REHABILITATIVE AND PSYCHIATRIC TREATMENT Following the withdrawal of opiates and/or barbiturates rehabilitative and psychiatric treatments are instituted. Residual symptoms of abstinence from drugs, such as feelings of weakness, varying degrees of insomnia and anorexia may persist for several weeks but "the physician must adopt a reassuring but uncompromising attitude." Opiates and barbiturates must not be indulged in once the withdrawal period is completed. Intercurrent physical illnesses are handled in the same manner as they would be in a nonaddict patient. If surgical procedures are required in an addict who has been withdrawn from drugs, opiates and barbiturates are administered preoperatively and postoperatively in the same dosages as would be given to a nonaddict. Once the acute phase of illness has passed, opiates and barbiturates must be rapidly eliminated. General rehabilitative measures consist of dietary, vocational, recreational and social procedures. Malnutrition is a common condition of addicted patients. But once drugs have been withdrawn recovery of appetite is spontaneous and a good general diet will rapidly improve the nutritional status. Gastrointestinal complaints often may be ameliorated by ancillary psychiatric measures after ruling out organic diseases. Often, symptoms suggestive of visceral disease are not confirmed and they may subside as the patient's adjustment within the hospital improves. Vocational therapy plays an important part in the rehabilitation of the addict. A large percentage of addicts have not developed a satisfactory work pattern. Mere assignment of a job to an addict patient carries little hope of permanent occupational adjustment. Nevertheless a job of some kind within the institutional setting is necessary to occupy part of the patient's time. In the younger addicts particularly, a profitable and interesting vocational assignment, leading to some specialized skill, may prove very helpful. A well-rounded school program, which functions at all educational levels, is a valuable supplement to vocational treatment. Complete vocational rehabilitation requires that during hospitalization plans should be made for finding the patient a suitable job in the community to which he returns. Such job placement may prove difficult because of social ostracism of former addicts. The inadequate recreational and social life of many addict patients reflects a further deficiency in their adjustment to our cultural environment; just as the addict frequently has not learned to work, neither has he learned to play. Recreational measures should be more than a matter of physical exercise and should teach socialization and group participation as well. For these reasons the recreational program should be diversified and include organized sports, motion pictures, shows directed and staged by patients, a library and facilities for playing indoor games, cards, etc. The above general rehabilitative measures are only supportive. Psychologic treatment directed toward the patient's personality needs is necessary if any permament success is to be expected. These include participation in Addict Anonymous (based on the principles of Alcoholics Anonymous), group psychotherapy and individual psychiatric treatment with a complete follow-up of the patient to his own community. In addition, where specifically indicated, such physical forms of psychiatric treatment as electroshock therapy, insulin shock, lobotomy, etc., may be used provided the severity and specificity of the emotional illness warrants this; but it must be emphasized that these more radical measures are of no value in the treatment of drug addiction per se. Addict Anonymous was first organized by the patients at the Public Health Service Hospital in Lexington, Ky. Participation in this program yields a type of mutual support and acceptance that some addicts are able to utilize whereas insight psychotherapy may be unacceptable. It has been the experience of the Lexington Hospital that Addict Anonymous has contributed significantly to better institutional adjustment. Many discharged addicts later identify themselves with their local "chapter" of Alcoholic or Addict Anonymous. Group therapy has been used in this institution on a trial basis. As with other types of treatment of addiction, the effectiveness of group therapy is difficult to evaluate since follow-up studies to determine the incidence of relapse in any specially treated group as compared to a group given routine treatment are very difficult to carry out. However, mutual discussion of emotional problems and social participation with other patients would seem partially to fulfill some of the obvious needs of the poorly motivated addict. Individual treatment of the addict is a challenging problem. Many addicts deny any need of psychiatric assistance and many frankly refuse therapy. The drug addict has "found something"-morphine which allays his vague free-floating anxiety. To demand of him that he relinquish a tested product for the relatively unpredictable success of psychotherapy is to demand more than many addicts can give. In older addicts frequently patterns of dependence, aggressiveness, passivity and other faulty adjustments have been so firmly established that significant changes in personality structure are not to be expected. However, there are many patients who have sufficient awareness of