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U. S. PUBLIC HEALTH SERVICE HOSPITAL, LEXINGTON, KY.

First admission and readmission of 18 years and under, June 30, 1951-June 30,

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First admission, 18 years and under, by race and sex, June 30, 1951-June 30,

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First admission, 18 years and under, by State, June 30, 1951-June 30, 1956

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First admission, 18 years and under, by status, June 30, 1951-June 30, 1956

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HOSPITAL TREATMENT OF THE NARCOTIC ADDICT

(By James V. Lowry, M. D., medical officer in charge, United States Public Health Service Hospital, Lexington, Ky.)

The treatment of a hospitalized narcotic drug addict is a relatively simple and a relatively complex procedure. Treatment of the physical addiction resulting from the pharmacological properties of the opiates is relatively simple. Treatment of the psychological addiction and of the basic mental disorder is relatively complex.

This paper will discuss the treatment of addicts at the United States Public Health Service Hospital at Lexington, Ky., and the characteristics of the addicts as they are seen at that hospital. It must be remembered that the addicts admitted to the hospital are not necessarily representative of addicts in the United States even though about 3,000 are admitted each year. No attempt will be made to explain some of the observations because the explanation must be arrived at by studies that cannot be done at the hospital. The word "addict" when used in this paper means a person who is physically and psychologically addicted to an opiate drug or a synthetic drug with opiate-like properties and who is or has been a patient at the hospital.

Why hospitalize addicts? It is expensive and requires specialized facilities and scarce personnel. The primary purpose is to provide an opportunity for treatment of the addict patient. Recovery from physical addiction can be attained in a few months in a drug-free environment with modern methods even if only passive cooperation of the patient is obtained. This is important because the continued use of narcotic drugs by an addict is in part due to physiological drives resulting from physical dependence. Hospitalization provides the opportunity to initiate or complete treatment of the psychological addiction and to begin social and vocational rehabilitation. This requires active participation of the patient. And therein lies the difficulty.

Hospitalization removes the addict from the environment that nurtured his addiction to an environment where the use of narcotic drugs is controlled. This is important not only to the person who lives in deteriorated metropolitan areas where drugs are available but also to the nurse or physician addicts who have access to drugs as an ordinary part of their occupations.

Hospitalization is a public health measure that prevents the spread of addiction by isolating a principal agent of dissemination-the narcotic addict. A common method of introduction to the use of narcotic drugs of addicts at the hospital was by another addict. This was often done by nonpeddler addicts giving drugs to a nonaddict for psychological reasons that are difficult to understand. Some addicts were introduced to drugs by other addicts who sold drugs for profit used principally to support their own addiction. Isolation to prevent the spread of disease could be accomplished by means other than hospitalization but this has been the accepted medical procedure for isolating sick people.

Some of the patients admitted to the hospital began their addiction in the course of treatment of an illness by a physician. Hospitalization provides an opportunity to terminate the addiction in those whose initiating illness is no longer present. If the initiating illness is still present, hospitalization and treatment can result in a reduction in the dosage of narcotic drug or in most instances an elimination of the use of narcotic drugs because of improvement resulting from specific treatment of the disease.

The hospital, located about 5 miles from Lexington, Ky., was opened in 1935. The functional capacity is about 1,200 patients. Three hundred and fifty of the 1,300 beds are in the infirmary wards-medical, surgical, psychiatric, tuberculosis, and withdrawal. The rest of the beds are in dormitories. The buildings are surrounded by 1,050 acres of land and are less prison-like in appearance than most prisons and more prison-like than most hospitals. It is a minimum custody hospital and about four prisoners depart without authorization each year. One patient was overheard telling a newcomer who was complaining about the accommodations, "Dis place is a boid's nest on da ground."

GENERAL INFORMATION ABOUT THE UNITED STATES PUBLIC HEALTH SERVICE HOSPITAL 1 AT LEXINGTON

The hospital is authorized by law to treat Federal prisoners and probationers, addicts committed from the District of Columbia, and voluntary patients who

1 This information is available from the hospital in a pamphlet entitled "Information for Prospective Voluntary Patients."

are addicted to narcotic drugs as defined in the Federal law. These include cocaine, codeine, dihydromorphinone (dilaudid), heroin, Indian hemp (marihuana), laudanum, meperidine (demerol), methadone (dolophine), metopon, morphine, opium, pantopon, paregoric, peyote (mescaline), and any other narcotic drug, the sale of which is under the Federal Narcotic Act. Persons addicted to barbiturates, alcohol, or other drugs are not eligible for admission unless they are also addicted to a narcotic drug.

