly to U.S. pressures, has fumbled with a notion of "drug dependence" (dependence of the cannabis type, dependence of the opiate type, etc.), while various promoters have been pushing "habituation," or "abuse," preferably coupled with some vague test like "harmful" (to the drug user himself or to society) or loss of the user's "self-control." And in the last few years, probably as a result of the White House Conference, a popular distinction has come to be made between so-called "hard" narcotics and those which are labeled "soft," which one observer notes is as fatuous as talking about "hard" and "soft" pregnancy. Even the word narcotic is properly descriptive only of sedatives and soporifics, and should never have been applied to stimulants like cocaine or hallucinogens like marijuana. Heroin and morphine are best described as analgesics.

As elsewhere in our narrative, the person most victimized by such confusion is the drug user. What chance has he of a fair shake when lawmakers and law enforcers neither know nor care about even the most fundamental realities of his condition? In the patterns that took shape under the Harrison Act after World War I, the only kind of drug user who needed "rehabilitation" in any specialized sense was the user of opiates or their synthetic equivalents. This addict was truly "hooked," especially if he had been using drugs of good quality over some period of time so as to build up a substantial tolerance, and it was his plight that led medical authorities in the 1919-23 period to open the various clinics which we have already described. The idea was to provide opium (including morphine and heroin) addicts with sustaining supplies of the drugs to which they were accustomed so they could go on functioning normally and would not be driven into criminality. But some of the clinics also doled out cocaine, from which there are no significant withdrawal symptoms and the continued use of which under nonmedical administration is unjustifiable. So to this latter extent, at least, Treasury agents who hounded the clinic operations out of existence must be conceded a point.

Concerned observers began to take interest in "rehabilitation" again in the late 1920's, particularly with regard to addicts trapped in the federal prison system, and this led Congress to enact the 1929 Porter fact, under which the U.S. Public Health Service was authorized to establish two "narcotic farms" for confinement and treatment of addicted persons who had been convicted of offenses against the United States. These were the already mentioned institutions, shortly rechristened "hospitals," established at Lexington and Ft. Worth in the mid-thirties, which continued to do fine work, in their limited way, until their demise in the early seventies. But since they dealt mainly with convicted federal prisoners and were never provided by Congress with significant resources for follow-up supervision or treatment of released inmates, they scarcely made a dent in the total addict population.

At the state level, most legislatures were content to add drug addiction to their already existing patterns for rehabilitating alcoholics or treating the insane, and in fact very little was done for addicts, or about their problems, anywhere. In 1956, as has been noted, the Daniel Committee came out with the ultimate law-enforcement proposal-that all addicts who could not be "cured" should be incarcerated for life in some segregated detention facility. Even President Kennedy's Ad Hoc Panel and Advisory Commission embraced the notion that addicts (still fuzzily confused with all drug users) should either be "cured" of their habits or else confined for life like nineteenth-century lepers if they continued to "relapse."

But as will also be remembered from the last chapter, while the President and his Attorney General brother were making moves to concentrate drug-law enforcement powers in the Department of justice, opposition leaders in Congress began a campaign of their own to keep control of the situation by developing the theme that addicts were really sick persons (and not inherently abnormal) rather than criminals after all, and that what was most needed were more efforts to rehabilitate them.

The Javits-Keating bills quickly picked up co-sponsorship in the Senate and support by parallel introductions in the House in the 87th Congress (1961). Most important was the elaborate civil-commitment measure, under which a defendant accused of a federal crime could, in the discretion of the court, if found to be an addict and if his crime was found to be addiction-related, be offered the alternative of mandatory civil commitment into the custody of the Surgeon General for treatment. If the Surgeon General agreed, and found that the defendant would benefit from treatment, a civil commitment for an indeterminate period up to thirty-six months, plus an additional two-year probationary period, would follow in lieu of the criminal prosecution. The purpose behind this was to hold addicts in hospitals for treatment as long as necessary, then keep them under close supervision in the community for the balance of the indeterminate sentence, and thereafter follow them for the additional probationary period with diminishing supervision. If at any time during the entire term an addict-defendant turned recalcitrant or returned to drugs, the criminal prosecution could be reinstated.

