Male voluntary patients are expected to go to the nearer hospital-those residing east of the Mississippi River to the Lexington Hospital, and those west of the River to the Fort Worth Hospital.

No authority to hold voluntary patients

When the Lexington Hospital first opened, it was assumed that the staff had the authority to detain voluntary patients against their will since the law stated, ". . . Provided, that if any addict voluntarily submits himself to treatment he may be confined in a United States narcotic farm for a period not exceeeding the maximum amount of time estimated by the Surgeon General as necessary to effect a cure of the addiction or until he ceases to be an addict within the meaning of this Act." But the first year that the hospital was open, a voluntary patient was released on a Writ of Habeas Corpus and went before the Federal District Judge in Lexington. The judge ruled that the patient had voluntarily committed himself to the hospital and could voluntarily demand his release; the hospital had no authority to hold the patient against his will. Since then there has been no legal authority to hold a patient when he demands his release, and a majority of the voluntary patients have signed out against medical advice. [Italic supplied.]

The mean period of hospitalization for voluntary patients was less than one month for those who left against medical advice before treatment was completed and five months for those who completed treatment for their addiction (Table 1). Only one-fourth of the voluntary patients remained until treatment was completed.

TABLE 1.-Mean days hospitalized for voluntary addict patients at Lexington and Fort Worth hospitals, 1963

The "average" addict: mid-1930's and mid-1960's

Pescor did a statistical analysis of the clinical records of 1,036 drug addict patients admitted to the Lexington Hospital during fiscal year 1937. He described "a statistical" addict composed of averages and highest frequencies: "Such a hybrid individual would be a white male prisoner, 38 years of age, given a twoyear sentence for illegal sale of narcotics by a Federal Court. As an adult he would live in a deteriorated metropolitan section. More than likely he would have to resort to illegal means to earn the additional income required to support his drug habit. He would marry but his marriage would probably terminate in separation or divorce. He would become addicted to morphine at the age of 27 through influence of associates and curiosity . . . He would probably relapse." Twenty-nine years later, the "statistical" addict is a younger individual in his twenties, a member of a minority group (Negro or Latin American) who has not come from a parental home “intact up to the age of 18." His choice of drug would be heroin, and he would likely have to resort to an illegal means of earning the additional income required to support his drug habit.

Shift from morphine to heroin and other drugs

In Pescor's study of 1937, morphine was most likely to be the first drug used, the drug of choice, and the last drug used. A trifle more than half of the patients he studied reported morphine as the last drug used; 43.3 percent, heroin;

and 3 percent opium. The majority expressed a preference for morphine; 23.2 percent, for heroin; and 6.9 percent, for opium smoking. The majority of Pescor's patients used more than one narcotic drug, but one-fourth used morphine exclusively; 7.4 percent, heroin exclusively; and 2.5 percent, opium exclusively.

Of the 3,066 addict patients discharged from the Lexington and Fort Worth Hospitals in 1964, 68.1 percent had a first drug diagnosis of heroin use (Chart 4). The next most frequent drug used was morphine (7.7 percent), followed by paregoric, dilaudid, codeine, pantapon, and opium. There has been a considerable decrease in the amount of morphine used and an increase in the amount of heroin, which is illegal in this country-all heroin traffic is carried on by the underworld.

In a 1964 statistical review of 1,000 consecutive first admission narcotic addicts conducted by Hamburger, 32.4 percent claimed or showed signs of using barbiturates and 22.8 percent were physically dependent on them.

WITHDRAWAL OF PATIENTS FROM NARCOTICS

The treatment program for the two hospitals has evolved over the past 30 years, and many refinements in techniques have been developed. It is now possible to withdraw most patients from narcotics with a minimum of physical discomfort. The treatment, which starts as soon as the patient enters the hospital, can be divided into several phases: (1) withdrawal; (2) convalescence; (3) rehabilitation; and (4) aftercare and follow up.

Convalescence

Following the withdrawal procedure, the patient begins to regain his appetite, and his weight and strength increase. But physical symptoms of irritability, restlessness, and difficulty in getting proper rest may last for several weeks. The patient remains in a convalescent unit until his physical condition and mental status have improved to the point where he can be transferred to the orientation unit. There he is interviewed by various staff members representing psychiatry, education, vocational training, social service, psychology, religious counseling, and recreational programs. A treatment program is formulated for each patient.

