sheltered community residential treatment program such as Daytop Village, or intensive treatment programs developed in prison, penal farms or commitment facilities.

Phase Ia (Community Clinics) is described fully in Section I-A, Phase Ib (Day-Night Care Centers) in Section I-B, Phase III (Re-Entry) in Section III, and Phase IV (prevention) in Section IV.

Addiction and treatment

In

Drug addiction is a sick way of life, and the addict is a sick individual. all likelihood, he is psychopathic and his addiction is merely a handle, a sign that he is in need of help. Unless the basic personality defect is corrected, it will only find some other form of symptomatic expression. Once the illness is treated, however, the ex-addict can emerge as a self-sufficient, productive example to the addict population yet to be reached. Giving him recognition as a potential community worker specialized in drug addiction will serve as a door for his reentry, providing jobs for hundreds, and maybe thousands, of ex-addicts for a period of 1-2 years before going on to other types of work in the community. The addict's intellectual ability has been found to be above average in most cases. If such a person is freed from his limitations to cope with reality, he will assume a role of constructive leadership in his community.

During the course of a year, it is generally assumed that one addict is responsible for the spread of addiction to four or five others. One ex-addict working in a community can be responsible for the withdrawal from addiction of 30 to 40 others during the same time. This is the most practical approach to widespread prevention of addiction and has been proved effective in the Puerto Rico experience.

The "If I can do it, so can you" statement of the ex-addict works the other way as well . . "If he can do it, so can I."

A comprehensive program of treatment would mean an effective communication between the addict society, the higher level of detoxified addicts, and the still higher level of the pre-rehabilitated and rehabilitated addicts. Once the addict reaches a certain plateau in his own development, he would turn to help those further behind him. This serves as an incentive to those yet to reach his level, and reinforces in his own mind the reality of his progress. A comprehensive program would mean more than addicts facing addicts because there is a point where professional help is needed that would be beyond the ability of someone not trained in the technical and complex field of the human mind. Community organizers who deal with all forms of social disorders would be needed to reach the user who has not acknowledged his addiction, or who is not yet addicted. Teachers, both for educational rehabilitation and those working in schools in areas of greater incidence of addiction and who can reach youngsters to either prevent them from experimenting with drugs, or to recognize those already using and refer them to agencies for help. Since addiction is spreading from the depressed areas to the more wellto-do suburban areas surrounding our cities, there would be a need to reach educators in many areas.

The role of the medical profession, including doctors, psychiatric nurses. psychologists and psychiatrists is obvious. These people help the addict through the period of detoxification and its accompanying physical discomfort and are directly involved and responsible for psychotherapy in group and individual treatment.

Penal authorities and probation officers who also come in contact with the addict could augment their roles to deal more effectively with the addict prison population for the benefit of the addicts and the prisons. All branches of the law from enforcement to correction, including lawyers and judges, and all other representatives of society who deal with the addict must be placed in positions where they can most effectively discharge their responsibilities. Much of the frustrated pessimism of the professionals in the field of addiction comes from the fact that they are misplaced and that there is no rational division of labor in this complex field.

Once an addict is committed to his own rehabilitation, he needs professional help to find a cure for the basic personality disorder underlying his adddietion. The professionals, trained to provide these services, must be helped by the Community Orientation Clinics and Day-Night Care Centers in the pre-admission preparation of the addict to become a responsible, responsive, treatable patient. Only then can the professional be effective.

This quality of initial responsibility is achieved by the utilization of meetings of functional peer groups. This concept is crucial to the system as a whole. Much work with addicts in the past has failed because the programs were so small that men of different stages of development were mixed together. Those who were more advanced became restless and more resentful than necessary under the continuing lack of understanding and development on the part of those not seriously and productively committed to the program as they were. This emotional parity has proven to be identifiable by specific fundamental criteria; it has also been a tremendous help in the development of morale since the patients are able to watch their own progress, subjectively felt, actually marked out objectively in a ladder on a bulletin board. Most of all, the principle of parity has been helpful within the groups themselves, to make possible the maximum amount of growth for each individual participating. The structure and concept of comprehensiveness

The most important aspect of this plan is the establishment of a strong and lasting structure, capable of survival without dependence on any one individual, or group of individuals. It is not a structure which can be abbreviated. All the components are needed because of the multiple handicaps which a hard core addict presents. There must be comprehensiveness at each phase: orientation in a Community Clinic, reduction of physical habit and further clarification of orientation in the Day-Night Care Centers, physical and mental detoxification in the Detoxification Ward, intensive therapy in the residential treatment facility, vocational training and strengthening of socialization capacity in the Halfway House. The addict is such an emotional "basket case" that all work would be of little help unless the entire program can be put into effect. Certification

From the point of view of the average addict, involvement in a long-term rehabilitation program is untenable unless he can be confident that the efforts demanded from him will be realistically rewarded by social and vocational acceptance on equal terms with his non-addict fellow citizens. The imperative need for the definition of uniform, official criteria for the certification of a successful treatment and reentry process thus becomes clearly apparent. The Narocotics Coordinator, in close consultation with every institution responsible for the treatment and re-entry of drug addicts will define the basic criteria for certification.

