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It has been my intention to indicate that a great many persons have important roles in the treatment program at the hospital-the aide on the dormitory, the vocational supervisor, the physician, the social worker, and the consultant, to name some. It was also my intention to emphasize that completion of hospitalization is not completion of rehabilitation for the patient. This can only occur after the patient has left the hospital and has returned to his home community.
One way of describing results is in terms of the number of persons who were hospitalized and treated. From the time the hospital opened in 1935 until the end of fiscal year 1955, 23,625 addicts were admitted a total of 45,058 times. Voluntary patients accounted for 29,002 of the admissions and almost 24,000 of these occurred in the last 10 years. A study of 17,741 patients admitted from 1935-52 was made in 1955 to determine the number of times patients were hospitalized. There were 34,539 admissions in this period. Fourteen percent of the patients were admitted three or more times and accounted for 42 percent of the total admissions. Twenty-two percent were hospitalized twice and 64 percent were hospitalized once. (see graph, Number of Times Admitted.)
Another way of determining results is to ascertain how many patients stay in the hospital until hospital treatment is completed. A study of the 765 male voluntary patients discharged in January through June 1955 showed that 40 percent stayed less than 15 days and an additional 15 percent left by the end of 30 days. About 30 percent stayed until hospital treatment was completed. (See graph, Length of Stay, Male Addicts, Voluntary.)
A study of 302 female patients discharged in the same period showed similar findings for the first 30 days but only 23.5 percent stayed until hospital treatment was completed. It should be noted that there was only a slight difference between the experience with first admissions and readmissions.
The results of hospitalization can be expressed by comparing the condition of the patient at the time of discharge with his condition at the time of admission. Patients are classified as "unimproved" if physical dependence is present at the time of discharge, or if there is no progress toward freedom from psychological dependence. "Hospital treatment completed" means that at the time of discharge there was freedom from physical addiction and enough progress toward freedom from psychological addiction had occurred so that discharge to the community is indicated. "Improved" is the status between these two.
In 1955 about one-third of the addict patients admitted stayed in the hospital for such short periods that their condition on discharge was "unimproved." These were voluntary patients. About one-third of the patients were discharged as "improved" and one-third reached the status of "hospital treatment completed."
The recovery from narcotic addiction is dependent upon many factors-the patient, what happens in the hospital, and what happens after he leaves the hospital. It would be interesting to know how many patients who were discharged did not become readdicted. While the results would not be related
to hospitalization alone, it could be assumed, perhaps, that there was some relationship. Pescor attempted such a study of 4,766 patients discharged in years 1936 through 1940. The followup information was obtained from four sources: first, the patient if readmitted; second, the arresting authority if the former prisoner or probationer's arrest was reported to the Federal Bureau of Investigation; third, probation officers, and fourth, letters mailed at 6-month intervals to former patients. Pescor felt that this method was crude and this opinion seems well founded since information was obtained on only 60.1 percent of the group even though 75 percent were prisoners and probationers. He did determine that 39.9 percent had relapsed in periods varying from 6 months to 6 years. It is interesting to note that paroled prisoners made the best record from the standpoint of abstinence. It was this group that received the most posthospital supervision and could not leave the hospital until there was a satisfactory plan for job, place to live, etc. An important item to remember is that parolees are a highly selected group and the results may be related to this as well as to what happened during and after hospitalization.
Rayport 18 studied 1,020 male patients consecutively admitted to the hosiptal to determine how many had first received narcotic drugs from a physician to the point of addiction, in the course of treatment for an illness. There were 141 such patients-137 white and 4 Negro, an incidence of 27 percent among the white patients and 1.2 percent among Negro patients. The average age of the whites was 47.4 years and the average duration of addiction 14.8 years. These 141 "medical addicts" were placed in three groups: those whose original illness was no longer present, 89 (63.1 percent); those who still had the original but reversible illness, 2; and those who had the original but essentially irreversible illness, 50 (34.7 percent). Treatment of the first group was similar to that of "nonmedical" addicts. Treatment of the second group required treatment of the original disease and of the addiction to opiates. All of the patients in group 3 were successfully treated for their physical addiction by the methadone substitution method and treated for their irreversible illness by the use of specific medication, non-narcotic analgesics and physiotherapy. After these patients had received no narcotics for about 100 days, 84 percent stated that they felt well or very well even though their cardiovascular, gastro-intestinal, pulmonary, bone and joint, or neurological diseases were still present.
There are a number of difficulties involved in the treatment of the patient with narcotic addiction. The patient must remain in the hospital if treatment of the physical addiction is to occur, yet 40 percent of the voluntary patients leave in less than 2 weeks.