Rehabilitation

From admission until discharge every effort is made to help the patient become drug-free and to learn to live without having to resort to the use of drugs. Psychologists administer a battery of psychological tests, designed to determine which patients are most likely to benefit from psychotherapy, give special tests to help in establishing diagnosis in problem cases, and conduct individual and group therapy. Social workers also conduct individual and group psychotherapy and, in addition, function as the liaison between the patient's family and the community, and assist in post-discharge planning and follow up, giving due regard to the family situation. For when addiction develops in one member of the family, the entire family constellation must be considered in the overall treatment program.

All physically able patients are given a vocational assignment, and every effort is made to help them learn good work habits and to work and live with others. The vocational staff members discuss any problems of unusual behavior with the patient's psychiatrists. The vocational and educational staff assist in preparing training programs in various units throughout the hospital. Monthly progress reports indicate the degree of adaptation the patient has displayed.

Another activity important to patient morale is the recreational program which offers not only entertainment but also an opportunity to become interested in sports and to participate as a team member or simply learn to play "by the rules." The religious and spiritual activities are another important part of the total treatment program. Regular Catholic, Jewish, and Protestant services are conducted for patients who attend on a voluntary basis. Counseling services are provided by the Chaplains for the three faiths. Additional religious counsel is provided for patients participating in an approved training program in pastoral counseling, conducted jointly by the hospital and a local theological seminary. The patients themselves conduct an Addicts Anonymous program similar to the Alcoholics Anonymous program. This program, in operation at both hospitals for 15 years, has been quite effective with many patients.

The hospitals seek to provide a social milieu which maximizes the therapeutic roles of all employees having contact with patients. Open and extensive communication between staff and patients is encouraged-informally at work and on the ward; and more formally in group counseling, ward meetings, patient council meetings, and group recreation. Recently at the Fort Worth Hospital an experimental effort to use selected patients in the therapeutic program was initiated. Selected patient leaders with staff guidance conduct regular group discussions with other patients.

The staff feels that most patients should remain in the hospital about six months. In this period of time, the physical effects of addiction can be reduced and the patient may begin to achieve sufficient control over himself so that he need not resort to narcotics or other addicting drugs.

Aftercare

When they leave the hospital, most patients need considerable help if they are to become useful citizens and assume responsibility for themselves and others. When they return to their communities, they will need help in obtaining employment and support in meeting some of the difficult problems in living that they are sure to encounter. Regardless of how hard the patient has worked in the hospital, the real proving ground will be in the community to which he returns. A helping hand from the family physician, the employment agency, a probation officer, a minister, or a social worker may go a long way in determining whether the patient becomes readdicted or whether he becomes a useful and productive citizen.

Return to community: Readdiction or responsible living?

Given the rising levels of skills demanded by society, many addicts are ill equipped to return to their old neighborhoods or to new ones-and command respectable and well-paying jobs. Nine-out-of-ten patients are from the lower economic group and only one-in-three has completed high school. Few jobs pay enough to maintain a "habit" that costs from a few dollars to as much as $75 a day.

Yet a study of the occupational status of addicts discharged during fiscal year 1964 revealed 58.5 percent unemployed or illegally employed; 2.5 percent employed in the health field as doctors, nurses, etc.; and 39.0 percent, in other occupations. Some follow-up studies have emphasized the negative aspects of the problem while others have emphasized the positive, as pointed out by O'Donnell in "The Relapse Rate in Narcotic Addicts: A Critique of Follow-up Studies." Pescor's follow-up study of 4,776 narcotic addict patients released from the Lexington Hospital from January 1, 1936 to December 31, 1940 found that : 39.9 percent had relapsed to the use of drugs, 13.5 percent were still abstinent, 7.0 percent had died following release, and that addiction status could not be determined in 39.6 percent of the cases. Excluding the dead and the unknown, 74.7 percent had relapsed to the use of drugs; 25.3 percent were still abstinent.