their anxiety to recognize the need for psychiatric help. As with the alcoholic, psychiatric success is difficult to evaluate and actual cure is regarded by some as unobtainable. Nevertheless, some of these patients are helped. "As with the chronic alcoholics many relapses may be followed by a permanent cure." If individual psychiatric therapy is to be administered it is necessary to evaluate the therapeutic prognosis of individual patients by medical, psychiatric and psychologic measurements so that patients potentially amenable to psychiatric therapy can be selected. Such measurements would eliminate the aged and chronically ill patients, the physically healthy addicts who have repeatedly resorted to drugs for the solution of their emotional problems, and the severely disturbed neurotics or psychotics who may defy treatment whether or not they are addicts. Experience indicates that psychiatric treatment should be directed toward young patients with relatively well developed ego strengths who express, or are capable of expressing, overt anxiety and whose strivings and goals show good contact with reality and awareness of social and cultural demands. The merits of psychoanalytical or nonanalytical treatment will not be argued here. Whatever type of psychotherapy is given should be individualized and administered at regular intervals over a prolonged period. Although continuation of psychotherapy after discharge may be difficult, every effort should be made to provide the patient with psychiatric treatment in the community to which he returns. Prognosis.-The use of addicting drugs to the point of physical dependence does not necessarily produce a habitual lifelong addict. Social and environmental pressures may lead to a state of addiction but once satisfactory treatment has been carried out the patient may find, either individually or through psychotherapy, ways of handling tensions and anxieties without resorting to drugs. Data are available that indicate that a fair percentage of addicts are able to abstain from the use of drugs for prolonged periods and, in some instances, permanently. Pescor, 15 in a followup study of 4,766 male patients discharged from the Lexington hospital between January 1, 1936, and December 30, 1940, found that the status of 39.6 percent was unknown, 7 percent had died, 39.9 percent were known to have relapsed to the use of drugs while 13.5 percent were known to have remained abstinent for at least 3 years. Vogel 16 stated that up to January 1, 1948, 11.041 patients had been admitted to this hospital. Of these 61.4 percent had been admitted only once, 25.6 percent twice, 6 percent 3 times, 2.9 percent 4 times and 3.8 percent 5 times or more. His report also showed that 54 percent of discharged male patients and 61.9 percent of discharged female patients had not been reported to have been admitted to any correctional institution or held for any law violation. Nemec 17 currently reports that since the opening of the Public Health Service Hospital in 1935 at Lexington, Ky, a total of 18,699 patients had been admitted through June 30, 1952. Of this number 12,005, or 64 percent were first admissions only; 4,004, or 21 percent, were second admissions; 1,170, or 6 percent, were third admissions, while all other patients with 4 or more admissions comprised the remaining 9 percent. Although there are no statistics available on the prognosis of barbiturate addietion, there is no reason to suppose that the outlook is more favorable than in narcotic addiction or alcoholism. Even though an addict may return to the use of drugs, hope should not be abandoned. Although the prognosis becomes worse with each relapse, cases are known that have abstained permanently after several relapses. Also, addicts, even though they do relapse, are frequently productive and socially useful during periods of abstinence between addictions. This definitely represents a considerable gain and makes further treatment worth while. Prevention of drug addiction.-The prevention of addiction would seem to depend on (1) control of the source and supervision of the dispensing of addicting drugs; 15 Pescor, M. J. A statistical analysis of the clinical records of hospitalized drug addicts. Pub. Health Rep. Supp., 143, 1943. 16 Vogel, V. H. Treatment of the narcotic addict by the Public Health Service. Federal Probation, 12(2) June, 1948. Unpublished data. 17 Nemec, F. C. (2) prompt and satisfactory treatment of addicts and (3) a well-directed mental health and education program. The legal control of all sources of narcotics and barbiturates is one effective prophylactic measure available. 