2

Figure 1 shows the overall scheme for the analysis of each sample. Essentially, 2 ml of urine were analyzed fluorometrically for morphine and quinine. The positive morphine or quinine samples were confirmed by subjecting a 15 ml aliquot of the urine to acid hydrolysis, extracting and subjecting the extract to thin-layer chromatography. A 25 ml aliquot was routinely applied to a column containing Amberlite XAD-2 resin.*

B- barbiturate; 0 opiate; P - phenothia-
zine; AH - antihistamine; Me - methamphe-
tamine; TLC - thin layer chromatography;
Solvent Systems-ethylacetate, methanol,
NH3 (85:10:10); chloroform, methanol, Nil3
(90:10:1); ethylacetate, methanol, water
and NH3 (85:10:3:1).

The urine samples for the fluorometric analysis were adjusted to pH 9-10 and extracted with 4 ml of chloroform :isopropanol (3:1, v/v). Two thirds of the organic phase was evaporated to dryness and the residue taken up in 0.1 ml of conc. H2SO4, 1 ml of water, 1 ml of conc NH.DH. The samples were autoclaved for 15 min., cooled and the presence of morphine determined fluorometrically in the automated turret spectrofluorometer (ATS) (excitation wavelength 392 nm, emission wavelength 425 nm). The remaining one third of the organic phase was reextracted into 0.1 N H2SO4. Quinine fluorescence was determined with excitation wavelength at 365 nm and emission wavelength at 450 nm.

RESULTS AND DISCUSSION

In Table I appears the data on the urinalysis from January, 1971 through September, 1971 in a NACC Methadone OPD unit. The highest level of abuse appeared during January especially for morphine and quinine. The percentage of the urine samples positive for morphine ranged between 0.2 and 6.6%, with an average of 1.6%. For quinine, the range was 1.6 to 13.0%, with an average of 4.4%. Codeine abuse was quite low averaging 0.2%. There appeared to be very little amphetamine abuse with the highest occurring in

2 Mule, S. J., and Hushin, P. L., Anal. Chem., 43: 708 (1971). Mule, S. J., J. Chromatog., 55: 255 (1971).

Mule, S. J., J. Chromatog., 63: 289 (1971).

April (0.8%) and the average being 0.3%. The range for the use of barbiturates was 0 to 5.4% with an average of 3.3%. An average of 1.4% was obtained for a large number of drugs commonly abused and classified as miscellaneous.

TABLE 1.-URINE ANALYSIS OF SAMPLES OBTAINED IN A METHADONE TREATMENT PROGRAM

Table II provides the data on specific drugs of abuse in the urine of the methadone maintained patients. In regards to the narcotic analgesics, the major drug detected was methadone, and this represented 93.8% of the total narcotic analgesics detected. Morphine and codeine were both quite low at 1.5 and 0.2%, respectively. Quinine represented 4.3% of the total positives for narcotic analgesics. This drug was present primarily because it is used as a dilutent for heroin in New York. The higher percentage of quinine in comparison to morphine (metabolite of heroin) is due to the fact that quinine is slowly metabolized in comparison to morphine, and, therefore, detected over a longer period of time. Apparently d-amphetamine and phenylpropanolamine represented about 40% of the total phenethylamine abuse. Secobarbital was the major barbiturate abused (49.0%) followed by phenobarbital (36.8%) and pentobarbitol (9.0%). Glutethimide abuse (37.5%) exceeded all other drugs in the miscellaneous category. It is quite possible that the relatively high percentage of diphenylhydantoin (25.0%) coupled with phenobarbital (36.8%) indicate abuse of this combined anti-epileptic preparation. Pentazocine and d-methorphan were detected in 5.3% of the miscellaneous group.

TABLE II-URINE ANALYSIS OF 4644 SAMPLES FOR SPECIFIC DRUGS WITHIN A METHADONE TREATMENT PROGRAM

CONCLUSION

It would appear at least with respect to the methadone treatment program located at one NACC outpaitent department that very little drug abuse occurs amongst these patients.

References on folio 1804.

APPENDIX 16

THE NEGATIVE EFFECT OF POLICE INTERVENTION ON A METHADONE

TREATMENT PROGRAM

(By Alan Fisch, M.D., Vernon D. Patch, M.D., and Anthony E. Raynes, M.D. Proceedings, Fourth National Conference on Methadone Treatment, 1972, pp. 475-477)

(Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, and Department of Psychiatry, Boston City Hospital, 818 Harrison Avenue, Boston, Mass. 02118.)