In a follow-up study of 1,912 addict patients who had been discharged from the Lexington Hospital between July 1942 and December 1955 and were living in New York City, Hunt and Odoroff found that more than 90 percent of the patients discharged had become readdicted within five years of discharge.

Nearly one-in-three addicts admitted to the Lexington and Fort Worth Hospitals is readmited-and 5.1 percent of addicts hospitalized return five or more times according to the U.S. Public Health Service data.

In considering the assistance that the discharged patient needs, the opportunity for parole for Federal prisoner patients should not be overlooked.

Pescor in a follow-up study, refers to the "theoretically ideal patient" as one released on parole with a home, employment, and the supervision of a parole officer as well as a parole adviser. [Italics supplied.] The trend over the past ten years points to considerably longer sentences and to fewer prisoner patients eligible for parole (Chart 6). Valliant also emphasized the advantages of parole when he stated that 67 percent of those who received at least nine months of imprisonment and a year of parole were abstinent for a year or more.

REASSESSMENT OF ENDS AND MEANS

The evaluation of the rehabilitation program for narcotic addict patients is difficult and complex. Patients must be followed for a long period of time to find out what happens after they leave the treatment center. Then a determination

must be made as to whether what happens to them is related to the rehabilitation program. It is important, yet extremely difficult, to establish criteria for success or failure.

Need for Long-range Studies of Drug Addiction

All of the existing follow-up studies leave many questions unanswered. There is urgent and pressing need for more research into the causes, treatment, and prevention of drug addiction and drug abuse. We need to know more about the longitudinal history of drug addiction from the time the individual is first introduced to the drug until he ceases using the drug or dies.

What happens to patients after they leave a treatment center depends largely upon the resources available to them in the community. This is the real proving ground for any treatment program. The aftercare phase of treatment has been neglected through the years, but there are encouraging evidences of interest by our political leaders, law enforcing agents, physicians, sociologists, and other social scientists.

President Directs Federal Government to Strengthen Addiction Programs

This concern is reflected in the statement made July 15, 1964 by President Johnson:

Narcotic and other drug abuse is inflicting upon parts of the country enormous damage in human suffering, crime and economic loss through thievery. The Federal Government, being responsible for the regulation of foreign and interstate commerce, bears a major responsibility in respect to the illegal traffic in drugs and the consequences of that traffic. That responsibility is shared by several departments of the Government and by a number of divisions, bureaus, etc. within them. I now direct those units to examine into their present procedures, to bring those procedures into maximum activity and, wherever necessary, put into effect additional programs of action aimed at major corrections in the conditions caused by drug abuse. I desire the full power of the Federal Government to be brought to bear upon three objectives:

(1) the destruction of the illegal traffic in drugs;

(2) the prevention of drug abuse; and

(3) the cure and rehabilitation of victims of this traffic.

STATEMENT ON FEDERAL NARCOTIC BILLS BY COMMUNITY SERVICE SOCIETY, 105 E. 22D ST., N.Y., N.Y., JUNE 1, 1966

S. 2113, 2114, 2115, 2116, introduced by Senators Javits, Kennedy et al.
S. 2152, introduced by Senator Dodd et al.

S. 2191, introduced by Senators McClellan and Lausche.

The Committee on Youth and Correction of the Community Service Society welcomes the introduction into the Congress of bills which propose treatment programs for arrested and convicted addicts and which modify existing penalties for narcotics offenses. The Committee believes these bills reflect the growing recognition that addiction is an illness and constitute a long overdue change in federal public policy which has hitherto stressed punishment of the addict rather than treatment and rehabilitation.

The Committee on Youth and Correction is composed of concerned and informed lay citizens who work toward the adoption of measures for the improve ment of social conditions and for increased effectiveness in meeting demonstrable social needs; these include improved treatment and rehabilitation programs for offenders, a strengthened Family Court and improved vocational training and employment services for youth. It has been studying the problem of addiction since 1950 and has pressed for comprehensive treatment and aftercare services to addicts since that time.

