NARCOTICS RESEARCH, REHABILITATION,
AND TREATMENT
HEARINGS
BEFORE THE
SELECT COMMITTEE ON CRIME
HOUSE OF REPRESENTATIVES
NINETY-SECOND CONGEESS
FIRST SESSION '" '"
PUESUANT TO
H. RES. 115, A RESOLUTION CREATING A SELECT COMMITTEE
TO CONDUCT STUDIES AND INVESTIGATIONS OF
CRIME IN THE UNITED STATES
PART 1 OF 2 PARTS
APRIL 2Q, 27, 28, 1971 ; WASHINGTON, D.C.
Serial No. 92-1
Printed for the use of the Select Committee on Crime
U.S. GOVERNMENT PRINTING OFFICE
60-296 WASHINGTON : 1971
For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C, 20402 - Price .$1.50
NORTHEASTERN UNiVERSin SCHOQL of LAW IMM
SELECT COMMITTEE ON CRIME
CLAUDE PEPPER, Florida, Ghairman
JEROME R. WALDIE, California CHARLES E. WIGGINS, California
FRANK J. BRASCO, New York SAM STEIGER, Arizona
JAMES R. MANN, South Carolina LARRY WINN, Je., Kansas
MORGAN F. MURPHY, Illinois CHARLES W. SANDMAN, Jr., New Jersey-
CHARLES B. RANGEL, New York WILLIAM J. KEATING, Ohio
Paul L. Perito, Chief Counsel
Michael W. Blommer, Associate Chief Counsel
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CONTENTS
April 26 1
April 27 77
April 28 209
June 2 341
June 3 _^____^ 391
June 4 .-. 481
June 23 553
Oral Statements by Government Witnesses
Health, Education, and Welfare, Department of:
Food and Drug Administration:
Edwards, Dr. Charles C, Commissioner : 393
Gardner, Dr. Elmer A., Consultant to the Director, Bureau of
Drugs ___ 393
Jennings, Dr. John, Associate Commissioner for Medical Affairs. 393
Health Services and Mental Health Administration:
National Institute of Mental Health:
Besteman, Dr. Karst, Acting Director, Division of Narcotics
and Drug Abuse 430. 439
Brown, Dr. Bertram, Director 430, 439
Martin, Dr. William, Chief, Addiction Research Center,
Lexington, Kj' 435,439
van Hoek, Dr. Robert, Associate Administrator for Operations. 430,439
Narcotics and Dangerous Drugs, Bureau of:
IngersoU, Hon. John E., Director 344, 439
Lewis, Dr. Edward, Chief Medical Officer 344, 439
Miller, Donald E., Chief Council 344, 439
Treasury, Department of, Hon. Eugene T. Rossides, Assistant Secretary,
Enforcement and Operations 61
Oral Statements by Public Witnesses
AREBA (Accelerated Reeducation of Emotions, Behavior, and Attitudes),
Dr. Daniel H. Casriel, director; accompanied by Rev. Raymond Massev
and Dr. Walter Rosen '_ 273
Brickley, Hon. James H., Lieutenant Governor, State of Michigan (on
behalf of Gov. William G. Milliken) 614
Brill, Dr. Henry, director, Pillgrim State (N.Y.) Hospital 51
Carter, Hon. James, Governor, State of Georgia 608
Casriel, Dr. Daniel H., director, AREBA (Accelerated Reeducation of
Emotions, Behavior, and Attitudes) 273
Chambers, Dr. Carl, director, division of research, New York State
Narcotic Addiction Control Commission 558
Davidson, Dr. Gerald E., a.ssociate director, Drug Dependency Clinic,
Boston City Hospital 322
Drug Dependency Clinic, Boston City Hospital, Dr. Gerald E. Davidson,
associate director ^^ ^ 322
DuPont, Dr. Robert L., Director, District of Columbia Narcotics Treat-
ment Administration 143
Eddy, Dr. Nathan B., Chairman, Committee on Problems of Dnig Depend-
ence, Division of ]\Iedical Sciences, National Academy of Sciences-
National Research Council 29
Gearing, Dr. R. Frances, associate professor, division of epidemiology,
Columbia University School of Public Health and Administrative
Medicine 105
Georgia, State of, Gov. James Carter ^ 608
(ra)
IV
Page
Gollance, Dr. Harvey, associate director, Beth Israel Medical Center 239
Hesse, Rayburn F., special assistant to the chairman, Federal-State rela-
tions, New York State Narcotic Addiction Control Commission 5.58
Holden, William, department head, MITRE Corp 80
Holton, Hon. Linwood, Governor, Commonwealth of Virginia .594
Horan, Robert F., Jr., Commonwealth attorney, Fairfax County, Va 255
Illinois Drug Abuse Program, Dr. Jerome H. Jaffe, director 210
Institute of Applied Biology, Rev. Raymond ^Nlassey 273
Jaflfe, David, department staff, MITRE Corp 80
Jaflfe, Dr. Jerome H., director, Illinois Drug Abuse Program 210
Jones, Howard A., commissioner, New York State Narcotic Addiction
Control Commission 558
Kramer, Dr. John C, assistant professor, department of psychiatry and
human behavior, department of medical pharmacology, University of
California (Irvine) 642
Kurkmd, Dr. Albert A., director, Maryland State Psychiatric Research
Center 505
McCoy, William O., Maryland State Psychiatric Pi,esearch Center 506
Maryland State Psychiatric Research Center;
Kurland, Dr. Albert A., director 505
McCoj^, William ,506
Taylor, Robert 507
Masse}', Rev. Raymond, Institute of Applied Biology 273
Michigan, State of, Lt. Gov. James H. Brickley (on behalf of Gov. WiUiara
G. Milliken) 614
MITRE Corp 80
Holden, William, department head.
Jaffe, David, department staff.
Yondorf, Dr. Walter, associate director, national command and con-
trol division.
Narcotics Treatment Administration, District of Columbia, Dr. Robert L.
DuPont, Director 143
New York State Narcotic Addiction Control Commission:
Chambers, Dr. Carl, director, division of research 558
Hesse, Rayburn F., special assistant to the chairman, Federal-State
relations 558
Jones, Howard A., commissioner 558
Pennsylvania, Commonwealth of. Gov. Milton Shapp 602
Resnick, Dr. Richard B., associate professor, department of psychiatry,
New York Medical College 1 .539
Rosen, Dr. Walter, New York, N.Y 273
Seevers, Dr. Maurice H., chairman, department of pharmacology, University
of Michigan Medical School 9
Shapp, Hon. Milton, Governor, Commonwealth of Pennsylvania 602
Taylor, Robert, Maryland State Psychiatric Research Center 507
Villarreal, Dr. Julian E., associate professor of pharmacology, University
of Michigan Medical School 1 483
Virginia, Commonwealth of, Gov. Linwood Holton 594
Yondorf, Dr. Walter, associate director, national command and control
division, MITRE Corp 80
Exhibits Received for the Record
exhibit no. 1
American Medical Association, Dr. Richard S. Wilbur, deputy executive
vice president, letter dated July 9, 1971, to Paul L. Perito, chief counsel.