Other bills in the New York senators' package provided, as we have related, for grants-in-aid to states for the construction of narcotic-hospital facilities, with authority vested in the Surgeon General to prescribe standards for state rehabilitation programs; specified in the alternative that drug addiction should be classified as a mental illness so that existing federal grant programs under the Public Health Service Act would be available; and called for massive research.

Almost as important as the substance of these measures were the political battle fines which emerged over them. On Capitol Hill, the New York delegation championed Governor Rockefeller and sought to squeeze maximum advantage from promoting efforts to "cure" the addict. In the executive branch the Kennedy forces, with Governor Brown as their hero, sought to concentrate enforcement action in the Department of justice and to play up repressive measures, including activities aimed at the new categories of "dangerous drugs." Within this struggle, the New York contingent stood to gain by emphasizing action at the state level, while the forces in control of the administration understandably wanted to hold as much as possible exclusively in the federal domain.

When the 88th Congress convened in 1963, the rehabilitation bills picked up additional sponsorship and momentum in both houses. Senator Javits urged that the medical-commitment approach, coupled with hospitalization, aftercare, and expanded research , was "the only way in which we can come abreast of this critical problem, which has its main impact in an absolutely alarming and sensational increase in the crime rates." Senator Keating pointed out that addiction was becoming "particularly acute among the youths of our cities" and that if probation and aftercare were widely used in lieu of long-term prison sentences, great savings would result, since it cost approximately $2,000 per year to keep an addict in prison whereas an adequate probation program would cost only about $350 per subject.

In this round, Keating also introduced a related measure providing for involuntary commitment of addicts who submitted themselves to the federal authorities on a voluntary basis, to meet the problem encountered by the narcotic hospitals when voluntary patients wanted to leave as soon as they had been detoxified.

Actually, California and New York had pulled slightly ahead of Congress on the civil-commitment front. In California a new law was enacted in 1961 authorizing the California courts to commit any person upon conviction of a misdemeanor or nonviolent felony, and any person turned in by his relatives or friends or volunteering for himself-whether actually addicted or "in imminent danger of becoming addicted"-to the California State Department of Correction for a maximum period of three years, commencing with at least six months of incarceration at a rehabilitation center. In New York, the Metcalf-Volker Act, which became effective in 1963, authorized civil commitment for addicts in similar categories into the custody of the New York State Department of Mental Hygiene, also for a maximum period of three years. By the end of 1963 the California program was under way with slightly over 1,000 patients at the California Rehabilitations Center in Corona and 600 in halfway houses or under supervision as outpatients, while in New York about 400 persons were undergoing detoxification in six state hospitals, with 300 more under outpatient control exercised through aftercare clinics in various facilities designated by the Commissioner of Mental Hygiene.

The Final Report of President Kennedy's Advisory Commission contained a vaguely stated proposal for a federal civil-commitment program-with everything concentrated, naturally, under control of the Attorney General and various Department of Justice agencies such as the Bureau of Prisons and the Federal Probation Service. The report characterized the New York program as undesirable and possibly unconstitutional, and commended the California commitment law as a superior model for other states to follow. Marijuana smokers were included, without any reservation, as proposed candidates for full rehabilitation treatment: "The Commission recommends that a Federal civil commitment statute be enacted to provide an alternative method of handling the federally convicted offender who is a narcotic or marijuana user."

The reshuffling which took place when President Johnson ousted Robert Kennedy from the Attorney Generalship had particularly curious effects on the drug picture, since Kennedy turned up as successor to Keating in the Senate, side by side with the surviving champion of rehabilitation Senator Javits. As Keating's heir, Kennedy had no choice but to become a cosponsor of the civil-commitment legislation. President Johnson in turn inherited the administration's position, which had originally been aimed at building up the post of Attorney General, and also inherited the ingenuous pronouncements of the Advisory Commission. In his first law-enforcement message to Congress, Johnson urged enactment of a civil-commitment law in the following terms: "The return of narcotic and marijuana users to useful, productive lives is of obvious benefit to them and to society at large. But at the same time, it is essential to assure adequate protection for the general public." (Italics added.)