INTRODUCTION

The City of Boston launched a comprehensive drug addiction treatment program in mid-1970. The program, including two outpatient clinics which utilize methadone withdrawal and maintenance techniques, a ten bed detoxification unit, a twenty patient day care program, a twenty-four hour information and referral service and a urine surveillance laboratory, was devised primarily to meet the needs of a rapidly growing heroin addict population in Boston. The entire program was established within the Boston City Hospital Department of Psychiatry; one of the outpatient clinics was set up at Boston City Hospital in the heart of Boston, while the other was set up in an outlying hospital facility in East Boston, which is a close-knit community of second and third generation Italo-Americans predominantly. The experience with the police in the latter clinic is the subject of this paper.

EXPERIENCE WITH POLICE

On August 19, 1970, approximately three weeks after the clinic opened in East Boston, State policemen from the Narcotics Division appeared at the clinic asking to inspect the clinic records. This was denied them by the clinic director on the basis of treatment confidentiality. The stated reason for the police request was to permit investigation of a complaint that methadone was being improperly administered to patients. It was later disclosed that the police were attempting to match the names of clinic patients with the names of narcotics prescriptions from private physicians. This "double dealing" is a felony in Massachusetts.

However, the statutes in Massachusetts governing the conduct of police in the affairs of a drug addiction treatment program are sufficiently vague to result in various interpretations of their supervisory duties and their rights to review records. In addition, the rights of addicts to confidentiality in a methadone treatment program are not clearly established as is the case in other medical treatment.

After an unsuccessful attempt on the part of the police to obtain a search warrant from the local district court, a series of negotiations quickly began between the State Police and program physician. Both sides were in agreement that inevitable publicity following further nose-to-nose confrontation would be damaging to the efforts of each. The discussions revolved around the belief on the part of the State Police that they had a right and duty to inspect any narcotics record; the clinic director and others held the belief that drug addicts would be less likely to avail themselves of treatment if it was

1 The East Boston Drug Rehabilitation Clinic offers a wide range of services in addition to methadone treatment, including individual counselling, group therapy, family counselling, vocational assistance and recreational activities. In addition, the staff is community-oriented, promoting liaison with agencies and community citizens groups.

known that their names would be disclosed to law enforcement officials. The negotiators included representatives of the drug program, the State Police, the State Attorney General's Office, the State Department of Mental Health and the Corporation Counsel for the City of Boston.

It should be noted that the original police investigators were well-known to many of the patients present in the clinic at the time of their first visit. During the early phase of the negotiations, the police continued indirect surveillance of the clinic patient roster by videotaping patients coming to and leaving the clinic. The camera disguised in a bread truck parked near the clinic was readily apparent to the patients and verified later by the police. In addition, further surveillance was done more openly from a squad car parked near the clinic.

About three months after the August 19th visit by the State Police, the lengthy series of negotiations over whether or not records would be provided by the clinic for police scrutiny was resolved by the decision of the State Police authorities to "take no further action". Although it was clear to all parties that an individual patient's record could be subpoenaed in the course of legal proceedings, the police relented in their desire to have continual access to the names of patients using the clinic.

Most important to the decision to "take no further action" were the provisions of Federal Public Law 91-513 of October 27, 1970, known as the Comprehensive Drug Abuse Prevention and Control Act of 1970. That Act includes the following:

"The Secretary may authorize persons engaged in research on the use and effect of drugs to protect the privacy of individuals who are subjects of such research by withholding from all persons not connected with the conduct of such research the names or other identifying characteristics of such individuals. Persons so authorized to protect the privacy of such individuals may not be compelled in any Federal, State or local civil, criminal, administrative, legislative or other proceedings to identify such individuals". Since methadone maintenance programs are still classified as research programs, it was felt that the Federal Act protected the privacy of patients who were being treated in the East Boston Drug Rehabilitation Clinic with methadone. In addition, other provisions in the Act relieved State Police of the responsibility for overall surveillance of narcotics records, as this was made a Federal activity.

Once it was made clear that the State Police were no longer attempting to be involved directly in the operation of the clinic, the clinic director held several meetings with groups of patients to inform them of this development. The purpose of the meetings was to reassure the current patient population and get the word out to the "street" that it was safe to come to the clinic for treatment. The first patient meeting was held immediately after the last meeting with the State Police on November 26, 1970.

PATIENT REACTION TO POLICE INVOLVEMENT

After the first appearance of the State Police at the clinic on August 19, 1970, the number of new patients making application for treatment dropped sharply following an initial "rush" on the new clinic facility. In addition, the number of new applications to the clinic declined steadily until mid-November when there were no new applicants for two weeks. Following the meetings with patients to inform them that the clinic was "safe" near the end of November, there was a corresponding sharp increase in the number of new applicants to the clinic. During September, October, and November, the clinic staff was informed by several community sources of the great reluctance of addicts to apply for treatment because the clinic was "bugged" by the police. (Figure 1.)

In the immediate post-August 19th period, the staff noted an obvious increase in aggressive behavior of the patients in the clinic. This was also correlated with a two-fold increase in the percentage of urine samples positive for barbiturates, e.g., 7% to 14% of the total. (Figure 2.)