Select Committee on Crime 16
EXHIBIT NO. 2
Seevers, Dr. Maurice H., chairman, department of pharmacology, Univer-
sity of Michigan INIedical School, curriculum vitae 1 22
EXHIBIT NO. 3
Defense, U.S. Department of, Dr. Louis M. Rousselot, Assistant Secre-
tary, Health and Environment, letter dated June 28, 1971, to Chairman
Pepper, with attachments _ 24
V
EXHIBIT NO. 4 (a) AND (b)
Eddy, Dr. Nathan B., Chairman, Committee on Problems of Drug De-
pendence, Division of Medical Sciences, National Academj^ of Sciences-
National Research Council: P»Ke
(a) Prepared statement 40
(b) Curriculum vitae 42
EXHIBIT NO. 5 (a) AND (b)
Brill, Dr. Henry, director, Pilgrim State Hospital, New York, N.Y.:
(a) Prepared statement 58
(b) Curriculum vitae 59
EXHIBIT NO. 6
State, Department of, David M. Abshire, Assistant Secretary for Congres-
sional Relations, letter dated July 2, 1971, to Chairman Pepper, with
attachments 70
EXHIBIT NO. 7
Treasur}^ Department of, Eugene T. Rossides, Assistant Secretary for
Enforcement and Operations, curriculum vitae 75
EXHIBIT NO. 8 (a) AND (b)
Jaffe, David, department staff, MITRE Corp.:
(a) Supplemental statement 101
(b) Curriculum vitae 102
EXHIBIT NO. 9
Ulrich, William F., manager, applications research, scientific instruments
division, Beckman Instruments, Inc., prepared statement (dated
June 27, 1970) 103
EXHIBIT NO. 10 (a) AND (b)
Gearing, Dr. Francis R., associate professor, division of epidemiology^,
Columbia University School of Public Health and Administrative
Medicine :
(a) Paper entitled "Successes and Failures in Methadone Mainte-
nance Treatment of Heroin Addiction in New York City" 121
(b) Position paper entitled "Methadone — A Valid Treatment Tech-
nique" 138
EXHIBIT NO. 11 (a) THROUGH (e)
DuPont, Dr. Robert L., director. District of Columbia Narcotics Treat-
ment Administration :
(a) Article entitled "Profile of a Heroin Addict" 166
(b) Study entitled "Summary of 6-Month Followup Study" 178
(c) Brief collection of statistical information entitled "Dr. DuPont's
Numbers 183
(d) An administrative order setting forth guidelines for methadone
treatment 183
(e) Article entitled "A Study of Narcotics Addicted Offenders at the
D.C. Jail" '_ 195
EXHIBIT NO. 12
Jaffe, Dr. Jerome H., director, Illinois Drug Abuse Program, curriculum
vitae 236
VI
EXHIBIT NO. 13 (a) THROUGH (C)'
Page
GoUance, Dr. Harvey, associate director, Beth Israel Medical Center:
(a) Article entitled "Methadone Maintenance Treatment Program". _ 249
(b) Letter dated May 7, 1971, to Chris Nolde, associate counsel,
Select Committee on Crime 253
(c) Letter dated Nov. 11, 1970, to Dr. Vincent P. Dole, Rockefeller
University from Carlos Y. Benavides, Jr., assistant district
attorney, Laredo, Tex 254
EXHIBIT NO. 14 (a) THROUGH (g)
Casriel Dr. Daniel H., director, AREBA (Accelerated Reeducation of
Emotions, Behavior, and Attitudes) :
(a) Article entitled "The Case Against Methadone" 296
(h) Article entitled "Casriel Institute of Group Dynamics, New
York, N.Y." (discussion of Dr. Revici paper on Perse) 302
(c) Submission entitled "Significant Therapeutic Benefits Based on
Peer Treatment in the Casriel Institute and AREBA" 311
(d) Introduction and explanation of the AREBA program 314
(e) Reprint of article from the Medical Tribune-World Wide Report
entitled "Therapy of Narcotic Addicts Sparks Psychiatric Theory". 315
(f) Article reprinted from the Sandoz Panorama entitled "The Family
Physician and the Narcotics Addict" 317
(g) Curriculum vitae 320
EXHIBIT NO. 15
Davidson, Dr. Gerald E., associate director, drug dependency clinic,
Boston Citv Hospital, study entitled "Results of Preliminary Perse
Study"....: 331
EXHIBIT NO. 16
Beaver, Dr. William T., associate professor, department of pharmacology,
Georgetown University School of Medicine and Dentistry, prepared
statement 334
EXHIBIT NO. 17 (a) THROUGH (e)
Health, Education, and Welfare, Department of:
(a) Jennings, Dr. John, Associate Commissioner for Medical Affairs,
Food and Drug Administration, prepared statement 420
(b) Edwards, Dr. Charles C, Commissioner, Food and Drug Admin-
istration, memorandum dated May 14, 1971, with attachments. 422
(c) van Hoek, Dr. Robert, Associate Administrator for Operations,
Health Services and Mental Health Administration, prepared
statement 430
(d) Brown, Dr. Bertram S., Director, National Insititue of Mental
Health, Health Services and Mental Health Administration,
prepared statement 469
(e) Steinfeld, Dr. Jesse L., Surgeon General, letter dated June 21,
1971, to Chairman Pepper 480
EXHIBIT NO. 18
Villarreal, Dr. Julian E., associate professor of pharmacology. University
of Michigan Medical School, prepared statement 502
EXHIBIT NO. 19
Agriculture, Department Of, N. D. Bayley, Director of Science and Educa-
tion, Office of the Secretary, letter dated July 23, 1971, to Chairman
Pepper, re thebaine 510
EXHIBIT NO. 20
Kurland, Dr. Albert A., director, Maryland State Psychiatric Research
Center, prepared statement 520
vn
EXHIBIT NO. 21 (a) and (b)
Page
New York State Narcotic Addiction Control Commission, Howard A. Jones,
Chairman-designate :
(a) Letter dated June 22, 1971, to the committee, re summary of
New York State drug report 578
(b) Prepared statement 580
EXHIBIT NO. 22
Holton, Hon. Linwood, Governor, Commonwealth of Virginia, prepared
statement 597
EXHIBIT NO. 23
Shapp, Hon. Milton, overnor, Commonwealth of Pennsylvania, pre-
pared statement 606
EXHIBIT NO. 24
Carter, Hon. James, Governor, State of Georgia, prepared statement 612
EXHIBIT NO. 25
Brickley, Hon. James H., Lieutenant Governor, State of Michigan, pre-
pared statement 617
EXHIBIT NO. 26 (a) THROUGH (f)
Letters and statements of officials of various cities regarding problems
of drug abuse:
(a) Boston, Mass., Mayor Kevin A. White 628
(b) Detroit, Mich., Mayor Roman S. Gribbs 630
(c) Hartford, Conn., Mayor George A. Athanson 631
(d) New Haven, Conn., Mayor Bartholomev.' A. Guida 634
(e) Philadelphia, Pa.:
O'Neill, Joseph F., police commissioner 637
Sofer, Dr. Leon, deputy health commissioner, office of
mental health/mental retardation 638
(f) Washington, D.C., Mayor Walter E. Washington 640
EXHIBIT NO. 27
Kramer, Dr. John C, assistant professor, department of psychiatry and
human behavior, department of medical pharmacology, L^niversity
of California (Irvine), prepared statement 662
EXHIBIT NO. 28
Statement submitted on behalf of S. B. Penick & Co., Merck & Co., Inc.,
and Mallinckrodt Chemical Works 670
EXHIBIT NO. 29
Becker, Arnold, public defender, Rockland County, N.Y., statement .__ 677
EXHIBIT NO. 30
Andrews, Rev. Stanley M., Libert}' Lobby, prepared statement 679
EXHIBIT NO. 31
Benson, Dr. Richard S., letter dated August 4, 1971, to Chairman Pepper,
re transcendental meditation (with enclosures) 681
EXHIBIT NO. 32
'Copy of letter sent to drug companies by Chairman Pepper re research
concerning narcotic blockage and atagonistic drugs 690
NARCOTICS RESEARCH, REHABILITATION,
AND TREATMENT
monday, april 26, 1971
House of Representatives,
Select Committee on Crime,
Washington^ B.C.
