TESTIMONY OF DR. LAWRENCE HART, DIRECTOR, DRUG TREATMENT PROGRAM, COMMUNITY HEALTH SERVICES, LOS ANGELES, CALIF.

Dr. HART. Mr. Chairman, I would also like to thank the committee for the chance to come here and testify. I would like to clarify my position.

The Department of Community Health Services which was formerly the Los Angeles County Public Health Department; we run our program with six active clinics.

We have 540 patients on our treatment program. We have a waiting list of over 4,000 to 5,000. I don't know if we could absorb the 5,000 how many more would emerge.

In terms of my testimony, in terms of brevity, I would like to submit my written testimony and the manual.

We did submit a modified protocol for your records. If I can hold in terms of weight of evidence, the factors, and the controls that we have to submit to maintain our program at the State level, including which are Federal and county protocol, it perhaps might give the committee a better idea of some of the controls now existing.

In addition to which I would like to comment as a physician on some of the remarks that were made previously concerning the legality and the knowledge of a physician in terms of understanding the penalties of the law.

I think we were answered in terms of losing our license, and right to practice with which every physician is cognizant. I think that these penalties are also inherent in the new FDA regulations as I have heard them coming out of Washington, being proposed, I think, for December 1.

I think that the present proposed bill by Senator Cook does have merit in the sense that it gives direction toward enforcement and control and you will see in our protocol we have instituted many measures of control, including terminating patients for one diversion of methadone and so on.

But, more important than that is this whole question of control. The problem in which we labor at a working level is to get service, to get the dollar to the patient, through the operating programs-we are answerable to different agencies, each of whom has different sets of regulations which at least overlap.

At most it duplicates some of the controls that we have to constantly reinforce. We are open to reinspection on a different basis by each different agency, and if there is anything that I hope to get across today, it is a plea to the committee for common sense implementation and advice to the FDA, the B.N. & D.D., all of the regulatory agencies in terms of trying to make sense and trying to make the regulations workable in the way in which they are defined, so that they do not overlap, they do not conflict, they do not impose incredible difficulties upon a program which is supposed to be serving patients.

Mr. BAYH. Could you gentlemen, either individually or in concert, give the committee, at your leisure, a specific list of these areas where there is overlapping, where the regulations are self-defeating with the purpose of the program.

Could you do that for us, please?

Dr. HART. Yes. See attachment No. 1. Please note there is no clear specification of areas of responsibility.

Mr. BAYH. So that we can consider those not only in the legislation but perhaps use a little influence in a nonlegislative manner?

Dr. HART. We will be glad to do this, of course, and I think Mr. Randell will be too.

Another point I would like to address myself to is money.

To take care of 5,000 patients, we need $10 million. This is a minimum. This is to provide all of the care-all of the care and rehabilitation, psychiatrists, psychologists, mental care, rehabilitation, all of the enforcement regulations that have been mentioned as part of the program.

The funding has to come from a central source. It has to come from a source whereby we answer in one cohesive, coherent, manner, and be responsible fiscally, certainly, but in a manner which does not involve us with one quarter of our activity in trying to account for various money problems within the programs themselves.

I was I would like to request the opportunity, similarly, to again in terms of time, perhaps submit this type of information to the committee in writing to perhaps expedite this hearing and also, perhaps, to bring the information more coherently to your attention. (See attachment No. 2.)

Mr. BAYH. It would be helpful if you would do that.

Dr. HART. All right.

I should like to rest on my written testimony, the statements I have made. I will be happy to answer any questions you might have.

Mr. Mitchell, who is program manager for the county program, has expertise particularly in the administrative as well as other aspects of the program.

I am sure he will be glad to answer questions.

Mr. BAYн. I appreciate you gentlemen taking the time to let us have your thoughts.

Let me throw a hard one at you from a layman's standpoint.
How long has the program been operating?

Dr. HART. Two years.

Mr. BAYH. After a 2-year assessment, do you feel that there is a place for methadone treatment in the overall problem? What role? Dr. HART. I think absolutely yes. The point was made very well, particularly by the sherif's department. This should however, be selective form of treatment.

There are people for whom methadone is not an appropriate modality. We do very careful screening and take time to try and determine if the patient should receive this. In lieu of any other modality, in terms of enabling people to function, to go without withdrawal symptoms, to hold a job down, to try and return them to a home situation, where this is possible, we elect to use methadone and I think in this context there is no doubt that it plays an important role.

Mr. BAYH. What percentage in this 2 years experience have remained on methadone maintenance; what percentage have had jobs; what percentage have dropped out; what is your general assessment? Dr. HART. May I defer the question to Mr. Mitchell?

Mr. BAYH. Yes; please.

Mr. MITCHELL. We have had as of our latest analysis a 70 percent employment rate. In the beginning of the program, when it was very small, we experienced employment rates of 90 percent. At the time of intake most of the intake groups averaged a 17 percent employment figure when they entered the program, and within 3 months or 4 months were able to reach on an average percentage anywhere from 70 to 80 percent. Last year we had a drop-out rate of approximately five percent.

This has been the experienced of other programs, and our dropout rate is expected to increase, and in the latest analysis, it has increased to approximately 20 percent.

This is due to incarceration, voluntary terminations, deaths, patients wanting to go into a drug free existence, etc., and also includes transfers to other programs.