The prisoner addicts are sent to the hospital by the Bureau of Prisons after conviction in a Federal court. Escape risks, persons with marked antisocial records prior to addiction and persons otherwise unsuitable are not sent to the hospital. Most of the prisoners have been convicted of violating the narcotic law but some are convicted of stealing and forging Government checks or other crimes.

The probationers from Federal courts and committed patients from courts of the District of Columbia are required to remain in the hospital until treatment is completed and are under supervision after return to their home community.

Voluntary patients are admitted at their own request if beds are available after eligible prisoners and probationers have been admitted. Federal law provides that the record of admission, treatment, and discharge of a voluntary patient shall be confidential and shall not be divulged and that such voluntary patient shall not forfeit nor abridge his rights as a citizen of the United States, nor shall such treatment be used against him in any proceedings in court. However, the hospital does not furnish refuge for known fugitives from justice. Voluntary patients able to pay are charged $7 per day for their hospitalization. Application forms are obtained from the hospital and when completed are mailed directly to the hospital. About 250 applications are received each month. The applicant is advised by letter that either he is to report to the hospital by a certain date, that his name is being placed on a waiting list and he will be notified when a bed is available, or that he is not eligible for treatment. Separate waiting lists are maintained for men and women. Letters of authorization are sent out in the order of receipt of the applications. The Lexington hospital accepts female from any State and males from east of the Mississippi River, Male patients from west of the river usually are treated at the United States Public Health Service Hospital in Fort Worth, Tex. Applicants should not go to either hospital until they receive a letter of authorization. Patients who present themselves without written notification may not be admitted.

Clothing is furnished to patients while they are in the hospital. They can bring their own house slippers, black or brown shoes, solid color sweater and plain socks. Prisoners are required to send other clothing home or donate it to the hospital. Suitable clothing and a $25 gratuity are provided at the time of discharge if the prisoner is indigent. The hospital provides transportation home for prisoners, probationers, and those indigent voluntary patients who stay until hospital treatment is completed.

Patients may correspond with relatives and other persons approved by the hospital staff; outgoing letters are limited to two per week. Mail is opened and read. Patients may receive telegrams but not telephone calls. Outgoing telegrams and telephone calls are restricted to emergencies. Money sent to the hospital for deposit in a patient's account must be in the form of certified check or postal money order. Commissary facilities at the hospital sell cigarettes, candy and small articles purchasable with coupons from commissary books. Men and women have quarters in separate parts of the hospital. There is no separation of patients by race or age, of prisoners, probationery, voluntary or District of Columbia committed patients.

THE ADDICT PATIENT

The important characteristics of addiction to opiate drugs are physical and psychological addiction. Physical addiction to opiate drugs is characterized by two unique phenomena. One of these is well known-physical dependence. Repeated intake of opiate drugs results in physiological changes which produce characteristic abstinence signs and symptoms when the opiate is discontinued. The other phenomenon, tolerance, is equally important. Repeated intake of opiate drugs results in the development of tolerance to some of the drugs's effects-the analgesic, euphoric, and sedative effects which are all-important to the addict. Little tolerance is developed to the gastro-intestinal or pupillary effects. Because of the development of tolerance the physiology of

the addict requires increasing amounts of narcotic drugs to obtain the desired effects. For this reason it is very difficult for addicts with physical dependence to stabilize on a maintenance dose. Physical dependence and tolerance appear to be related to changes in the sympathetic and central nervous systems and in the endocrine glands.3 Changes in function associated with physical dependence may include cessation of menstruation in women and disinterest in sexual activity with impotence in the male. Meperidine (demerol) in addition to the usual effects of opiates produces impaired vision, mental confusion, and sometimes convulsions. About 50 percent of the meperidine addicts admitted in a 3-year period were physicians, nurses or other persons associated with the medical profession.5

Why did the patients continue to use narcotic drugs once the introduction had been made? The answer varied with the particular individual. For some persons narcotic drugs provided an escape from anxiety, loneliness, despair, frustration, anger or hostility into a placid world of unreality. For some narcotic usage was the ultimate in hedonistic experiences which combined the pleasures that other persons derive from work, love of wife, family, or friends, personal or group accomplishments, or service to others. For others the intravenous injection of narcotics provided the ecstasy of the adult at orgasm and the somnifacient satisfaction of the satiated infant at the breast. The addict with

his narcotic drug had little interest in any person, belief or thing; an addict without drugs was principally interested in obtaining a supply. This motivation for drug usage has to be replaced by a desire to live without narcotic drugs if treatment is to be successful.

Addiction to opiates, as stated above, is characterized by physical and psychological addiction. The psychological addiction is related to the basic mental disorder of the patient. A few patients are admitted to the hospital who have physical addiction without psychological addiction. They usually developed their addiction in the course of treatment of some physical disease.