The committee met, pursuant to notice, at 10 :05 a.m., in room 2359,
Rayburn House Office Building, Hon. Claude Pepper (chairman)
presiding.
Present: Representatives Pepper, Mann, Wiggins, Steiger, Winn,
and Keating.
Also present : Paul Perito, chief counsel ; and Michael W. Blommer,
associate chief counsel.
Chairman Pepper. The committee will come to order, please.
The House Select Committee on Crime today begins 7 days of
public hearings which will cover four separate but related areas of
narcotic addiction. We have been examining the complex problems of
drug abuse and drug dependence since our inception as a committee
on crime in May 1969. The heroin addiction crisis has reached threat-
ening proportions. Our cities are beseiged. Our suburban areas have
become infected. Even our rural areas are now feeling the shocking
effect of this malady. Drug abuse and drug dependence have become
so unmanageable that they are now responsible, both directly and
indirectly, for contributing to 50 percent of the street crime in our
Nation. While our population has increased 13 percent from 1960 to
1969, crimes against property increased 151 percent, and violent
predatory crimes increased 130 percent.
In the face of this mounting evidence of spiraling street crime, our
citizens are properly asking whether their Government is helpless,
or corrupt, or even worse, totally incapable or unwilling to deal with a
public health epidemic.
The national heroin addiction epidemic places an impossible burden
upon an overburdened criminal justice system. This heroin epidemic
forces our police to allocate their resources unequally in attempting to
stem the illicit drug traffic. Testimony taken by our committee in New
York, Washington, San Francisco, Boston, and Miami vividly dem-
onstrated the fact that prosecutors must devote an inordinate amount
of their time and staff to the investigation and prosecution of cases
which are heroin connected. Our Crime Committee investigators have
revealed that in New York, as in most of our major cities, the adminis-
tration of criminal justice has been brought to a virtual standstill be-
cause of the volume of heroin related cases. Probation officers through-
out the country have advised our investigators that they cannot begin
(1)
to cope witli the burdens imposed on their officers b}' heroin addiction
probationers. For the same reason, our prisons also are overloaded and
our detention facilities arc strained beyond imagination. How can these
institutions be expected to perform the pi-oper function of confinement,
which is rehabilitation ? Correction and rehabilitation are not only hin-
dered by the heroin epidemic, they are made virtually impossible. As a
direct result, our alleged correction process has become a myth, and
recidivism flourishes in every major city in our Nation.
The cost in terms of dollars is staggering. The cost in terms of lives
lost is appalling. Truly, the heroin addiction epidemic has become a
national tragedy.
If we attempt to compute the monetnry loss resulting from this
heroin epidemic, we must include the involuntary social costs; that
is, the cost for law enforcement and the administration of criminal
justice, the cost of production losses. Our statistical computation of the
national dollar loss due to the heroin epidemic ranges from $1.5 to $2
billion aniuially. But this staggering amount of lost dollars pales into
insignificance when we consider the loss of human life related to heroin
addiction. Dr. Milton HelpeT-n, chief medical examiner of New York
City, told our committee in June that in 1960 there were 199 narcotic-
related deaths in New York, but this figure soared to 1.006 deaths in
1969. Sadly, of the 1,006 narcotic-related deaths in 1969, 255 were teen-
agers. Heroin addiction is the leading cause of death in New York
among adolescents and young adults between the ages of 15 and 35.
The heroin death rate in New York is not typical for densely popu-
lated metropolitan areas.
In Dade County, Fla., my congressional district, 41 young people
died from heroin last year, and nine deaths have already been re-
ported as of this year.
The death rate for narcotism in Washington and Miami have at-
tested to similar growth patterns.
You may wonder why our witness list today includes three out-
standing scientists and medical clinicians but only one law enforce-
ment official. You may wonder why a committee on crime is soliciting
the views of the scientific and medical communities and not concen-
trating exclusively upon local police officials and narcotics agents.
You may wonder why this committee is vitally concerned about the
insignificant amount of Federal and State dollars devoted to research
into the development of more eflFective blockage and antagonistic
drugs, and synthetic substitutes for heroin and morphine.
It is precisely because we have taken a comprehensive view of the
national and international drug abuse and drug addiction problem
that we are today examining the capabilities of our scientific and
medical communities to deal with this national heroin epidemic.
We have for too long relied solely upon law enforcement to control
this public health menace. This is not to suggest that law enforcement
should not play a vital role in what should be a national commitment
to stem the tide of narcotic addiction arid interdict the flow of illicit
heroin into our country. However, we can no longer delude ourselves
with the thought that law enforcement alone is capable of controlling
or even substantially reducing the flow of illicit heroin into the
United States or of reducing the number of addicts daily threatening
our cities. Heroin addiction is clearly crimogenic. Information gath-
ered by our investigators leads us to conclude that a svibstantial por-
tion of our addict population must not only steal, but also deal^
in order to pay for their voracious habits. Every addict dealer is a.
walking health menace.
Dr. Robert DuPont, of the District of Columbia Narcotics Treat-
ment Administration, estimates that the average addict in the District-
gets illegal possession of $50,000 worth of goods a year to sustain his
addiction.
The mounting evidence of the growing illicit flow of heroin into
the United States compels the conclusion that we must search for new
and imaginative answers. Our scientific and technological capabilities
must be enlisted in the fight. No longer will the prosaic law enforce-
ment approaches of the past serve as guides for future congressional
conduct.
It is with this prospective that we open 7 days of heai'ings in which
we plan to explore some brave new worlds in our struggle against the
menace of a national heroin epidemic.
