STATEMENT OF GEORGE SOLOMON, M.D., ASSOCIATE PROFESSOR OF CLINICAL PSYCHIATRY, STANFORD UNIVERSITY MEDICAL SCHOOL; FORMER CHIEF OF STANFORD PSYCHIATRIC SERVICE, PALO ALTO VETERANS' ADMINISTRATION HOSPITAL

Dr. SOLOMON. I intend to do that, Senator Cranston, because much of what I have to say has been covered by the gentleman from the Aquarian program, and I agree with most of what Dr. Cohen had to say.

Incidentally, I must preface my remarks to say that officially I do not represent the Veterans' Administration nor Stanford University, and I speak as an individual physician.

I shall summarize my statement and comment on some of the other points brought out.

One thing that has not been said that I should like to emphasize is that the problem of heroin addiction is really part of the broader problem of psychiatric casualties in Vietnam. Although these casualties have been purportedly very low-for example, 12 per 1,000 troops in 1968 compared with the ratio of 35 per 1,000 per year in the Korean conflict-this low rate, I feel, is utterly misleading. The supposedly low rate has been linked to the fixed tour of duty of 1 year, good communication with home, periods of rest and recreation, relatively brief periods of actual combat, and especially to lessons learned from previous wars; namely, reluctance to evacuate cases of "battle fatigue" to the rear. Our experience in the Veterans' Administration hospital in Palo Alto has shown that very few of our psychiatric casualties have ever come to psychiatric or even medical attention in Vietnam.

Of 50 random psychiatric admissions of Vietnam veterans to the Palo Alto Veterans' Administration hospital in early 1970 and 1971, only eight had come to medical attention because of emotional problems while in the service. Many were seriously ill. Of these 50 patients, 60 percent had diagnoses of psychotic illnesses, the most common being paranoid schizophrenia. More than one-half had drug abuse problems. Many had been referred to the VA hospital through police, rather than medical channels. I want to emphasize, too, that drug abuse often coexists with emotional problems.

Senator CRANSTON. Do you have any data that relates with earlier wars?

Dr. SOLOMON. I did mention the figure in the Korean conflict, comparing 35 per 1,000 per year with the 12 per 1,000 figure in Vietnam. I think, however, the actual rates of psychiatric casualties in Vietnam are just as high as in Korea and considerably higher if drug abuse is included.

Senator CRANSTON. On the point of how many had earlier mental problems

Dr. SOLOMON. How many of these individual people had earlier mental problems in their own histories?

Senator CRANSTON. In prior wars, yes. In the middle of page 1 of your prepared text you say of 50 psychiatric admissions of Vietnam veterans to the Palo Alto VA hospital, only eight got medical attention because of emotional problems while in the service.

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Dr. SOLOMON. What would the percentage have been for prior I would say that probably over 50 percent would have been recog in the service. I am not sure of that figure, but I think it would majority.

Now, I also feel that some individuals in Vietnam who are h emotional symptoms utilize heroin essentially as a tranquilizer, s their symptoms would have shown up in other ways if they ha become addicted. As was said before, heroin addiction can be se a symptom of mental illness or emotional problems, and can be sidered itself as a chronic and relapsing disease, as Dr. Cohen Why don't these cases show up early in Vietnam? There has strong evidence that if a person is evacuated for mental reason never gets back in the front lines, and there has been a tenden return persons with emotional or behavior symptoms to combat. In relationship to heroin specifically, I think that in some way use of drugs, as was commented on by some of the former addicts before, makes it possible to face otherwise unbearable situation when you ask why didn't command notice it, perhaps there was a subconsciously not to notice it. Many veterans will make a state such as, "If I wasn't stoned, I would have split."

The extensive use of administrative discharges has been comme on, so that emotional problems manifesting themselves in behavio drug abuse are seen as disciplinary problems and not me problems.

One thing that has not been commented upon, particularly, is late appearance of psychiatric problems after returning home. employment problem was mentioned in these hearings. But I th that there are other issues that make the reentry of the Vietnam eran particularly difficult in this war.

He is not returning a hero. He may even be regarded as a par His attitudes toward our country may have altered significantly, what he has seen in Vietnam may have changed him in very imp tant ways, so he is not the same person as when he left. Soldiers s great deal of corruption, devastation, and futility. They become illusioned with what they were taught by their parents, the "est lishment" and their superiors.