The rehabilitation bill which Congress finally passed was entitled Narcotic Addict Rehabilitation Act of 1966. We shall analyze it in some detail because, despite Senator Hughes's efforts, Congress has left it virtually untouched since that time (although most of it has been equally neglected by the executive and judicial branches.)

The bill combined provisions for handling addicted persons who had run afoul of certain federal criminal laws with provisions for accommodating addicts civilly committed or wishing to submit to treatment on a voluntary basis. It began with a noble declaration:

It is the policy of the Congress that certain persons charged with or convicted of violating Federal criminal laws, who are determined to be addicted to narcotic drugs, and likely to be rehabilitated through treatment, should, in lieu of prosecution or sentencing, be civilly committed for confinement and treatment designed to effect their restoration to health, and return to society as useful members.

It is the further policy of the Congress that certain persons addicted to narcotic drugs who are not charged with the commission of any offense should be afforded the opportunity, through civil commitment, for treatment, in order that they may @e rehabilitated and returned to society as useful members and in order that society may be protected more effectively from crime and delinquency which results from narcotic addiction.

The definition of "addict" which this measure introduced into federal law was the vaguest catch-all so far: "any individual who habitually uses any narcotic drug . . . so as to endanger the public morals, health, safety, or welfare, or who is so far addicted to the use of such narcotic drugs as to have lost the power of self-control with reference to his addiction." It was, however, tied to the Harrison Act enumeration, so that even though it applies to nonnarcotic. substances like cocaine and omits barbiturates, it happily excludes marijuana.

The Act (NARA) was intended to provide rehabilitative treatment in three categories. In the first, individuals charged with offenses against the United States (except crimes of violence, selling or smuggling drugs, and repeating offenders-in other words, except everything but minor first-offenders, of whom there are not many in the federal courts if one excludes the District of Columbia) were given a complicated option to elect so-called civil commitment in lieu of the threatened criminal prosecution. This choice can only be made if permitted in the discretion of a judge, must be made within five days after it is offered, and will only be allowed if the Surgeon General certifies that facilities and personnel are available to treat the addict and finds, moreover, that he is likely to benefit from treatment.

Accused persons passing through all this were thereupon supposed to be committed to a federal Public Health Service institution or a local public or private facility with which the Surgeon General has made special reimbursement arrangements. Incarceration is for a period of not less than six or more than twenty-four months, followed by parole-like supervision on an outpatient basis under the jurisdiction of the Surgeon General so as to complete a total period of thirty-six months within the program. If during this period an individual is found to be no longer amenable to treatment-"cannot be further treated as a medical problem"-or if he misbehaves or begins using drugs again, he is sent back to the court and the criminal charge which has remained in abeyance is revived. If he survives the three years and comes out 'cured,' the criminal charge is dropped.

The second category under the Act is persons who have been found guilty, by plea or trial, of an offense against the laws of the United States (except, again, any "crime of violence" or any sale or smuggling offense involving drugs unless it is also found that the offense was committed primarily because of the defendant's own addiction, and excluding repeaters). Here, once more in the discretion of the court, this convicted offender may be turned over to the custody of the Attorney General-if the Attorney General certifies that he is likely to be rehabilitated through treatment, and if adequate facilities and personnel are available-for an indeterminate period of ten years (or the maximum sentence that could otherwise have been imposed, if that is less). A period of at least six months must be served in custody in an institution prior to any conditional release under supervision. The Attorney General is authorized to place addicts released under this program in the jurisdiction of the U.S. Board of Parole or any appropriate public or private agency to whom supervisory responsibility may be contracted.