In January, our committee filed a heroin report with the Congress
in which we recommended that our Government advocate and nego-
tiate toward the total eradication of worldwide opium cultivation. We
are convinced of the futility of relying solely upon overburdened and
devoted customs and narcotics agents whom we have assigned tlu' im-
l)0ssible burden of policing our borders and ferreting out heroin traf-
fickers. Responsible law enforcement officials have told our committee
that the combined efforts of our dedicated Federal and State narcotic
agents result in seizures of less than 20 percent of the heroin smuggled
into our country. Even if we were to double the size of our narcotic
enforcement agencies and provide them with unlimited spending au-
thorization, we might be able to increase our seizures 100 percent and
thereby seize 40 percent of the heroin destined for the addicts' eager
veins. But what about the remaining 60 percent ? How can we possibly
expect customs agents to search the 250 million people who pass
through our borders each year ? How can we possibly and reasonably
expect the customs agents and narcotic officials to inspect the 65.310.-
807 cars and trucks, the 306,476 planes, and the 156,994 ships wiiich
entered our country last year ?
We have been told by the customs and narcotic officials that on the
ordinary size ship arriving at the Port of New York there are 30,000
places where heroin can be concealed.
On a local level, a recently concluded study by the New York State
Investigations Commission revealed that in 1970, officers of the under-
cover unit of the narcotic division of the New York City police made
7,266 buys of narcotics, and made 4,007 arrests in connection therewith.
In all of these citywide arrests made in a year's time, a total of 4.97
pounds of highly adulterated heroin was seized. The cash used by the
New York police to make these purchases totaled $91,197.50 — that is
over $1,100 an ounce for highly diluted heroin. Surely it cannot be
argued that these arrests and seizures, at a tremendous cost of man-
power and actual cash outlay, are having a significant impact in stem-
ming the tide of organized narcotic trafficking in the city of New
York.
It seems highly unlikely that the continued diligent efforts of dedi-
cated narcotics agents, on all levels, will result in a significant increase
in the rate of heroin seizures. It seems clear that if the opium poppy
continues to be cultivated legally there will inevitably be illegal traffick-
ing in the heroin derived from this poppy.
Consequently, our committee is today examining the question of
whether we really need the opium poppy. If we can supply the pain-
killing and cough-suppressing needs of our Nation by reliance upon
domestically manufactured synthetic substitutes, then this Congress
should take the lead today in banning the importation of all crude
opium. It is to this end that we will devote a portion of this hearing.
We will then hear from law enforcement experts and scientific re-
searchers about the possibility of policing such a worldwide ban. We
also want to know whether our Federal law enforcement officials
believe that this bold step would be helpful to them, not only in stem-
ming the illicit flow of heroin into the United States, but also as a
lever in bargaining with officials from opium-producing countries.
We then plan to look at the state of development of narcotic block-
age and antagonistic drugs. Our interest is not confined to methadone,
which looks promising but is also fraught with problems. Our inter-
est is also in assessing the potential of developing longer lasting block-
age drugs such as acetylmethadol, which is being used experimentally
by Dr. Jerome H. Jaffe, in Chicago. We also want to know whether the
so-called heroin antagonists are, as Dr. Stanley Yolles (former Direc-
tor of the National Institute of Mental Health) commented, the most
promising area in narcotics research. If this is true, our committee
wants to know why more adidcts are not now being treated in rehabili-
tation centers throughout the country with nonaddicting cyclazocine
and naloxone. What are the results of experiments with antagonist
drugs? Do scientists really believe that these drugs offer a viable
alternative to methadone maintenance and drug-free treatment
modalities?
Additionally, as a committee on crime, we must not only be con-
cerned with the humanitarian aspect of opiate addiction, but also the
burden that such addiction imposes upon a society threatened and
ravaged by crime directly rebated to tliis addiction. Is methadone
maintenance an efficacious method of reducing crime perpetrated by
addicts under treatment? Does methadone maintenance reduce the
illegal activity of addicts and provide a vehicle to move these addicts
back into our society ? Is methadone maintenance safe if properly
administered in a comprehensive rehabilitation program ?
Do the deaths recently attributed to methadone — we have had six
reported deaths in the last few weeks here in the District of Colimi-
bia — do the_ deaths recently attributed to methadone mean that we
must reconsider the present posture of methadone maintenance or are
these deaths a natural incident and to be expected with the rise of
methadone treatment programs? These are just some of the ques-
tions which this committee wants answered during the course of these
hearings.
"VYe also want to know whether the guidelines recently promulgated
by the Food and Drug Administration will serve as a barrier against
wrongful, negligent, and unlawful practices by some physicians who
have dispensed methadone. We want to examine the critical question
of how can methadone, an admittedly dangerous synthetic drug, best
be dispensed. "We want to know whether methadone maintenance
can truly be an effective therapeutic approach with the proper and
costly support services.
Finally, this committee intends to survey and evaluate our present
Federal and State expenditures relating to opiate research. We want
to know if new drugs are on the horizon. Certainly the scientific genius
of this country should be implored and employed to help solve this
national calamity.
It might well be that at the conclusion of these 7 days we have
raised more questions than we have answered. However, we can no
longer afford to avoid the unpleasant evidence of the geometric
growth in narcotic addiction. This tragedy, however, might well push
us into a needed national mobilization of our medical and scientific
resources to destroy the awful heroin traffic and to deal humanely
with those who suffer from it. I know I sjDeak for all the members of
this committee when I conclude by stating that this committee is
ready to make the sacrifice, financial and otherwise, which is neces-
sary to wipe out this national health epidemic.
At this time, let us place in the record a copy of House Resolution
115, introduced January 3, 1971, and approved March 9, 1971, which
created the Select Committee on Crime in the House of Representa-
tives, described its purposes, set its goals, laid its jurisdictions, and
delineated its functions.
(H. Res. 115 follows:)
6
92D CONGKES.S
1st J>kssion
H. RES. 1 1 5
IN TIIK IIOISK OF llKriiKSFXTATLVKS
.I.\.\i m;v -J-I. 1!)71
.Me. I'l rrii; ( I'of liiiiist'lf iind .Mr. A\'i(;(:in>) siil)inittc(l tin- r()ll()\vin<r I'esohition ;
wliii-li wiis ivIVri'i'd to tin' ("oiumittfe on Knlcs
Fi:ni!r\i;v l*.">. I'.'T!
]>r|)()ilc(l uilli ;iiii(Mi(liiiciits, ivI'eiTi'd to tlic House Ciilciidar, ami ofdorcd to
1)0 i)rir>t('d
.Mmmii !). 11)71
( 'oiisidiTi'il, ;nii(Midi'd, and ajifced lo
RESOLUTION
;i liesolred, That, effective Jamiarv o, 1971, there is
2 hereby created a select coiimiittee to he composed of eleven
3 Memher.s of the House of Kcpreseiitative.s to ))e appointed
4 \>\ \\\(' S])eaker, one of \\ii(nii he shall desijiiiate as chainnaii.
5 Any vacancy occnrrinji' in the niciuliersliip of the select
G coiiiniitlee shall he liHed in the same manner in wjiich the
7 oriuinal ai)pointment was. made.