Mr. BAYH. Under your methadone maintenance program is it possible to move toward a total detoxification?

Mr. MITCHELL. That is the ideal goal and according to NIMH, as the programs are experiencing longer periods of patient being on methadone, the success rate for people maintaining a drug free existence seems to be increasing.

So, there may be some optimism for the long-range picture.

Dr. RANDELL. If I can comment on that, our program is directed at this problem. Our program is directed at the drug free state and we have had in the past 22 years between 30 and 40 percent of the patients go from heroin to methadone to drug free.

Mr. BAYH. Thirty to 40 percent?

Dr. RANDELL. Yes.

Mr. BAYH. Out of about how many patients?
DR. RANDELL. A total patient population of 65.
Mr. BAYH. What can we do to up that to 6,500?

Dr. RANDELL. What we are trying to do is up that to 3,600 in the next 30 days. We are negotiating a contract with SAODAD and NIMH for a contract of 150 additional patients.

Mr. BAYH. Now, this 65, are those very carefully selected individuals, or is that just across the board?

Dr. RANDELL. No; they were not carefully selected in the health department. It is on a first-come, first-served basis and we do various things to test the motivation of the patient, such as charge. Ours is a private program.

Mr. BAYH. What has been your experience, Doctor?

Dr. HART. We are faced within the mandate of our particular programs to take care of the patients on a waiting list on a first-come, first-served basis.

But, we try and determine motivation in our intake. We do try and determine the medical fitness and we do try and determine any psychotic state which would preclude the use of methadone.

But, we do screening. It is not anything to the extent that was mentioned earlier, by the Los Angeles police department, but very extensive.

Mr. MITCHELL. We have a little bit of a different patient population, too. Our average age for males is 36 and our average for females is 32. They have been addicted for well over 10 years, been in prison at least twice, and arrested very frequently, possess a 10th grade education, have very few marketable employment skills, and a very spotty employment record.

We are dealing perhaps with a different population than Mr. Randell's organization which may have an impact, on the figures.

Mr. BAYH. The figures that Dr. Hart has talked about, as far as employment-you two are in the same program?

Mr. MITCHELL. Yes.

Mr. BAYH. Well, you have mentioned the number of people that had jobs.

Dr. RANDELL. In talking to the other program members and there were about five or six, the figures that Mr. Mitchell reports are consistent with the other programs in southern California.

Mr. BAYH. We have the statistics nationwide to show that a large part of the methadone diversion problem has been from individuals enrolled in methadone programs.

Has your effort to try and decrease the dosage, to actually reduce the daily dosage, has that been a significant help there? What else can we do?

Dr. HART. We are just starting this decreased dosage. We have to do this gradually. We do make an attempt to observe the patient taking the medication at the site, and we have them swallow this. There are ways that they try to get around it, but we are pretty well aware of most of the tricks.

The problem, perhaps, lies, if any, in terms of take-home dosages over a weekend when services are not available because of staff shortages, money problems and so on; we do not have the budget.

I think that perhaps a 7-day-a-week program would obviously obviate the take-home privileges and to a certain extent lessen the diversion of methadone.

Mr. BAYH. How would you assess the accuracy of the sheriff and police department statement that we have between 30 and a hundred thousand addicts in the Los Angeles County area?

Dr. HART. I think they quoted us, I think it is very accurate and I think it is a close estimate to ours.

Mr. BAYH. It is very frustrating when one realizes the dimensions of heroin addiction.

Dr. HART. Yes.

Mr. BAYH. And our ability to deal with such a small part of it, although it is better than not dealing with it at all.

What in your judgment can be done to reach the 30 to 100,000? The statement was made by one of the law enforcement officers that it was his judgment that people are hooked because they want to be hooked. Is it that simple? Are there things we can do to increase the incentive to get them involved in your programing?

We are all aware of the first response to give you more money so that we can do a better job and reach more people. If we give you 10 times the money, you are still going to be reaching only one-third of those, at the minimum estimate, and one-tenth of the maximum estimate. Is there something else we can do besides more money?

Dr. RANDELL. Let me see if I can answer that.

Mr. BAYH. Surely.

Dr. RANDELL. I think I can speak for the other members. We believe that methadone maintenance is only one of the choices that should be available to heroin dependent persons. We would like to see, I think, methadone maintenance as a choice, not as the only choice but as a choice readily available to any heroin dependent person who qualifies and desires it.

I think then we would see an impact in this community.

For example, if someone in this room was, in fact, a heroin dependent person who was poverty stricken and applied for methadone theatment in this county, he would probably not be treated for 6 years at the present rate of expansion.

So, I think that when the heroin addict knows this dilemma he does go for treatment.

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Mr. BAYH. You mentioned your opposition to the institutionalization program.

Dr. RANDELL. Yes.

Mr. BAYн. I take it that you feel this would lessen the number of people who would come forward voluntarily?

Dr. RANDELL. I think we have a history of hostilizing patients against treatment of heroin addiction at Lexington and Fort Worth. I think the reason those institutions are no longer favorable is because of the success records. I think that voluntary treatments of heroin dependent patients should be mandatory, whatever form of treatment he chooses.

Dr. HART. I would like to go on record as supporting that stand. I think that the problem is one of motivation.

You do not motivate by fear.

Mr. BAYн. Well, I guess the further question that I wanted to ask you gentlemen is probably the most specifically important one, the cause of our being here.

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