The third category consists of addicts (within the same sweeping definition of addiction) who submit voluntarily to the program or who are involuntarily committed to it on petition of a relative. After elaborate hearing and screening procedures (and if it is found that federal facilities are available and no appropriate state or other institution can be used), the individual, now called a "patient," is committed to the custody of the Surgeon General for incarceration in a Public Health Service facility for not less than six months, followed by three years of supervisory control. If the patient resumes drug use during the supervisory period, he may be recommitted to hospital incarceration for another six month stretch, and if he tries to escape or otherwise misbehaves while institutionalized he is subject to the same criminal sanctions applied to federal prisoners.

The 1966 Act also included the substance of other Javits-Keating (and subsequently Javits-Kennedy) proposals, such as authorizing the Surgeon General and the Public Health Service to establish outpatient facilities, either directly or by contract with local agencies, and to cooperate with the states and their subdivisions to encourage research and the development of local programs; a limited federal grant-in-aid authorization; and-importantly, at last-a provision slightly loosening the penalty structures applicable to marijuana, so that parole once again became available to marijuana offenders, including those who were already in prison serving long sentences for marijuana convictions. Also-at last-young persons committed under the federal Youth Corrections Act were made fully eligible for applicable benefits under the rehabilitation options. No provision was made in NARA for federal support for the construction or staffing of state treatment facilities, but this was remedied, in a modest way, two years later in the so-called Alcoholic and Narcotic Addict Rehabilitation Amendments of 1968.

As might have been foreseen, the provisions in all three basic "rehabilitation" categories were so complicated and so restricted that they have not been widely used. Even in so-called Title II cases involving convicted offenders, recourse to the Act has been sharply limited on the ground that facilities are not available to the Attorney General to implement its provisions. The Bureau of Prisons provides approximately a hundred beds for convict-addicts at each of four medical centers in Connecticut, Michigan, West Virginia, and California. Aftercare arrangements have been made with a score of local agencies. But only a few hundred persons in the federal prison system have been allowed the benefits of this program since its inception. In the other classes-minor offenders choosing civil commitment instead of prosecution under Title I and addicts volunteering or civilly committed under Title III-from the start the Surgeon General used his prerogatives virtually to nullify the Act by rejecting applicants found unlikely to respond to treatment or for whom it was certified that no facilities were available.

In 1967, to take pressure off the Surgeon General, the National Institute of Mental Health created a new Division of Narcotic Addiction and Drug Abuse, to run the two hospital centers, supervise research grants and projects in the field, and, through its Narcotic Addict Rehabilitation Branch, to oversee the rehabilitation program in both its inpatient and aftercare phases. For a time the program appeared to be expanding: one so-called halfway house began operating in San Antonio in connection with the Ft. Worth hospital, more contracts were let for outpatient facilities and supervision, and six regional field offices were established to monitor future activities. A total of more than twenty local community centers were launched with federal assistance amounting to approximately $10 million per year. A few additional millions from Mental Health Center Act funds found their way into matching grants for constructing and staffing addict treatment facilities. A few million more are being allocated to research projects (concentrated heavily on marijuana); several training programs for workers in the drug-rehabilitation field were set up, and a flood of pamphlets, posters, comic books, films, and teaching kits were produced and distributed. In 1970 President Nixon himself called for stepped-up educational and training efforts, whereupon $3.5 million were allocated to the Office of Education and an extra $1 million to NIH for these purposes.

But the concept of NARA, besides being buffeted among the three federal arms, suffered fundamentally from another of the great weaknesses of federal systems-namely, that unglamorous responsibilities can be shrugged off by each branch of government upon another. And rehabilitating addicts, as contrasted with trumpeting enforcement "wars" against them, is unglamorous in the extreme. The NIH Division renamed the Lexington hospital "Clinical Research Center," with the avowed purpose of turning it into a research and demonstration center for the guidance of local authorities. Its intake was limited to eligible civil-commitment patients who happened to meet its research needs, plus a flow of candidates for referral to local centers and facilities. In 1969 it was announced that the administration planned to close both the Lexington and the Ft. Worth hospitals altogether; they were kept open by vigorous protests from the Kentucky and Texas congressional delegations until after the 1970 elections, but Ft. Worth has been closed since then (dumping some 150 addict-inmates on the streets) and the "clinical research" at Lexington has been further restricted.