8 )Six\ 2. The select connnittee is authorized and directed to
0 conduct a full and complete investigation ;uid study of all
10 aspects of crime affecting- the United States, including, but
11 not limited to, (1) its elements, causes, and extent ; (2) the
12 preparation, collection, and dissemination of statistics and
1 (lata; (->) the sliariiis" oF iiiloniiatioii. staiti^itics, and data
2 amoiio' law enforcement awncies, Federal. State, and local.
3 inchuling' the excliange of infoi-niation. .statistics, and data,
4 with foreign nations; (4) the adeqna(-y i»l' law enforcement
^ and the administration of justice, inchuling' constitutional is-
^ sues and prohlems pertaining thereto: (.")) the effect of crime
'^ and distnrhanccs in the metro]iolifan nrhan areas: ((>) the
^ effect, directly or indirectly, of crime on the connnerce of
^ the Nation: (7) the treatment and rchahilitation of ])ersons
^^ conxicted of crimes; (8) mcasni-es relating to the reduction..
^^ control, or prevention of crime: (11) measures relating to the
^- injpi'oxement of (A) investigation and detection of crime,
^'^ (B) law enforcement techniques, including, hut not limited
•^ to. increased cooperation among the law enforcement agen-
-^■^' cies, and (C) the efTcctive adnnnistration of justice: and
^^ (10) ineasures and progi'ams h>r increased respect for the
' ]n\y and constituted authoi'ity.
•"^ Si'.C. .'5. I'or till', pui'posc of making such in\estigations
and studies, the. conmiillee or any suhcoimnittee thereof is
a,uthori/ed to sit and act. suljject to clause 31 of rule XI of
21 • • •
the Rules of tlie House of Kepresentativcs. during the pres-
00 . ...
ent Congress at such times and places within the United
23 1 • •
States, includmg any Commonwealth or possession thereof,
24
wliether the House is meeting, has recessed, or has ad-
95
journed, and to hold such hearings and reipure, h\' suhpena
8
3
1 or odierwise, tlu' aUciKljiiicc and tcstiiiioii}- of ^iicli \vitiicsscs
12 and tlio ])r()dut'ti()n of such Ixxtks. records, correspondence,
3 menioiaiidiims, })ai)('rs, and documents, as it deems iieces-
4 'ijary. Snbpenas may l)c issued over the signature of the chair-
5 man of the connnittee or any member designated b\' him and
^ may be served liy any person designated by such chainnan
7 or member.
8 Sec. 4. The select connnittee shall report to the House as
9 .sooii as lU'acticable during the present Congress the results
10 of its investigations, hearings, and studies, together with such
11 recommendations as it deems advisable. Any such report or
12 reports which are made when the House is not in session
13 shall be filed \\ith the Clerk of the House.
9
Chairman Pepper. The committee is very much pleased to call at
this time Dr. Maurice H. Seevers, one of the Nation's most respected
researchers in the held of driio- abuse and drug addiction.
Dr. Seevers holds both a Ph. D. in pharmacology and an M.D. from
the University of Chicago.
In the course of his distinguished career, Dr. Seevers has served as a
research fellow in pharmacology at the Universit}- of Chicago ; an
instructor in pharmacology at Loyola of Chicago ; associate professor
of pharmacology at the University of Wisconsin; and as associate
dean of the University of Michigan Medical School. Since 1042, he
has served as professor of pharmacology and chairman of the depart-
ment of pharmacology at the University of Michigan IMedical School.
Dr. Seevers is a past president of the American Society of Pharma-
cology and Experimental Therapeutics, and has served as chairman
of the executive committee of the Federation of American Societies
of Experimental Biology.
He is a consultant to the National Research Council's Committee
on Problems of Drug Dependence ; a member of the American Medical
Association's Committee on Alcoholism and Drug Dependence: and
chairman of the American Medical Association's Committee on Re-
search on Tobacco and Health.
Dr. Seevers has served as a member of the board of scientific coun-
selors of the National Heart Institute ; the Drug Abuse Panel of the
President's Advisory Committee, "Wliite House Conference on Nar-
cotics and Drug AlDuse; and the Surgeon General's Committee on
Smoking and Health.
Dr. Seevers presently serves as the American coordinator of the
United States- Japan Cooperative Program on Drug Abuse; he is a
member of the Expert Advisory Panel on Drugs Liable To Produce
Addiction of the U.N.'s World Health Organization; and is a con-
sultant to the Minister of Health and Welfare of Japan. Dr. Seevers
was recently appointed by President Nixon to the President's Com-
mission on Marihuana and Drug Abuse.
He has served on the editorial boards of numerous scientific journals
and has received honors befitting a man of his wisdom and dedication,
including three honors from the Government of Japan.
Dr. Seevers, we are indeed honored to have you here today, and very
grateful to you for coming here.
Mr. Perito, our chief coimsel. You may inquire.
Mr. PERrro. Thank you, Mr. Chairman. Dr. Seevers, I understand
that you have a prepared statement.
STATEMENT OF DE. MAURICE H. SEEVERS, CHAIRMAN, DEPART-
MENT OF PHARMACOLOGY, UNIVERSITY OF MICHIGAN MEDICAL
SCHOOL
Dr. Seevers. I do.
Mr. Perito. Would you care to read that statement ?
Dr. Seevers. Thank you, sir.
I will address myself primarily to the question of whether it is pos-
sible to substitute synthetic drugs for horticulturally derived
substances.
60-296— 71— pt. 1 2
10
The question currently before your committee, the substitution of
synthetic narcotic analgesics for narcotic analgesics or their semisyn-
thetic derivatives derived from opium is not a new one. Nor has it re-
mained unanswered by competent authorities in the past. In 1951, the
Committee on Drug Addiction and Narcotics — now the Committee on
Problems of Drug Dependence — National Academy of Sciences-Na-
tional Research Council, was confronted by the following questions
by the Munitions Board (Minutes of the seventh meeting, January 15,
1951, "Bulletin of the Committee on Drug Addiction and Narcotics") :
1. What percentage of national requirements for opium derivatives could
safely be replaced by synthetics ?
2. If at some stage during a national emergency our stocks of opium should
become exhausted and irreplenishable, how serious would be the consequences
on <he public health in view of the availability of synthetic substitutes?
The Committee answered thus — this was in 1951, 20 years ago:
All uses of morphine, codeine, and other products and compounds derived from
opium for systematic relief may be replaced adequately with substitutes now
known. The only question for which a complete answer cannot be given at pres-
ent is whether or not replacement of codeine for self-medication for cough re-
lief with synthetic agents would be as safe as the use of codeine itself? An im-
mediate and intensive effort should be directed toward the answer to this ques-
tion of safety.
For several years prior to this response the Committee was be-
sieged with requests to test new synthetic analgesics for their depend-
ence liability on voluntary ex-addicts at the USPHS Hospital at Lex-
ington. This facility was then, and still is, the only place in the world
where such studies can be conducted on man.
The industrial output has always been far in excess of the capacity
of tliis clinical unit.
