The annual admission rate has varied considerably in the last 10 years. A rise from 1,753 in 1946 to 4,166 in 1953 was followed by a decline to 2,848 in 1955. The changes were due to the fluctuations in the annual rates of admission of voluntary patients-from less than 1,000 per year prior to 1946 to a high of 3,499 in 1953 and then down to 2,231 in 1955. The admission rate for prisoners has been fairly constant. The annual admission rate of probationers has declined steadily from a high of 222 in 1947 to a low of 53 in 1955. Annual Admissions.)

ANNUAL ADMISSIONS
1938-1955

U.S. Public Health Service Hospital
Lexington, Kentucky.

(Se graph,

1938 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 Fiscal Year

8

One of the changes in the addict population in the hospital is the increase in number of young Negro addicts. In Pescor's 1936 series there was 8.9 percent Negroes. In 1955 the percentage was 52 percent. The age distribution of the white males in 1936 and 1955 was similar-a fairly equal distribution by decades from 20 to 60. In the 1955 study 70 percent of the Negro males were under age 30 as compared with 27 percent of the white males. A study of 347 females discharged in 1955 showed that 48 percent were Negro and 85 percent of these were under age 30 with no female Negro over 40. The white females, like the white males, were fairly evenly distributed by decades from 20 to 60. (See graph, Age and Race: Male Addicts.)

Since Pescor's 1936 group was mostly prisoners, a study was made of the medical records of prisoners to obtain information on the age of onset of addiction as given by the patient. The data on the first 200 prisoners admitted in 1955 and the first 100 admitted in 1956 are compared with Pescor's findings:

These findings are in keeping with the age on first admission to the hospital of male addicts in 1955; 65 percent were 30 and under.

There has been a decrease in the number of Chinese addicts in the hospital from about 100, 10 years ago, to about 15 now. The number of Jewish addicts has decreased in the same period from about 100 to about 25.

Questions are frequently asked about the criminal records of addicts prior to addiction. A study was made of the Federal Bureau of Investigation records of the first 200 prisoners admitted to the hospital in 1955 and the first 100 admitted in 1956. This group is not representative of the patients admitted, since there were almost four times as many voluntary patients admitted in the same period. Voluntary patients were not included because Federal Bureau of Investigation records could not be requested. It is not necessarily representative of Federal prisoners who were addicts, because the prisoners who were sent to Lexington by the Bureau of Prisons are a selected group. It is obvious that it would not be representative of addicts generally. However, the findings were as follows: 30 percent of the prisoners had convictions prior to the stated age of onset of addiction.

TREATMENT PROGRAM

The treatment program is based on more than 20 years of clinical experience and research. The planning takes into consideration the individual and group characteristics of the patients, the limitations in terms of the number and quality of staff, the limitations imposed by law, and the limitations in our knowledge. The goal of the treatment program is as simple to state as it is difficult of accomplishment-to prepare addict patients to return to their home communities where they can continue their rehabilitation and live without using narcotic drugs.

When the addict comes into the gatehouse at the entrance to the hospital grounds his treatment program begins. There he surrenders any narcotic drugs and enters an environment where he is protected from the misuse of drugs. As soon as the usual medical record information is obtained in the admitting unit, a physical examination is done and appropriate medication is ordered. patient is admitted to the withdrawal ward if there is physical dependence on narcotic drugs and if there is no complicating disease requiring admission to some other infirmary ward.

12

The

Much has been written about the agonies of the opiate abstinence syndrome, and it is certainly a period of physiological upheaval. A system of measuring the intensity of the syndrome was developed by Himmelsbach 10 and Kolb." If a patient has physical dependence on an opiate drug, the severity and time of onset of the abstinence signs will be related to the dosage and the particular drug used. The signs include sweating, lacrimation, rhinorrhea, yawning, dilation of pupils, gooseflesh, muscle jerking (not convulsions), and cramps, anorexia, vomiting, diarrhea, insomnia, increases in blood pressure and temperature. These signs may be precipitated by the use of nalorphine.1 With competent medical care and use of the methadone substitution method the discomfort and dangers of the abstinence syndrome are minimal. This method is described in a number of publications by Isbell,13 Wilker," and Fraser 15 of the Addiction Research Center of the National Institute of Mental Health which is located at this hospital. The method, in brief, is to administer methadone orally in quantities just sufficient to keep signs of abstinence at a tolerable level and then to steadily reduce the dosage. The treatment of the acute phase of the abstinence syndrome which results from physical dependence on narcotic drugs usually requires less than 2 weeks. This is followed by a period of convalescence or subacute symptoms lasting about 2 weeks when the patient regains his strength, weight, and appetite, but is irritable, restless, and has difficulty in sleeping. Complete recovery from physical addiction takes about 4 months. The time and severity will vary somewhat according to the degree of tolerance and physical dependence of the patient and this in turn is determined by the drug used, duration of use, and daily dosage. When the patient is no longer receiving methadone and the acute abstinence signs and symptoms have abated,