The Committee on Youth and Correction, in the Department of Public Affairs, is part of the Community Service Society, founded in 1848, which is the oldest and largest voluntary family welfare agency in the country. It works to preserve and strengthen family and community life through direct services to troubled people, and social action and research.

In this statement the Committee is limiting its comment to selected features of the pending legislation and reserves the right to submit further comment at a future date.

Summary description and comparison

The main features of these bills are:

Voluntary commitment to treatment for non-criminal addicts, proposed in S.

2191;

Civil commitment of arrested addicts in lieu of prosecution, proposed in S. 2113 and S. 2152;

Commitment of addicts after conviction, proposed in S. 2114, S. 2152 and S.

2191;

Modification of some existing penalties for narcotics violators-S. 2114 and S.

2152;

Federal financial assistance to state and local treatment programs for addicts S. 2115 and S. 2116, S. 2191. (It should be noted that S. 2152, introduced by Senator Dodd for the Administration, makes no provision for such federal financial assistance.)

Civil commitment in lieu of prosecution

3

The Committee supports this program and favors making it available to arrested addicts who violate any federal law, as in S. 2152 (Title I, Section 101 (g)),' rather than confining it to violators of narcotics laws, as in S. 2113 (Section 2(a)). The Committee opposes the exclusion of certain categories of addicts from eligibility as proposed in both S. 2113 (Section 2(c)) and S. 2152 (Title I, Section 101 (g))-such as those with two or more prior felony convictions or those who have previously been in two or more civil commitment programs. The Committee suggests that convictions for felonies which involve violence are proper grounds for exclusion, but proposes that other addicts with prior felony convictions be evaluated individually for suitability for the program, possibly with the assistance of the probation service. The same procedure is suggested for those who have been in previous commitment programs; given the present limited level of knowledge about effective treatment, a failure in a program may not necessarily be the fault of the addict.

To recapitulate, the Committee supports civil commitment of arrested addicts in lieu of prosecution, and urges that it be extended to addicts who violate

1 S. 2152, Title I, Section 101(g): "Eligible individual" means any individual who is charged with an offense against the United States, but does not include

(1) An individual charged with a crime of violence.

(2) An individual charged with selling a narcotic drug, unless the court determines that such sale was for the primary purpose of enabling the individual to obtain a narcotic drug which he requires for his presonal use because of his addiction to such drug.

(3) An individual against whom there is pending a prior charge of a felony which has not been finally determined or who is on probation or whose sentence following conviction on such a charge, including any time on parole or mandatory release, has not been fully served: Provided, That an individual on probation, parole, or mandatory release shall be included if the authority authorized to require his return to custody consents to his commitment.

(4) An individual who has been convicted of a felony on two or more occasions. (5) An individual who has been civilly committed under this Act or any State proceeding because of narcotic addiction on two or more occasions.

2 S. 2113, Sec. 2(a): Subject to the provisions of subsection (c) of this section, any person charged with a violation of a Federal penal law relating to narcotics shall upon his appearance before a committing magistrate, be informed that

(1) the prosecution of the criminal charges against such person (unless he is a person within the purview of subsection (c) of this section) shall be held in abeyance in the manner hereinafter provided, if he elects to submit to an examination to determine if he is a narcotic addict;

(2) he shall have ten days following his appearance before the committing magistrate within which to make such an election; and

(3) if he makes such an election within the prescribed ten days and it is determined on the basis of an examination that he is a narcotic addict, the court shall have jurisdiction to order him to submit to a mandatory civil commitment in accordance with the provisions of this Act.

3 S. 2113, Sec. 2(c): The provisions of this Act shall not be applicable in the case of any person charged with a violation of a Federal law relating to narcotics if it appears that-(1) the violation involved the sale of narcotics by such person so charged to another, with knowledge that the person to whom the sale was made intended to dispose of such narcotics by resale :

(2) there is pending against the person in a court of the United States or of any State a prior charge of a felony and such charge has not been finally determined, or the person has been convicted of a felony and the sentence following such conviction, including any time on parole, has not been fully served;

(3) the person has been convicted in a court of the United States or of any State on a total of two or more prior occasions of a felony or

(4) the person has been civilly committed by the United States or any State on a total of two or more prior occasions because of his narcotics use.