Having utilized the rhesus monkey as a laboratory model of mor-
phine dependence since my graduate student days in 1925, and found
this species remarkably similar to man in its response to this class of
drugs, I suggested to the committee that this animal might be utilized
as a preliminary screen to reduce the number of drugs to be tested in
man. After 3 years of development during which the results on mon-
keys were compared carefully with those obtained on humans at the
Lexington facility, satisfactory testing procedures were available.
Since that time, this monkey colony at the University of Michigan has
become a world facility. Over 800 drugs of this class have been evalu-
ated, representing the world output, including all of these Avhich have
reached the market. Some possess properties superior to those of mor-
phine. Dozens of those tested, although not profitable for marketing
at the present stage, could be used safely and effectively in man.
Tlius 20 years after the limited affirmative of the NRC Committee
the scientific answer today is an unqualified affirmative.
But other questions which relate to the practical a]:)plication of this
scientific affirmative cannot be answered with such precision and as-
surance. Whereas I make no claim to expertise in all of these areas, I
have been involved on the scene over the last 30 3'ears, and sor.ie com-
ments may be pertinent. The elementary question, of course, is two-
pronged. ,.,j(,,
One aspect is, would the total elimination of quota production by
U.N.-recognizcd producing countries prevent the smuggling of non-
11
quota production from unrecognized countries? The second aspect,
would it be possible to control illicit production or snuiggling of syn-
thetics when it is currently impossible to control heroin ?
The answer to these two questions is clearly in thenegative without
international cooperation, a most uncertain probability in view of the
strong economic factors involved. May I remind you that the 10th
:session of the Economic and Social Council of the United Nations in
1956 came within one vote of adopting a resolution which would have
prohibited the production of synthetic narcotics. This action was of
such great concern to Commissioner Anslinger that he asked me to
write a paper on the subject. This paper was entitled "Medical Per-
spectives on International Control of Synthetic Narcotics." This arti-
cle raised the ire of representatives of the producing and manufactur-
ing nations, especially France, Turkey, Yugoslavia, and India. They
objected to many of the statements made in this article and for many
reasons but especially the following :
On the contrary, the scientific and medical advances in the synthetic and nar-
cotic field have been so rapid that even today very few natural products are in-
dispensable to the public health. The evidence in favor of the "synthetics" is so
impressive when subjected to comparative analysis that the author is tempted
to predict that the day is not far distant when the Commission will be confronted
with resolutions which would propose to abolish forever the cultivation and
production of all "horticulturally derived" narcotics.
Probably you have heard the following statistics but to refresh your
minds: 163 tons of morphine were manufactured legally in 1969. Ap-
proximately 90 percent of this was converted into codeine. Codeine,
although present naturally in opium, is present in such small amounts
that it is not commercially practical to obtain codeine without convert-
ing it from morphine.
This quantity of morphine was produced from 1,219 tons of opium
production and 28.274 tons of poppy straw. This was the licit produc-
tion of opium. It is controlled by the International Control Board
of the United Nations. Almost three-fourths of the total, 864 tons, was
produced by India. The second largest producer was the U.S.S.R., 217
tons ; the third largest, Turkey, with a production of 117 tons, less than
one-tenth of the total. The combined production of Iran, Pakistan,
Japan, and Yugoslavia was only 16.7 tons. If the assumption is correct,
that most of the smuggled heroin which comes into the United States
is derived from licit opium production, then it is clear that licit pro-
duction greatly exceeds legitimate medical needs.
The 1970 report of the International Narcotics Control Board of the
United Nations which furnished the above figures also contained the
following statement :
Yet if leakages from licit production could be virtually extinguished, smugglers
would still be able to have recourse to opium which is produced illegally or be-
yond Government control. There are now extensive areas of such production
and it is essential that, side by side with reinforcing monopoly controls over
licit production, major efforts should be made to eliminate poppy cultivation in
these areas. The regions chiefly involved are situated in Afghanistan, Burma,
Laos, and Thailand ; and there is also some production in parts of Latin
America.
Other questions must be dealt with. In my opinion, placing restric-
tions on natural narcotic analgesics would inspire massive resistance
by organized medicine and the allied professions. Having served on
12
a variety of committees of the American Medical Association dealing
with druss for over 20 vears, I am fully aware that physicians are
extremely conservative about drug therapy. Codeine, for example,
ranks high on the list of "most prescribed" drugs for the relief ot
cough and minor pains. It is a constituent of many mixtures which
are "prescribed for a varietv of sedative and antispasmodic effects.
Whereas we do have effective substitutes for codeine which are
known to be safe, they have made relatively little inroads in the pre-
scribing of codine. Furthermore, they do not substitute for codeine in
all respects, particularly since they lack its analgesic and mild sedative
properties. Relative costs, although not a compelling factor, must be
considered. Tax-free morphine is now one of the cheapest compounds
available to medicine today.
The paramount question then which confronts you, in my opinion.
is not whether synthetics will substitute for "horticulturally derived"
narcotics but rather whether outlawing the latter in favor of synthetics
will accomplish the objectives of significantly diminishing abuse of
all narcotic analgesics or, in fact, of even heroin itself.
I say this because of several international situations. I just returned
from Japan last week where I consulted with the Minister of Health.
They know exactly how most of the heroin and opium arrive in Japan,
largely down the Mekong River from the countries which I mentioned
earlier, transshipped through Macao in Hong Kong. From there it
is smuggled into their many ports, some by air, but mostly by sea to
Kobe and Yokohama, et cetera.
The Japanese have done a good job of heroin control. In 1964, the
Japanese had a sharp rise in heroin abuse. They make an all-out effort
to control this. They have available to them the facilities which I
doubt are available in the United States. In the first place, when they
say an all-out Government effort they really mean it. This goes from
the Prime Minister on down. In the last 4 or 5 years they have helcl
several thousand public meetings all over Japan in which governors,
states, mayors, even the Prime Minister participate. These are usually
held in theaters or a public auditorium and may be attended by as
many as 3,000 or 4,000 people. The hazards of drug addiction are
graphically portrayed.
Furthermore, radio, television, newspapers, and other communica-
tion media have made an all-out campaign against heroin.
One of the things which I believe contributes significantly to their
success is the fact that Japan has attacked one drug at a time rather
than to try to hit the whole area of drug abuse. This goes back to 1955
when they had the world's largest epidemic of stimulant drug abuse.
In that year there were 55,000 arrests of methamphetamine abusers.
Two years later they had reduced this by strong countermeasures to a
level of about a thousand arrests. This is the only extensive epidemic
of drug abuse, with which I am familiar, in the world that has been
controlled in such a short time. They later did a similar job of con-
trolling heroin.
One of the situations involves different attitudes toward authority.
In Japan, when an expert goes on television, such as a professor in 'a
major university, people listen to him. I am certain this rarely occurs
13
in this country. This raises the question whether we really have the
capabilities of adopting successfully this type of approach.
But the Japanese have their problems as well. I bring this in inci-
dentally because it doesn't bear on your major thrust but it is a drug
abuse problem which must be dealt with.
Last year, Japan had 40,000 arrests for glue sniffing, with 200 deaths.
That is one kind of substance which is almost impossible to control.