If treatment of the psychological addiction is to be initiated, then the patient must have some motivation to live without narcotic drugs. There is little purpose in hospitalizing persons who do not have any desire to actively work toward this goal. To date medical science has discovered no way of artificially instilling this motivation. It has to be generated within the patient by the patient, or by persons in the environment who are important to the patient, or by the demands of society. There is no way known to measure motivation objectively. Its presence has to be inferred from verbalized attitudes and from actions.
Clinical and laboratory research has provided a very satisfactory method for treatment of physical addiction to opiates-the methadone substitution methodso this presents no difficulties if the patient is in a drug-free environment.
17 Pescor. M. J. Followup Study of Treated Narcotic Drug Addicts. Supplement No. 170 to the Public Health Reports, 1943.
18 Royport. M.: Experience in the Management of Patients Medically Addicted to Narcotics. JAMA, 156: 684-691 (October 16, 1954).
There have been some reports stating that chlorpromazine and reserpine are of value in the treatment of the acute opiate abstinence syndrome. To date the reports are based on clinical usage with poor or no controls and usually the reported intake of narcotic drugs in what the addict says he thinks he has been using. This information has no value. Fraser and Isbell studied the effects of chlorpromazine and reserpine in patients who were in a rigidly controlled environment and who were administered known amounts of narcotic drugs for specified periods and in whom abstinence signs were measured by objective criteria. Neither chlorpromazine nor reserpine administered orally or intramuscularly reduced the intensity of the acute abstinence syndrome from morphine.
It is indeed unfortunate that the treatment of the psychological addiction to narcotic drugs is not as well developed as the treatment of physical addiction. Research has provided relatively less knowledge that is useful to the clinician. Psychological addiction is closely related if not a manifestation of a mental disorder and these same mental disorders occur in persons who are not addicts. One can expect then, that improved methods for treatment of the psychological addiction will become available as research on mental disorders progresses. Completion of hospital treatment marks the beginning of community treatment and rehabilitation. While it is necessary to remove the addict from the setting in which addiction occurred to a controlled environment, if hospitalization has served its purpose it has prepared the patient for return to the community. Hospital treatment can start a patient on the way to recovery but it cannot provide a lifelong immunity that protects the patient against relapse. Hospital treatment can initiate rehabilitation but it must be completed after the patient returns to the community.
Senator LANGER. Thank you, Dr. Lowry.
We will recess until tomorrow morning at 10:30 in the District Committee Room. That is over in the Capitol.
(Whereupon at 4: 15 p. m. the hearing was adjourned, to reconvene at 10:30 a. m. Tuesday, December 18, 1956.)
19 Fraser, H. F., and Isbell, H.: Chlorpromazine and Reserpine: (A) Effects of Each and of Combinations of Each With Morphine, (B) Failure of Each in Treatment of Abstinence From Morphine. Accepted for publication, Arch. Neur. & Psych.
TREATMENT AND REHABILITATION OF JUVENILE
TUESDAY, DECEMBER 18, 1956
UNITED STATES SENATE,
SUBCOMMITTEE OF THE COMMITTEE ON THE
JUDICIARY TO INVESTIGATE JUVENILE DELINQUENCY,
Washington, D. C. The subcommittee met, pursuant to recess, at 10:40 a. m., in room P-36, United States Capitol, Senator Estes Kefauver (chairman of the subcommittee) presiding.
Present: Senators Kefauver and Langer.
Also present: Ernest Mitler, special counsel and Peter N. Chumbris, associate counsel.
Chairman KEFAUVER. Call your first witness.
Mr. MITLER. Dr. Himmelsbach.
Would you give your name please?
TESTIMONY OF DR. CLIFTON K. HIMMELSBACH, MEDICAL DIRECTOR, CHIEF, DIVISION OF HOSPITALS, UNITED STATES PUBLIC HEALTH SERVICE
Dr. HIMMELSBACH. Clifton K. Himmelsbach.
Mr. MITLER. You are the Director of the United States Public Health Service.
Dr. HIMMELSBACH. No, sir; I am Chief, Division of Hospitals in United States Public Health Service.
Mr. MITLER. And what is the relationship of your department to the United States Public Health Service Hospitals at Fort Worth and Lexington?
Dr. HIMMELSBACH. Those are two of our systems of United States Public Health Service hospitals that deal with known indigents. We have 2 systems of hospitals, 1 for indigents and 1 for other beneficiaries. In the systeming of hospitals with which I am connected there are 16, 12 general medical and surgical hospitals and 4 specialty hospitals.
The 4 specialty hospitals are 1 for TB, 1 for leprosy, and 2 for neuropsychiatric disorders, the 1 at Fort Worth and the 1 at Lexington.
Mr. MITLER. Yesterday a portion of the hearing was devoted to the question of the need for followup program from Fort Worth and from Lexington and from any drug-treatment center, and could you tell us what the existing followup program is from these two hospitals that come under your jurisdiction? What provisions are made at the present time?