By mid-1971 only 1,500 patients had gone through the federal treatment program to the aftercare stage, aftercare being provided by over a hundred small-scale contracts in forty states, with emphasis thus dissipated away from such severe problem areas as New York California, Illinois, and the District of Columbia. An estimated 9,000 patients were in treatment in twenty-three federally funded local centers, and NIMH was predicting that by the end of fiscal 1972 the number of centers might be increased to thirty and the number of patients involved to between 12,000 and 15,000.

Under strong pressure from federal authorities, who supplied a BNDD counsel as reporter for the project, the National Conference of Commissioners on Uniform State Laws is drafting a Model Act, expected to parallel closely the provisions of NARA, for promulgation among the states. If this results in a flood of similar state programs-as it almost certainly will-the federal role will be further restricted in favor of the politically agreeable alternative of merely handing out federal funds to be spent by state and local authorities on "little NAIWs."

The most interesting, most promising, and most controversial rehabilitation efforts now being made in connection with addiction to the opiates are those which rely on the administration of methadone, a synthetic. equivalent of morphine developed by German chemists during World War II when Germany's access to natural opium crops was cut off. The effects of methadone are very similar to those of morphine and heroin, except that they act a little more slowly and last longer. Also, although methadone is indisputably addicting, withdrawal symptoms are somewhat milder than those of withdrawal from a comparable addiction to the other opiates. Moreover, it is believed to produce a slightly less intense euphoric 'high" when administered to addicts and (like any related substance with cross tolerance) it prevents increased euphoria from other opiates taken when it is present at a high level in the system.

It is worth stressing once again that the differences among opium derivatives and their synthetic equivalents are minor. The oft-heard assertion that heroin is notably more dangerous, or really much more likely to produce addiction than any of its sister substances, is misleading nonsense. Although heroin is fast-acting and has almost double the strength of morphine for an equivalent volume, the overall effects of comparable dosages are virtually indistinguishable. This is also true of methadone. A long-time addict, who does not know which drug he is receiving, can scarcely judge anything from effects alone. Neither Nalline reactions nor the chromatography processes used in urinalysis will distinguish heroin from morphine; the body metabolizes them identically. And identification of synthetics like methadone in such tests is not easy or certain unless the equipment used is extremely sophisticated.

Methadone was released in the United States in 1947 and soon came into use at Lexington and other hospitals as the preferred drug for administration in small quantities to alleviate the discomforts of withdrawal. It gradually acquired a popular reputation as a "good" narcotic in contrast with the "bad" qualities ascribed to heroin (no more foolish, perhaps, than' the "hard" and "soft" categories). This helped make it possible for two courageous New York doctors, Marie Nyswander and Vincent P. Dole, to launch an experiment at Rockefeller University Hospital, commencing early in 1964, in which they administered methadone on a controlled basis, but in large and steady dosages, to heroin addicts. The Dole-Nyswander theory is that by providing an adequate solution for the direct problems of addiction (methadone is administered orally, on a daily basis, and never given out for self-administration when there is any danger of diversion or abuse), their program frees the addict of pressures associated with his quest for drugs and thus enables him to work out other problems such as finding employment, restoring family ties, and malting personal readjustments, with psychiatric help if necessary. Only thereafter are efforts made to reduce or eliminate his drug habit, when the patient has readied himself to go free of his dependency.