To do so, we would have to control all sales from paint stores and pur-
veyors of more than 50 related solvents. Lacquer thinner is used exten-
sively in Japan by teenagers 16, 18 years old. So Japan is not without
her problems, but they have done a remarkably good job in controlling
amphetamines and heroin addiction. I was told by the Ministry that it
liacl been reduced to a level where they though it was probably impossi-
ble to reduce it further. I think this is important — to recognize that
control will never be absolute.
Chairman Pepper. Mr. Perito, any questions ?
Mr. Perito, Dr. See vers, I had the opportunity to look at your lab-
orator3^ The committee has not had that unique opportunity.
I wonder if you could kindly explain to the committee exactly what
is being done in your primate laboratory and how that laboratory is
financed ?
Dr. Seevers. This laboratory has been in operation for 20 years. As
I indicated — we have tested during this time some 800 drugs. This test-
ing procedure started about 1953. We set it up originally on an entirely
objective basis and it has always remained so. Dr. Nathan Eddy, who
is here in the room, has been a long time collaborator on the project. He
received these drugs on a confidential basis from industry. This facil-
ity has been available to those who wish to submit for testing. Dr. Eddy
sent them to our laboratory by code number so that we do not know
the identity of the supplier.
Once the tests have been made the information is channeled back
to Dr. Eddy and he informs the manufacturer.
Until about 5 years ago, our testing procedure involved primarily
drugs which would substitute for morphine or for heroin. In other
words, we were looking for a drug which was superior to morphine
in the sense it reduced respiratory depression, less side effects, less tol-
erance development, and less what we call, in general terms, addiction
liability, the capacity to produce physical dependence.
We tested many compounds for 15 years and didn't find any that
would fulfill most of these qualifications. Wlien it was discovered that
some of the antagonists, which I understand you are going to consider
later, also possessed pain-relieving properties, somewhat like mor-
phine, and yet did not produce physical dependence or lead to addic-
tion, then a new concept was born. Since that time we have tested a
hundred or more antagonists. We have done this with the objective of
finding a substance which would still be useful as a pain reliever but
did not have a capacity to produce physical dependence. I understand
that is a class of drug that you intend to explore.
We maintain a colony of around a hundred monkeys. They receive
an injection of morphine every 6 hours, day and night, right around
the clock, 7 days a week. When we want to test a new drug we simply
substitute for the morphine which they ordinarily receive. If this drug
14
suppresses signs of abstinence we then can qiiantitate this in a rough
way and say this drug has morphine-like properties. This has been a
A^^ery useful test.
The number of drugs that have gone to Lexington during this
period for test — and they were sent only to Lexington if they possessed
some special propeities that were superior to morphine — I would
guess, maybe, is in the order of 40. I am not certain about the exact
number. The facility at Lexington has never had the capacity to test
more than six or eight drugs in a year.
The ultimate test, of course, is whether the effect in man is desirable
or undesirable. Monkeys are not men, but close enough to it that it has
been a very useful screen. We hope to continue it.
I feel certain that the direction which the research is taking today,
moving to find a compound of antagonist type, ultimately will be suc-
cessful. We have some good compounds now. Unfortunately, they are
too short acting and have to be administered too often to fulfill the
practical requirements as substitutes.
This class of drugs, incidentally, acts entirely opposite to metha-
done. ]\Iethadone simply suppresses and acts like heroin. These new
drugs antagonize heroin and create a situation so that an individual
taking the antagonist can take the heroin without anv effect on him.
In fact, in proper amounts, it completely wipes out any effects of
heroin. In the long run, this is an area where money could be well
spent. I think it is possible to find techniques to make available for
practical use, substances that we currently have available.
Many other antagonists have been screened in our laborator}^ which
are potential candidates for this type of action. But they have been
of no particular interest to the manufacturers, so they were just
dropped after testing. But a careful review of all antagonists that have
been studied in the laboratory might uncover some longer acting com-
pounds that might be useful.
Dr. Eddy, I run sure, will speak to this point, because he has been
the one that has channeled the compounds to our department and can
look at the problem with perspective.
Chairman Pepper. Doctor, you do think it is within the realm of
feasibility to develop an antagonistic drug which for all practical
purposes immunizes the addict against the euphoria th.at he ordinarily
gets from taking heroin ?
Dr. Seevers. I think so. Of course, one problem that you must recog-
nize—a practical problem — is whether it is possible to take heroin
addicts and force them to take this drug. This is analogous to the
methadone situation. I don't believe you will ever get beyond the
vohmteer situation where the addict says "I want to get rehabilitated
and will take the drug voluntarily." I suppose theoretically it would be
possible to force any addict to take the drug. I have doubts whether
it could be done from the enforcement point of view.
Mr. Perito. Dr. Seevers, could you explain how your laboratory is
financed ?
Dr. Seevers. W^ll, up until recently the National Research Council
Committee of the Problems of Drug Dependence had collected money
from a wide variety of industrial groups. This is, I believe, the only
granting agency in the National Eesearch Council. They have col-
lected this money and have used it to support our laboratory and also-
15
from other clinical projects of which Dr. Eddy has been largely re-
sponsible. He can outline this better than I.
What is going to happen in the future I am not certain. I believe
the Bureau of Narcotics and Dangerous Drugs is going to support
the laboratory because they need this kind of information. But this
has not been completely clarified as yet.
I will retire this year. A^^iether my successor, not yet appointed,
is amenable to carrying on this program at Michigan is not yet known.
But I am assuming that he is, because it is a well established and
on-going program. Dr. Julian Villarreal, currently in charge of the
program, I understand, will testify before your group. He is fully
capable of taking over this program and has done a beautiful job in
the last several years.
Mr. Pekito. Doctor, would it be possible for your laboratory to
develop an eflecti^'e synthetic analgesic which does not have addiction
liability ^
Dr. Seevers. Well, none of these antagonists have significant ad-
diction liability. This is their advantage, of course. They do not evoke
the cellular changes in the brain which is responsible for the phenom-
ena of physical dependence. We have compounds at the present time
that can be administered chronically and they do not produce physi-
cal dependence.
I am not quite sanguine enough to say that we could develop a eom-
pound that, if it has any subjective effects, would not be abused by
some persons. We have on the market a substance of this type now
which does not produce significant physical dependence: pentazocine.
I'his compound has shown some small abuse. The number of people who
will abuse this drug which does not produce subjective effects is very
small. I think if we can reduce abuse to a minimal level, it is probably
the best we can ever expect to do.
Chairman Pepper. Have you had any deaths from the use of pen-
tazocine ?
Dr. Seevers. Not to my knowledge. There have been a few re-
ported cases of drug dependence.
Mr. Perito. Directing attention to your statement about synthetic
substitutes for codeines; do we now have a single drug which will
effectively substitute for codeine or do we have to use a combination
of drugs ?
Dr. Seevers. Well, we have a compound which is a little more
]3otent: dihydrocodeinong. This has been used but since it is more
potent, it is more subject to abuse. But it is not entirely synthetic.