I don't think we can overemphasize the profound psychologi effect to many veterans of their unique personal experiences in t war. They, as I said, do not get reinforcement when they come ba as having done a good thing. Many civilians will regard them as d fiends or killers, and some employers want a long period of time elapse before they will accept an application from a veteran of Vi nam, to be sure he is not an undesirable person.

We had a patient, whom I call in my statement "C," who was captain in the military police. He came from a conventional, midd class background. He strongly believed in our country and our cau in Southeast Asia. While in Vietnam, he gradually began to chan his attitudes and values. His daily experiences, particularly in refe ence to profiteering, corruption, and vice, appalled him. He read the protest movement on the campuses. Upon returning home, " had difficulty relating to his parents, whose values he no longer share and to his peers, especially the anti-war groups who could not en

phathize with his experiences in Vietnam. He could not find a good job and failed an attempt to re-enter college. "C" became a heroin addict after returning to the States.

Traditionally, we think of three factors in drug addiction: susceptible personalities, emotional stress, and availability of drugs. In regard to susceptible personalities, it has been pointed out that many middle-class, educated young people are becoming addicted nowadays. That is true, but if you look at the selective process for how one ends up in Vietnam, it seems that those who are in some ways disadvantaged have an over-proportionate representation. If you are intelligent, wealthy, and articulate, you can go to college and write convincing, erudite statements of conscientious objection, or obtain medical or psychiatric disqualification.

In the military itself, Vietnam is no longer considered an elite or desirable tour, and once in Vietnam, the "grunt" out in the field is the one not cunning enough to stay back. Thus, those in the field exposed to the most may have the least capacity to cope with it.

The nature of the stress itself seems to be self-evident, but let me mention some special features of the stress in Vietnam.

Young officers are often not well trained for the peculiar kind of guerrilla war being fought. Their men may have little faith in their leadership. Stories of poor judgment on the part of lower echelon command are very common. There is emphasis on "kill ratios" rather than territory secured, so men are facing situations which would otherwise seem unwise or immoral.

The fixed 1-year tour of duty leads to continual changes of make-up of units, preventing the development and maintenance of essential espirit d'corps. The identity of the enemy is unclear, with a blurring of distinctions among Vietcong, North Vietnamese soldiers, and civilians.

There is even ambivalence about Indochinese allies. For example, "X" was considered a "gung-ho" soldier. He deeply resented antiwar demonstrations at home. After Vietnamization of the Delta, he was involved in ferrying ARVN troops by helicopter to areas of operation in the Delta. Frequently the South Vietnamese soldiers were reluctant to land and had to be forced from the "choppers," sometimes by beating their hands as they clung to the runners. Two of "X's" friends were killed by bullets from U.S. M16 rifles shot by resentful ARVN troops after they had been landed. "X" turns to heroin in order to be able to keep flying, while many of his friends refused flying status. He is now militantly antiwar.

A major stress is the absence of a credible relief system and the breakdown of consensus about the war, even in Vietnam itself. Now that the President has committed the United States to progressive withdrawal, soldiers are even more reluctant to risk their lives. In the absence of a sense of righteousness and meaningfulness, in the presence of strong, basic moral principles, and with the younger generation's tendency not to accept the reasons or rationalizations provided by the "establishment" or older generation, strong feelings of guilt may ensue. Lack of external support reinforces guilt. Unresolved guilt may have a variety of self-destructive consequences. The soldier may himself feel victimized by our society for being in Vietnam, leading to resent

ment and bitterness. Fear, low morale, guilt and anger are powerful emotions. Heroin is a powerful antidote.

Regarding availability, heroin in Vietnam, plentiful since the latter part of 1969, is strong, cheap and ubiquitous. The drug sold in Vietnam is over 95 percent pure, while "street" heroin in the United States is generally 40 percent pure. A $10 a day habit in Vietnam roughly translates into a $200 a day habit at home.

Veterans who are addicted to heroin are very heavily so. Some have even reenlisted to return to Vietnam for inexpensive, powerful heroin. The habit may begin by "sniffing." Often soldiers think they are taking cocaine, but in reality they are establishing an addiction to heroin.

The pusher may be a "papa-san," a family man with whom the lonely soldier forms an affectionate parent-surrogate relationship. A drug-supplying papa-san of one of our patients offered his daughter in marriage, considered a great honor. On the other hand, another of our patients reported killing his "boy-san" who "burned" him by not returning with the heroin for which he had been given money.