Basic guidelines tested at the Addiction Research Center of the Commonwealth of Puerto Rico will be utilized as a starting point for the development of certification criteria in New York.

1. Certification of successful re-entry will be a result of consensual agreement among those individuals, professionals and non-professionals, who, as a result of their close relationship with the candidate during the re-entry period, have a personal knowledge of part of the individual's total functioning. This will provide a more nearly integral evaluation of the candidate than is possible by any single evaluator.

2. The process of evaluation for certification shall cover at least the following five areas:

(1) Psychological testing and evaluation.

(2) Social function.

(3) Vocational capabilities.

(4) Psychiatric evaluation.

(5) Adherence to prevailing moral and ethical values.

3. Certification shall not be considered as an absolute affirmation of cure. Rather it will be considered as permanent until proven otherwise. A close postcertification follow-up is necessary to evaluate and refine the whole process.

4. Certification will be extended by the Narcotics Coordinator pursuing recommendation by the appropriate institution. However, to maintain the uniformity of the procedure, the recommendation will be reviewed by the Rehabilitation Advisory Board. This Board, created for this specific purpose and chaired by the Narcotics Coordinator, will be composed of leading representatives of the treatment and rehabilitation programs and will be responsible for continuously evaluating such programs.

5. Once certified, the certificate holder will be able to count upon the official backing of the City and State of New York in his efforts to achieve a respectable, productive place in our society.

6. Any certification can be re-evaluated and if necessary revoked by the Rehabilitation Advisory Board. The Board shall establish the adequate procedures for such action.

Dr. RAMIREZ. One point included in this paper that I want to highlight here is that the process of development of the basic idea of treatment rehabilitation in New York is dependent upon a revolutionary approach to the thinking of all, if possible, the existing methods, programs, techniques, and approaches that have proven to have some effectiveness in the difficult task of rehabilitating drug addicts. In other words, we have no magic system. It is just a matter of rationally linking together, which up to now has been fragmented, scattered efforts.

Senator MCCLELLAN. In other words, what may be beneficial to one might not to another, and you have taken them all together in a composite program and use them as you determine they will produce a result.

Dr. RAMIREZ. That is correct.

This revolutionary approach which proved so effective in the Commonwealth of Puerto Rico is being instrumented right now in New York City through the utilization of intensive dialogue among participating agencies, interior and exterior retraining of professionals and nonprofessionals, and the utilization of all legitimate, legal, fiscal, and administrative inducements.

This effort covers the crucial aspects of motivation of the addiet, of treatment, rehabilitation, community development of prevention, followup, data-gathering, training for professionals and nonprofessionals, and ongoing research and evaluation of the system.

This effort has never been attempted before. It is being attempted now with the collaboration of the top men and women of the behavioral sciences, medicine, law enforcement, corrections, city and State administration, private agenices, and the general community.

However, besides enthusiastic collaboration and personal devotion and sacrifice, we are launching this effort with the help of all available sources of funds, private, city, State, and we sincerely hope Federal funds, as proposed by the bill under discussion here.

Our program in New York City is a huge demonstration project. I urge the subcommittee that it be considered as such in its totality. To give you an estimate of our requirements, on learning from the Puerto Rican experience, we find that to engage and we use the concept of engaging the addict, all the way down through the community where he lives, through all the different series of treatments in the rehabilitation process until he goes back into his own community as a rehabilitated person-we find that to engage an addict in the meaningful treatment, in any of the different of meaningful treatments, be it outpatient or institutionalized, will cost, if you average out the cost, around $3,000 per person per year. If we recognize that to cope with the drug addiction program in New York City, as in other large cities of the United States, we have to engage in such meaningful treatment a large portion of the totality of the drug addicts, in New York it is calculated to be 30,000 people which we have to engage in meaningful treatment at any single time, it means that in New York City the ideal annual outlay to maintain these people in meaningful engagement will be around $90 million a year for several years.

A followup study of 1,900 residents of New York City who were discharged from the Lexington hospital between July 1952 and December 1955 showed that more than 90 percent of the group became readdicted-generally within six months.

Public Health Service investigators, reporting on a five-year study of 453 addicts released from the Lexington hospital, said the study showed that 97 percent of the group became readdicted at some point during the study period, about 42 percent voluntarily stopped use of drugs sometime during the survey, and patients over 30 years of age showed a greater ability to remain drug-free than those under 30.

Investigators have pointed out that such study findings underscore the need for systematic community programs of aftercare or supervision for discharged addicts, or a combination of both.

Various State and city actions since World War II have created centers with programs to implement the Public Health Service effort in research and treatment in narcotic addiction.

Most recently, demonstration and pilot projects supported by Public Health Service funds have begun to explore possible ways of controlling drug addiction and of providing aftercare for the rehabilitated addict in the community.