18 19 For example, during the last world war, when smuggling of contraband narcotics was at a minimum, the census at the Lexington hospital was significantly reduced. In the United States the highest occupational incidence of narcotic addiction is among physicians and nurses, those having the greatest accessibility to narcotics. Prompt treatment of all addicts is, of course, indispensable since each addict is a potential source for extension of addiction. For example, it is well known that if one spouse is an addict the other spouse is much more apt to become addicted. In the United States mental health and educational programs are now being employed more extensively and, after several years, we may be able to better evaluate their effectiveness in reducing addiction. The physician should avoid prescribing barbiturates continuously for relief of nervousness and insomnia, especially in neurotic patients or those with a history of alcoholism, because such patients are prone to take drugs in excess and so become addicted. Likewise, caution is in order when administering natcotics to this class of patients.20 The physician should also employ the same care in the prescription and administration of any of the new synthetic analgesics that he knows to be applicable to the use of morphine. All of these substances (methadone, dromoran, nisentil, etc.) have morphine-like properties, have proven addiction liability and are subject to the same restrictions as morphine and its derivatives. EXHIBIT No. 3 [Reprint No. 924 from the Public Health Reports, May 23, 1924 (pp. 1179-1204)] THE PREVALENCE AND TREND OF DRUG ADDICTION IN THE UNITED STATES AND FACTORS INFLUENCING IT1 TREASURY DEPARTMENT, UNITED STATES PUBLIC HEALTH SERVICE, HUGH S. CUMMING, SURGEON GENERAL By Lawrence Kolb, Surgeon, and A. G. Du Mez, Pharmacologist, INTRODUCTION There have been published during the past decade many estimates of the number of persons in the United States addicted to the use of narcotics. The numbers estimated range, in round numbers, from 100,000 to 1 million (1-6). Some of the estimates are mere guesses, as they were based on nothing tangible, but most of them represent sincere attempts to arrive at accurate figures. All, however, are open to criticism on the ground that they are based on insufficient data, or that not all of the pertinent factors were taken into consideration. For the same reasons the published statements in which it is asserted that the present trend of addiction to narcotics in this country is upward are subject to criticism. Owing to the lively interest which has been taken in the problem of addiction to narcotics throughout the world since the end of the World War, and as a result of the enactment of new laws for the more rigid control of narcotics in this country, there have been made available additional statistics on the traffic in narcotics and on certain other phases of addiction. It is believed that the proper interpretation of these statistics and their application to the problem in hand-make possible a more accurate estimate of the number of narcotic addicts in this country than any heretofore published, and serve as a means with which to determine accurately the trend of addiction. For these reasons, the study herein reported was undertaken. 18 Tennyson, Alfred L. The history and mechanism of national and international control of drugs of addiction. Am. J. Med., 14: 578, 1953. 19 Anslinger, H. J. Narcotic control by physicians. J. A. M. A., 148: 1275-1277, 1952. 20 Vogel, V. H. The treatment of narcotic addiction. Postgrad. Med., 12: 201-206, 1952. 1 Reprint from the Public Health Reports, vol. 39, No. 21, May 23, 1924, pp. 1179-1204. NUMBER OF ADDICTS It is realized that it is impossible at the present time to make an exact count of the persons addicted to narcotics in the United States, in an individual State, or even in one of our larger cities, because of the social and legal factors tending to make addiction a secret practice. It is believed, however, that it is possible, by utilizing all of the information now available, to delimit the number by certain maximum and minimum figures. With this object in view, a number of the more important narcotic surveys made in recent years were analyzed; also the reports made by agents of the Bureau of Internal Revenue and other persons on the narcotic clinics conducted in different parts of the country; statistics on the dose of addiction, world production of narcotics, and the quantities imported into this country were compiled and studied; and numerous physicians in different parts of the country were interviewed in person to ascertain the number of addicts they were treating in the course of their practice. The results of these analyses and studies follow. 1. NUMBER BASED ON NARCOTIC SURVEYS AND CLINIC REPORTS Tennessee survey (4).-One of the most complete surveys of drug addiction for a large community was made in Tennessee by Lucius P. Brown, State food and drugs commissioner. In 1913 Tennessee passed a law regulating the sale of narcotic drugs, and under it regulations were made which provided for the refilling of prescriptions for persons addicted to opiates. The purpose of these regulations was to minimize the suffering among addicts and to keep the traffic in opium from going into illegitimate channels. In order to obtain a regular supply, addicts were required to send to the pure food and drug inspector their own affidavit accompanied by one from a physician certifying to their addiction and giving certain other information. In the discretion of the board of rules and regulations a permit would then be issued authorizing the refilling of the prescription. This permit would be surrendered by the addict to a pharmacist, who was required to make a copy and return the original to the food and drug inspector. On January 1, 1915, after 12 months of operation, there were 2,370 persons of various ages, white and Negro, registered under this system. Commissioner Brown was of the opinion that all of the addicts in Tennessee had not registered, and he fixed 5,000 as the probable number in the State. Using this figure as a basis he