This first Dole-Nyswander program was undertaken in tacit defiance of the federal Narcotics Bureau and local enforcement authorities in New York, but because of its eminent auspices it was not molested, and it soon began producing good results with a small, carefully selected group. By 1967 more than a hundred patients had survived on stabilized dosages, and by 1969 over a thousand were being managed successfully through three hospital centers in New York City. Attrition to alcoholism and other drugs cut into the program, and dropouts almost invariably went back to heroin. But "cure" in terms of total abstinence was not the primary objective, and the results claimed for maintenance were spectacular:

We have observed the almost literal return to life of people who have been as far down as it is possible to go-and whose present dignity and personal stature are the equal of many "decent" citizens we know. Visitors to our methadone services are often disturbed by their inability to tell who are patients, who are staff members, and who are both. The ex-addict on methadone is distinguished by only two things-the "tracks" inside his arms, and his new outlook on life.

Attacks were made from all sides on the alleged immorality of furnishing drugs to sustain addiction, and critics pointed out that this was really no more than the perennial error of substituting a new drug for an old one, as morphine had once been given to cure alcoholism and opium eating, and heroin had once been hailed as a nonaddicting remedy for the morphine habit.

But methadone has caught on. It is inexpensive (a few cents per day for an average maintenance dosage) and it has long been available through legitimate channels to persons with authority to prescribe. The ultimate promise of methadone is that it may offer a face-saving retreat from some popular and official exaggerations about heroin. Saying it "alleviates the craving" for heroin and "blocks" the euphoria of heroin highs is a good way to sugar-coat the reality that methadone is substantially a heroin equivalent. Stressing the novelty of methadone "treatment" preserves the fiction that all--or most, or many-opiate users are curable, or motivated to seek an abstinent state, or perhaps curable before they are motivated. By talking of methadone "centers" public-health authorities sidestep the ancient clinic controversy. Because the drug is easily and legally manufactured by U.S. drug houses, sinister myths about Chinese tongs, Sicilian criminals, Marseilles laboratories, and malevolent Turkish farmers can be avoided. And out-and-out maintenance of "incurables" can be camouflaged as long-term withdrawal.

At very least, methadone programs are drawing opiate addicts out of the drug culture -and away from the peddler-police domain. With urinalysis it is demonstrably easy to hold heroin and other related drug abuse by methadone patients to a minimum--easier, for instance, than keeping illicit drugs out of all but the most secure hospital and prison facilities.

More than three dozen methadone treatment units have been launched in New York since the Dole-Nyswander pioneering. Work with the drug is being carried on in every major urban center where addiction is a problem, including a score of projects sponsored and financed under Title IV (the grant-in-aid provision) of NARA. Private practitioners have taken on addict-patients in some instances, and programs have also been launched on a large scale by militant organizations such as the Black Man's Liberation Army, whose Washington, D.C., centers are reportedly in contact with more than 13,000 users, including some 3,000 nonblacks.

Nonetheless, development of methadone treatment has been harassed and resisted, instead of being encouraged, by some "experts" and authorities who have a stake in the status quo. Private undertakings like the Black Man's Liberation Army were forced to close from time to time by federal authorities who threatened their medical advisors, interfered with their suppliers, and sought to cut off their operating funds. Doctors prescribing methadone have been castigated, menaced, and in a few cases indicted. Accidents and diversions, inevitable in any large-scale program, are publicized out of proportion. Local police have sometimes sought to frighten addicts away from the programs by openly seizing lists of applicants and patients or by infiltrating the centers with undercover agents. Most sadly, some of the liberal and militant groups that should have been foremost in supporting methadone programs have been misled into fighting them by assertions that methadone is merely being used in an evil plot to perpetuate the enslavement of minorities (as if any enslavement could be more degrading than that of user to pusher and user-pusher to high-handed "nark').

The methadone dosages used to ease withdrawal symptoms range from five to twenty milligrams daily, depending on the severity of the user's habit. Maintenance doses administered by Dole and Nyswander to stabilize between euphoria or intoxication on the one hand, and drug-starvation symptoms on the other, reach the 100-to-200-milligram range (referring in all cases to oral administration). The only medical problem frequently associated with such dosages is a tendency to constipation. But law-enforcement spokesmen, supported by a few compliant echoers in the scientific community and by the customary parroting at the U.N. Commission, now take the line that maintenance dosages are a new, "experimental" use for methadone, requiring restrictive "Guidelines" and subject to all the crippling safeguards imposed on testers of new and untried substances.