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In addition to the diagnosis of drug addiction there is usually enough information derived from diagnostic studies to establish the presence of a mental disorder. Kolb and later Felix' developed classification systems of these disorders that were operationally useful. These have been superseded by utilization of the nomenclature in the Diagnostic and Statistical Manual of Mental Disorders, of the American Psychiatric Association, published in 1952. The mental disorders most frequently present are personality trait disturbances, sociopathic personality disturbances, psychoneurotic disorders, and personality pattern disturbances. Occasionally patients are admitted with schizophrenic or affective reactions.

Personality trait and sociopathic personality disturbances are present in the patients hospitalized here with progressively increasing frequency. These individuals appear to be the products of a disorder of maturation in emotional development. The behavior shown by such persons indicates that development is fragmentary and may include behavior that would be normal for an infant, a young child, a preadolescent, and adolescent all in the same person. At different times or at the same time they may be dependent, demanding, narcissistic, stubborn, pouting, passively obstructive, have temper tantrums. Today is the reality in time. Some have acted out their feelings in a manner that brings them into conflict with their immediate family, group, or with society.

The personal history of many of these patients shows the absence of the father or a weak father and/or mother during the patient's childhood. The failure of emotional maturation may be related to this absence of any constant person with whom identification could occur. If there was no chance of identification then there could be no introjection and formation of internalized emotional control and growth. With some patients identification and introjection may have occurred, but it was an unhealthy person that served as the model. Some of the most interesting and unexplained phenomena observed at this hospital are the remarkable changes in the characteristics of the "typical" addict,

2 Wikler, A.: Recent Progress in Research on the Neurophysiological Basis of Morphine Addition. Am. J. Psych. 105: 329, 1948. 3 Eisenman, A. J., Isbell, H., Fraser, H. F., and Sloan, J.: 17-Ketosteroid Excretion in a Cycle of Morphine Addiction and Withdrawal. Fed. Prof. 12: 200, 1953. 4 Isbell, H., and Fraser, H. F.: Addiction to Analgesics and Barbiturates. and Exper. Therap. 99: 355-397, August 1950.

J. Pharmacol.

Rasor, R., and Crecraft, H. J.: Addiction to Meperidine (Demerol) Hydrochloride, J. A. M. A. 157 654-657, February, 1955.

Kolb, L.: Types and Characteristics of Drug Addicts. Mental Hygiene, 9: 300-313, (April) 1925.

Felix, R. H.: An Appraisal of the Personality Types of the Addict. American Journal of Psychiatry, 1: 462-467, 1944.

if one can use such a concept. The 1955 model addict differs from the 1936 "statistical addict" described in Pescor's study of a thousand admissions. He isn't a "white male prisoner 38 years of age given a 2-year sentence for illegal sale of narcotics." He is a Negro male voluntary patient in his twenties. He didn't have a parental home "intact up to the age of 18." He probably can't remember seeing his father, and his mother was away trying to earn a living as a domestic. He wouldn't "become addicted to morphine at the age of 27." He would start on heroin at about age 20. He would not "prefer morphine." He would prefer heroin. His first arrest would not "occur at the age of 28 for violation of drug laws." He would be a young voluntary patient whose FBI record could not be requested by the hospital. He would not "as an adult be subject to some chronic disease, such as heart trouble, arthritis, tuberculosis, or asthma." He would be free of such afflictions.

These considerations of the characteristics of the addict and of addiction must be given consideration in the planning and organization of a treatment program.

CHARACTERISTIC OF THE HOSPITAL ADDICT POPULATION

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The average daily population of addicts in the hospital has varied relatively little over the years, but significant changes have occurred in its composition. The average daily population was near 900 from 1945 to 1949. From 1950 to 1955 it has been about 1,100 except for 1951 and 1953, when it was about 1,200. Prior to 1946 there were less than 100 voluntary patients in the hospital. This daily average increased each year until the high points of over 600 in 1951 and 1953. A rapid fall in 1954 to 400 was followed by a decline to 328 in 1955. There has been a gradual decline in probationers in the hospital from a high of 86 in 1947 to 18 in 1955. The number of prisoners has varied from a high of almost 900 in 1944 to a low of 492 in 1952 and a steady increase to 732 in 1955. (See graph, Average Daily Population.)

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138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 Fiscal Year

8 Pescor, M. J.: A Statistical Analysis of the Clinical Records of Hospitalized Drug Addicts. Supplement No. 143 to the Public Health Reports, 1943.

The basic data used in this part were provided by Mary L. Tonks, Medical Record Librarian, and Walter K. McCurry, Administrative Assistant.

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