estimated 215,000 for the entire country. He then added 25 percent to allow for conditions which he thought existed in more thickly settled communities and arrived at 269,000 as the possible number of addicts in the United States. Treasury Department survey (5). —A special committee appointed by the Secretary of the Treasury in March 1918, made the most comprehensive survey of drug addiction that has yet been made in the United States. One of the means used by this committee for securing information consisted of sending out questionnaires. For the purpose of ascertaining the number of addicts under treatment, questionnaires were sent to every physician registered under the Harrison Act, and replies were received from approximately 30% percent of them. A total of 73,150 addicts was reported. If there had been 100 percent replies with the same average maintained, there would have been shown to be 237,655 addicts under treatment for the entire country. Pennsylvania survey (7).—In 1917 there was created in Pennsylvania a bureau of drug control, operating under the State narcotic law. A survey made by this bureau shows that in 1922 there were treated in the hospitals and State institutions of Pennsylvania 1,652 addicts. For 5 years this bureau industriously collected the names and addresses of drug addicts living in Pennsylvania, and in that time they obtained less than 9,000 names. The chief of the bureau estimated that, counting the aged and infirm addicts and all persons who necessarily use narcotics for incurable diseases, there were not more than 20,000 habitual drug users in the State. On the basis of the 1922 census and 20,000 addicts for Pennsylvania, there would be a total of approximately 242,000 addicts in the United States. United States Army findings (8).-The mobilization of manpower following our entrance into the World War was a means of furnishing the country with valuable data concerning various diseases of young men and the conditions which disable. Data on addiction to narcotics were among the information thus obtained. Up to May 1, 1919, there had been recommended for rejection because of various mental and nervous diseases, 72,323 men out of a number approximated at 3,500,000 (9). Among those recommended for rejection, only 3,284 were drug addicts. Col. Pearce Bailey, chief of the section of neurology and psychiatry, in commenting on this, states that some persons particularly interested in drug addiction had warned them to be prepared for 500,000. He also intimates that there was very little traffic in drugs in the camps in this country and in France, as practically no cases of drug addiction were reported among the soldiers. He points out that access to drugs by the soldier was not easy, and "addicts, if they had been in France cut off from the drug, would have been found inevitably in the hospitals." The Army rate, if applied to the entire population of this country as shown by the 1920 census, would give a total of approximately 99,500 addicts in round numbers; but this rate, for obvious reasons, can not be applied to the country as a whole. Clinic reports made by revenue agents (10).-Early in 1919 there was a feeling among some members of the medical profession and officials in different parts of the country that it would relieve the suffering and distress of addicts who had been deprived of legal means of securing narcotics if a cheap source of supply was made available to them. In response to this feeling a number of clinics were opened and operated in different parts of the country for variable periods of time. Some were operated for a few months only, while others remained in operation several years. The narcotic division of the Bureau of Internal Revenue has in its possession reports on 44 of these clinics, 34 of which contain statistical information relative to the number of addicts treated, etc. These records have been reviewed and the data compiled therefrom are presented, together with the population of various cities in which the clinics were held, in the following table: Most of the clinics were opened in 1919 and most of them were closed before 1921. One closed in 1923 and one still operates in a modified way. In compiling the above figures from the reports, the highest number of addicts recorded at any one time or in a certain year are given. For instance, if at the time of inspection the clinic was taking care of 125 addicts and the records showed that 300 had been given narcotics in the course of the year, or the life of the clinic, if in operation for less than a year, this particular clinic was credited with 300 addicts. Or, if a statement was made that there were a certain number of addicts in the city, as in the case of Shreveport (419), the highest figure given was used. No reduction whatever was made in the totals for transients, although the reports show that many of the clinics treated addicts from distant as well as nearby places. The table shows that there were 4,123 addicts in 34 cities having a total population of 4,182,952, or 0.98 addicts per 1,000 persons. At this rate there would have been 104,300 addicts in the United States at that time. New York City clinic (11).-A clinic not included in the foregoing list was the one located in New York City. This was one of the largest and one of the first of the kind to be opened. During the period April 10, 1919, to January 16, 1920, |