During the five-year life of the New York Demonstration Center providing community aftercare for 900 rehabilitated addicts ranging in age from 16 to 72, one finding emerged clearly: for the addicted person coming out of the hospital, a guidance center is not enough.

In 1962 a new demonstration began in New York City to explore the potential role of a local public health agency working to provide constant, step-by-step support for the addict emerging from hospital treatment into his place in society. This project and the earlier five-year study are cooperative projects of city authorities and the National Institute of Mental Health.

The public health approach to the problems of drug addiction involving prevention, treatment, and social rehabilitation is being introduced at community level where, if this approach is to succeed, factual knowledge about the subject of drug addiction must become common knowledge.

Five measures were urged by the American Medical Association and the National Research Council of the National Academy of Sciences in 1962 for the prevention, control, and treatment of narcotic addiction, in summary: after complete withdrawal, followup treatment for addicts at rehabilitation centers; compulsory civil commitment of drug addicts for treatment in a drug-free environment; rehabilitation of the addict under continuing civil commitment; research in prevention of drug addiction and the treatment of addicted persons; and dissemination of factual information on narcotic addiction.

Important research in drug addition is being done in various disciplines, including biochemistry, psychiatry, psychology, sociology, and law.

Surveys in Chicago proved residents of areas of high drug use have one thing in common: social and economic deprivation.

Similarly, a study in New York City found that three-fourths of the adolescents using drugs were concentrated in 15 percent of the city's census tracts and that these were the poorest, most crowded, and most dilapidated areas of the city. Young people who experiment with drugs know that what they are doing is both illicit and dangerous but have a "delinquent" attitude of pessimism, unhappiness, and a sense of futility, and they distrust authority.

A medical authority reported that narcotics addicts generally are found to be noncompetitive individuals who prefer to handle their anxieties by avoiding the situations that provoke anxiety. One principal source of anxiety relates to the expression of sex; drugs reduce the sexual urge. Another source of anxiety relates to aggression; drugs take the edge off aggressiveness.

A few States have had laws making addiction itself a crime, but a 1962 Supreme Court decision declared such laws unconstitutional.

The Harrison Narcotic Act, passed in 1914, has been interpreted by the Supreme Court as making possession of any amount of narcotics obtained illegally a criminal offense.

Illegal possession of narcotics is punishable by imprisonment of from two to ten years for a first offense, and a minimum mandatory sentence of five years is the penalty for selling narcotics.

For subsequent criminal offenses with narcotics, prison sentences range from 10 to 40 years.

perhaps under the general description of hallucinogens or mind expanding or psychedelic agents, as part of the definition of the drugs that are included.

Senator MCCLELLAN. You think it should include LSD?

Dr. RAMIREZ. It should be included.

Senator MCCLELLAN. We had some witnesses yesterday who said they didn't have enough information about LSD to know whether it should be included or not.

Dr. RAMIREZ. I have enough information to be convinced about it. Senator MCCLELLAN. You have enough information that you are convinced.

Dr. RAMIREZ. Exactly. Of course, I think it should be made clear on this particular substance or group of substances, that such substances, under the discretion and supervision of the Surgeon General, could be utilized in strictly controlled clinical settings for medical and research purposes only.

I have no comments on the commitment proceedings. They are carefully thought out and I am sure there are more qualified witnesses than myself who have thoroughly clarified the subject of establishing the setting for eventual treatment and rehabilitation.

Since my main responsibility is in the area of development and coordination of prevention, treatment, rehabilitation, training, and research, I am particularly interested in title IV, which covers the posthospitalization care programs. I strongly recommend the provisions of this title. I see in it a realistic, urgently needed Federal support for the kind of efforts required to cope with the addiction problem simultaneously in the community, in prison, and inside any commitment facilities, whatever they are, however they are defined.

I would urge that the subcommittee be generous and specific in the recommendations as to sums of money made available to the Surgeon General for the purposes expressed in section 402.

I would suggest, however, an amendment to this section. I would recommend that the Surgeon General be empowered to grant sums to the States and municipalities only when such States and muncipalities are endeavoring, as is the city of New York, and as are several other cities across the Nation, to achieve a truly comprehensive global coordinated approach.

I have had personal communication with several people in the field in other large cities in the States, who are trying to develop the same kind of thinking in dealing with the problem of addiction in their own cities and the consensus, in my own professional opinion, is that the idea of doing it in a comprehensive global way is a necessity.

In other words, when such a program, such a comprehensive global program is being planned or developed in a city, funds made available to private institutions not meeting the requirements established by the State or the city planning and coordinating bodies will thwart rather than help in the efforts of the total push approach to the problem of drug addiction. It has to be a coordinated, collated effort.

Another final suggestion would be to urge the subcommittee to divide and maintain the necessary communication and feedback structures to integrate Federal efforts with efforts developed at the State and city levels. Allow me to repeat my thanks for the opportunity to