Prior experience with hard drugs clearly predisposes to addiction in Vietnam. The nearly universal use in Vietnam of marihuana, itself more potent than the usual "grass" smoked here, makes its role unclear in regard to leading to use of stronger drugs. "Z" reported being "righteously strung out" prior to induction, but was taken into the Army anyway. However, he "cleaned up" promptly in the service and performed very well. He was in charge of a group of Vietnamese civilians. A cook was raped and murdered by one of his unit. “Z” promptly returned to using heroin.

Let me take a public health model approach to the problem of heroin addiction in Vietnam. "Primary prevention" refers to prophylaxis against the disease. The first method is to eradicate the diseasecausing agent, in this case heroin. The "reservoir" of the agent might be dried up. It seems unlikely that sources of supply in Laos and Thailand promptly can be eliminated. The "vector" or mode of transmission, in this case distributors and pushers, might be interdicted a complex socioeconomic, political and enforcement issue.

A second approach is increasing the resistance of the host-providing less susceptible personalities, reducing the stress, or “immunizing" by educational programs. Previous drug education has suffered in credibility because sufficient differentiation was not made between marihuana and hard drugs and because so much other military briefing turned out to lack validity, leading to a discounting of such instruction. Neither eradicating the agent nor increasing resistance seem realistic short-term solutions. The final method of primary prevention is eliminating exposure to the agent, namely, withdrawal of all U.S. troops.

"Secondary prevention" involves reversal of the disease process. As in all illness, early detection and treatment are highly desirable. There should be vigorous case-finding in Vietnam. The principle of amnesty from disciplinary action is essential. Heroin addiction must be considered and treated as a medical problem.

Soldiers might be observed for needle "tracks," for evidence of being "on the nod." and be subject to urine tests for opiate metabolites. De

toxification centers utilizing methadone withdrawal should be set up in Vietnam. Soldiers will not turn themselves in for withdrawal or readily accept withdrawal without methadone. Addicts refer to tranquilizer drugs such as thorazine as "aspiring." The addicted soldier is terrified of being sick and of how to maintain his habit after returning home. He will avail himself of adequate, compassionate treatment in Vietnam.

It is obvious that "secondary prevention" will not be sufficient for many addicted soldiers, especially those with particularly "heavy" or longstanding habits. Many will relapse even if withdrawn. Facilities must be available for "tertiary prevention,” accepting the addict as a handicapped person and providing for his complete rehabilitation. Methadone maintenance programs are very useful in this regard. The drug abuse treatment program of ward 4B2 of the Palo Alto Veterans' Administration Hospital under the leadership of Vincent P. Zarcone, M.D., assistant professor of psychiatry, Stanford University School of Medicine, reports an 80 percent early success rate with heroin addicts on methadone maintenance. There was success with only 4 of 14 addicts not on methadone maintenance.

However, Dr. Zarcone's group feels strongly that methadone maintenance alone is insufficient and must be combined with a complex therapeutic milieu including: group and individual psychotherapy; family groups; "progress and planning" meetings involving representatives of staff and patient community which focus on the individual's progress and include his making a "contract" specifying new behaviors to be attempted; community meetings; ward government; psychotropic drugs; and rehabilitation services.

There is a combination of encounter group techniques and task orientation. The three phases of the program, namely, "cleaning up,” "getting your head on straight," and "learning to live in the real world," last 12 to 16 weeks. After discharge, those on methadone maintenance return every morning for medication, once a week for social therapeutic involvement, and monthly for progress and planning.

A therapeutic community takes time and effort to establish. It depends heavily on peer group pressure; for example, patients' knowledge of one another to ferret out drug-taking behavior. Patients respond to basic American values of democracy, participation, and fairness exemplified by the community.

Staff must be young, relatively "hip" and work to develop cohesiveness. Conscientious objectors and carefully selected former addicts have worked out well as staff members. The 4B2 program, with a population of 21 patients, has a staff ratio of approximately one to one. The enormity of the problem of adequate tertiary prevention is immediately apparent. Official figures state that 10 percent of troops. currently in Vietnam are addicted to heroin; the actual rate may be at least double that. A typical patient of ours reported about 35 of his unit of 96 men were "shooting up." Where can we find and train that many treatment personnel, particularly core professionals?

The problem of drug abuse in soldiers and veterans must be tackled by the inilitary, by the Veterans' Administration and by community resources. As many addicts as possible should receive at least prelimary treatment prior to discharge from the service.