We shall return to the details of this latest chapter of the methadone story as a final example of cynicism and folly in the American drug saga. Meanwhile let it be noted that while millions are spent on drug-education comic books, on teaching monkeys to smoke pot, and on buying the favor of indifferent Turkish poppy growers, nearly every significant methadone program in the country has a waiting list of desperate applicants trying to survive on the street until they can be admitted.

Other approaches to rehabilitation, sometimes coupled with methadone programs and urine testing but usually nonclinical, are also having modest success. For twenty years an offshoot of Alcoholics Anonymous, calling itself Narcotics Anonymous, worked with addicts in the Lexington and Ft. Worth hospitals and has maintained somewhat fluid chapters in New York, Chicago, and Los Angeles. Its achievements have been comparable to the effectiveness of A.A. in working with alcoholics: while not making large dents in the addict population it has enabled a number of persons who respond favorably to its religion-oriented program to free themselves from the drug habit and remain abstinent.

In 1958 a promising new endeavor was launched in California with the founding of what came to be known as Synanon, a private group organized by addicts and managed by ex-addicts with the assistance of a volunteer medical staff. Addict-candidates are admitted selectively and are subjected to what is called "attack therapy," fighting their problems in an atmosphere in which their fellow addicts will not tolerate weaknesses or self-pity. And this has helped hundreds, at least, to "make it." There are now other Synanon facilities scattered about the country, plus dozens of imitating groups-Daytop, Phoenix, Odyssey, Topic, Dare, Second Renaissance, Rap, etc.-each accommodating small communities of live-in members. Even the NIMH doctors at Lexington have one, called Matrix House. Techniques vary somewhat with group or "encounter" therapy and individual counseling instead of the tough Synanon program. These ventures have been helped by federal grants and local funding, though on a small scale, and they still number their participants only in dozens or hundreds. Some addicts who have been helped remain permanently and occupy themselves with assisting others; others are able to move back into society with more or less continuing contact and support from the organization.,

The U.S. Public Health Service's experimental halfway house at San Antonio has already been mentioned. There are now many similar facilities and programs aimed at easing the transition of treated or imprisoned addicts back into society, especially since the same concept has caught on with respect to rehabilitating prisoners in general. In these, addicts released from incarceration can live under more or less close supervision while at the same time going into the community to seek employment and make readjustments to a drug-free life. With urine testing they can also be effectively policed to prevent backsliding.

In sum, these contemporary efforts to rehabilitate drug addicts-remembering that we are talking only of drug users who have a true addiction problem-cannot be entirely written off, although the purported "cure" of such persons by pushing them involuntarily into rehabilitation programs is scarcely a realistic total solution. Since their inception in the 1930's, the two U.S. Public Health Service hospitals have admitted more than 80,000 addict-patients, and although reliable follow-up studies have been sparse, it is generally agreed that the relapse rate over the years has been no less than a pathetic 90 per cent, and probably considerably higher. Methadone withdrawal, urine-monitoring programs, the use of narcotic antagonists, and supportive group projects like Synanon and Daytop all play their part in salvaging addicts-by the handful-from the drug-using community. But it cannot be fairly concluded that they represent a main line of approach.

The hard-rock limit is that no user can be truly freed from his addiction or his bad habits by therapeutic efforts until he wants to be helped. And conversely, when most users become strongly motivated to give up drugs or bring their habits under control it is not much of a strain for them to do so. Most authorities agree that substantial numbers of drug addicts who, despite periodic hysteria to the contrary, do not generally become seriously involved with addicting drugs until they are young adults-have always simply dropped their habits and ceased to be addicts when they mature and move into middle age.

Finally, it might be observed that recently a new motive toward abstinence has been coming into play: the demand for ex-addicts to window-dress new projects and lecture young people so far exceeds supplies that this has itself become a rewarding career for those who can qualify.