10 Himmelsbach, C. K., and Small, L. F.: Clinical Studies of Drug Addiction. Supplement to the Public Health Reports: 125, 1, 1937.

11 Kolb, L., and Himmelsbach, C. K. Clinical Studies of Drug Addiction. Supplement to the Public Health Reports, 128, 1938.

12 Isbell, H.: Nalline, A Specific Narcotic Antagonist. 18 Isbell, H. Medical Aspects of Narcotic Addiction.

of Medicine, 31: 886-901, December 1955.

Merck Report, 62, 2: 23-26, 1953. Bulletin of the New York Academy

14 Wilker, A. Rationale of the Diagnosis and Treatment of Addictions. Connecticut State Medical Journal, 19: 560-568. July 1955.

15 Fraser, H. F.: Treatment of Drug Addiction. American Journal of Medicine, 14: 571-577, 1953.

transfer from the withdrawal ward to an orientation ward is made. When necessary, patients are transferred to another infirmary ward-medicine, surgery, tuberculosis, or physchiatric.

Each patient has an administrative physician. He is the physician who is responsible for coordinating and supervising the patient's program from the time he leaves the withdrawal ward until he is discharged from the hospital. The administrative physicians are first-, second-, and third-year psychiatric residents. Their work is supervised by staff psychiatrists. The patient may be in individual or group psychotherapy with another psychiatric resident; he may have his most meaningful relationship with his vocational supervisor or dormitory aid; or he may be in casework therapy with a social worker, but the overall responsibility for the patient rests with the administrative physician. He formulates the program, follows the progress of the patient and, except for prisoners, decides when the patient is ready to return to his home community. This system has been in operation since July 1955, and is based in a large part on the research of Stanton and Schwartz.16

The patient remains on the orientation ward for about 2 weeks while convalescence is occurring. During this time group discussions for orientation purposes are held with the patients. The patients are interviewed individually by members of the vocational, correctional, social service, and psychiatric staffs for diagnostic purposes and written reports made. The patient's administrative physician prepares a diagnostic summary formulation from the reports. This is reviewed with him by a staff psychiatrist and a treatment program for the patient is formulated.

Every patient who is physically able to work has a job. Most of the young addicts have had erratic or no work records. One purpose of the work assignment is to enable these self-centered and many times hostile persons to work with other people and to accept authority. Immature adults, like normal children, resist and reject authority because it limits their freedom of action. To many of our patients authority is regarded in terms of their past experience with their parents and society-as hostile, punitive, and rejecting. Constructive, consistent relations with authority figures of a different type may permit a modification of previous reaction patterns.

The program varies from one patient to another according to the patient's needs and the limitations of staff time and facilities. One element is common to all programs-residence in a drug-free environment for a minimum period of 4 months to recover from the physical addiction. This period also initiates the disestablishment of the habit of using narcotic drugs as a pattern of living to relieve anxiety or for euphoria. Those patients who appear to be suitable are offered the opportunity for individual psychotherapy and/or group psychotherapy. It is not expected that all patients will remain in the hospital until psychotherapy is completed because this may need to be continued beyond the time when hospitalization is indicated.

Group psychotherapy and activity therapy appear to be more suitable than individual psychotherapy for patients with personality trait or sociopathic disturbances. Because of their emotional immaturity, dependency, and hostility the most useful program seems to be one similar to the activity programs used with disturbed children. The immediate "therapist" is the person with whom the patient spends the most time. In most instances this would be the vocational supervisor. Consideration is given not only to the vocational needs of the patient but when indicated to the needs of the patient for continued association with a particular kind of staff person. The vocational supervisors are apprised of the patient's problems when it appears to be indicated and the supervisor can phone or otherwise discuss the patient with the administrative physician at any time. Staff psychiatrists provide consultation in discussions with groups of vocational supervisors.

The hospital is not a vocational training school but it does have a large variety of well organized and active vocational training programs which it is hoped serve as a medium for nurturing emotional maturation. The education and vocational training unit chief assists the section chiefs in the design of training programs preparing patients for "payroll" jobs. The accomplishments of the patients in these programs are amazing when viewed in the light of their past vocational history or lack thereof. It demonstrates the unactivated potential for change that exists within these patients. Each month the vocational supervisor sends a report to the patient's administrative physician rating the patient

16 Stanton, A. H.. and Schwartz, M. S. The Mental Hospital. Basic Books, Inc., 1954.

on cooperation, attitude, interest, dependability, and progress in skill learning. Ratings have been found to be useful indicators of ability to adapt to living in the hospital. Toward the end of his hospitalization assistance in getting employment is provided.

For many of the patients narcotic drugs were the only source of pleasure in living. One source of pleasure for most people is recreation-reading, athletics, movies, television, bowling, music, etc. The hospital attempts to provide the patients with opportunities for developing interests in recreation as one facet of living. These patients are able to participate more readily in passive recreation or individual activities than in any endeavor that requires active cooperation as a team member. Recreation can serve as a vehicle for learning to live with other people and to accept the limitations of behavior imposed by the rules of the game.

Part of the patient's day and evening is spent in the dormitory with other patients. This presents many opportunities for constructive, destructive, and neutral associations. Since narcotic drugs were the central and sometimes the exclusive preoccupation of the patients before hospitalization, much time is spent in discussions on this subject. Until a few years ago the women patients were in a separate small building a short distance away from the main building. A frequent comment by the staff at that time was that the men spent so much time talking about drugs. Now the comment is that they spend so much time talking about women.

The aide on the dormitory has an important role in the hospital program. The responsibilities include helping the patients learn to live with other persons without more than the ordinary amount of strife; helping the patients to learn other adult patterns of living and, most important, the aide can listen to patients' problems and when indicated provide advice and encouragement. The dormitory aide can get assistance from his supervisor or if the problem is with regard to a particular patient then he can consult with the patient's administrative physician. A 12-month training program of classroom, demonstration, and supervised assignments is used to prepare aides for their work.

The social work service participates in the diagnostic studies and has the responsibility of identifying the social service needs of the patient. The principal activity is to provide casework services to patients. The problems presented range from personal problems of the patient in the hospital to family problems in a community many miles away. The staff does all the work related to parole and is the liaison with the probation officers.

Religion is an important part of the lives of many patients. The hospital has Catholic, Jewish, and Protestant chaplains whose duties include conducting services, individual counseling, and group discussions. The College of the Bible of the Christian Church operates a chaplain-training program at the hospital which is supervised by the Protestant hospital chaplain. The trainees work with patients as a part of their training.

Acting out behavior of persons with neuroses or character disorders is a problem whether at home, in the community, or in the hospital. For 20 years this hospital had a so-called adverse behavior clinic which has now been discontinued. Patients with problems are assisted by the staff members who have direct relations with them. When necessary, the supervisor, administrative physician, or a staff psychiatrist is available. Action that appears most helpful to the patient is taken.

When is hospitalization terminated? For the prisoner this is determined by the sentence received, the action of the Board of Parole, and earning of "good time." For some who demonstrate that they are unsuitable for treatment at the hospital it is terminated by transfer to a prison. Patients who are on probation or are committed by the District of Columbia courts remain until hosiptal treatment is completed. Voluntary patients can terminate their stay at any time.

Of the 350 infirmary ward beds, 150 are for nonaddict patients with mental disorders. Most of these patients are Merchant Seamen or United States Coast Guard personnel who have been transferred from other United States Public Health Service hospitals that do not have psychiatric services. The few addicts who are psychotic are admitted to these wards. About 85 beds are in the withdrawal wards for men and women. The medical and surgical wards have about 115 beds. The staff of the Addiction Research Center of the National Institute of Mental Health and about 30 consultants in the various medical specialties are available as consultants to the regular hospital staff.