The search for a codeine substitute has been one of the primary
aims of industry in the last decade. It is easy enough to find substi-
tutes for morphine because we have got a Avhole list of them. But
those, that hPvVe sufficiently low potency, that they could be used as
codeine is used, with minimal addiction potential, is something we
have not quite achieved.
Chairman Pepper. Just one question. Doctor, how do you think we
can best induce organized medicine to accept a synthetic substitute
for morphine and codeine ?
Dr. Seevers. I don't think we will have any trouble with morphine.
The problem would be with codeine because it is so widely used. In
fact, the amount of morphine used in this country is very small com-
pared to the use of Demerol or other synthetics. The vast bulk of
16
strong narcotic use is ^Yith drugs other than morphine at the present
time.
Chairman Pepper. Well, we expect to contact and elicit a response
from the American Medical Association on this matter.
(The correspondence referred to above follows :)
[Exhibit No. 1]
American Medical Association,
Chicago, III., July 9, 1911.
Mr. Pattl L. Pekito,
Chief Counsel, Select Committee on Crime, House of Representatives,
Congress of the United States, Washington, B.C.
Dear Mr. Perito: This is in response to your letter requesting our opinion
concerning the substitutability of synthetic drugs for codeine and morphine. At-
tached to this letter is a brief review of various available synthetic drugs. As you
will note from the conclusions stated therein, it is our opinion that at the present
time no drug is fully satisfactory as a substitute for morphine or codeine.
We indeed appreciate the concern of the committee in its efforts to find a
means of curtailing the drug abiise problem prevalent today, and I want to assure
you that the medical profession is also desirous of attaining this goal. We do
not believe, however, that removing moTphine and codeine from the physicians'
drug armamentarium is an appropriate remedy. We strongly recommend that
these drugs should remain available to physicians so that their patients will not
be deprived of the valuable benefits of these drugs.
Thank you for the opportunity of providing our views, and we would appreciate
this letter and memorandum being included in the record of your hearings. If we
can be of further assistance to the committee, we shall be pleased to do so.
Sincerely,
Richard S. Wilbur, M.D.
[Attachment]
MORPHINE substitutes
Thousands of compounds have been synthesized and tested in the search for
a substitute for morphine. In addition to analgesic potency, this search has
focused on lack of addiction liability as a primary objective. To date, these efforts
have not been completely successful, although some advances have been made.
At the present time, nine strong analgesics, that are prepared synthetically (i.e.,
not derived from opium) are available on the market. These are :
1. Levorphanol Tartrate (Levo-Dromoran),
2. Methadone Hydrochloride (Dolophine).
3. Meperidine Hydrochloride (Demerol).
4. Pentazocine (Talwin).
5. Alphoprodine Hydrochloride (Nisentil).
6. Anileridine Phosphate (Leritine).
7. PiminO'dine Esylate (Alvodine).
8. Fentanyl (Sublimaze).
9. Methotrimeprazine (Levoprome).
Meperidine was the first of this group to be introduced and although earlier
it was thought to be nonaddicting. later it was found to have an addiction
liability approaching that of morphine. Nevertheless, it is the most widely used
of the strong analgesics. This may suggest that it is capable of substituting for
morphine in many cases ; however, it is recognized that meperidine Is not an
adequate sub.stitute in certain ca.ses, e.g., acute myocardial infarction.
Several of the available compounds are chemically related to meperidine, drug
numbers 5-8 in the above list. These were prepared in the attempt to improve
on the properties of meperidine. The actions of these drugs are generally similar
to those of meperidine, and although each has individual characteristics, which
limits its use in certain conditions, none is superior to meperidine, and like it
none of these would be an adequate substitute for morphine in all cases.
Both levorphanol tartrate (Levo-Dromoran) No. 1 and methadone hydro-
chloride (Dolophine) No. 2, are effective strong analgesics and have other
properties in common with morphine, including addiction liability ; however, in
17
practice, experience has indicated that neither would meet the requirepients in
all cases of an adequate morphine substitute.
The newest member of this group is No. 4 pentazocine (Talwin). It is the
only one with a low addiction potential, being less than that of codeine ; thus,
it is not subject to the controls of the narcotic laws. Although pentazocine is an
effective strong analgesic, as with all other drugs in this group, in certain cases,
morphine would be preferable. Additional compai-ative studies are necessary to
fully evaluate the potential use of this new drug, particularly in relation to
the older drugs.
Compound 9, methotrimeprazine (Levoprome), differs chemically from all
others of this group, being a phenothiazine derivative and related to the anti-
psychotic group of drugs. Although it does have strong analgesic properties,
its side effects of marked sedation and hypotension greatly limit its uses and
would prevent it from being an daequate substitute for morphine.
Most controlled studies with these drugs have been conducted to determine
equivalent analgesic potencies (i.e., milligram dosage), and have been carried
out in only a few types of pain, e.g., postoperative, cancer. Their broader use-
fulness in a variety of painful conditions has been determined by clinical
experience.
On the basis of this evidence it is concluded that, taken as a whole, the
group of available strong analgesics could be substituted for morphine in some
cases ; however, no single agent of this group is capable of substituting alone
for morphine. At present, evidence from experimental studies are not available
to define the preferred drug in each case. Many additional comparative studies
and further experience are necessary, particularly with newer agents like
pentazocine, to determine their ultimate efiicacy in various conditions. Further-
more, there are certain situations, e.g., acute myocardial infarction, adjunct
to anesthesia in cardiac surgery, pulmonary edema of heart failure, certain
cancer patients, in which none of the synthetic analgesics are capable of satis-
factorily replacing morphine.
CODEINE SUBSTITUTES
To act as a satisfactory substitute for codeine, a drug would need to have
the following properties :
1. Analgesic activity.
2. Antitussive activity.
3. Oral effectiveness.
4. Low addiction potential.
Of the presently available drugs none possesses all of these properties; how-
ever, it is not necessary for a comiwund to have both analgesic and antitussive
properties to be useful. Those drugs that have one or more of these properties
are considered individually below from the standpoint of a potential codeine
substitute.
Propoxyphene (Darvon) is an orally effective analgesic but it is less potent
than codeine and would not provide pain relief comparable to codeine in many
cases. Propoxyphene has low addictive liability but no antitussive activity.
Pentazocine (Talwin) lacks antitussive activity but possesses the other three
properties necessary to substitute for codeine. However, insuflBcient compara-
tive data are presently available to fully evaluate its potential as a substitute
for codeine as an oral analgesic.
Several agents are marketed as antitussive agents : these are orally effective
and have no or low addiction potential. The most widely used of this group is
dextromethorphan. Although it and the others of this group may be adequate
for relief of the milder types of cough, i.e.. associated with the common upper
respiratory infections, they would be inadequate for severe cough. For use
in this situation, a strong analgesic with antitussive activity such as methadone
may be required, but this drug has a greater addiction liability than codeine.
In conclusion, no other single drug has all the properties of codeine : thus,
none would be a satisfactory substitute. That other drugs have some of the
properties of codeine is recognized, but an adequate substitute for codeine's
use either as an analgesic or antitussive is not available at present.
NARCOTIC ANTAGONISTS
The use of the narcotic antagonists in addition to morphine and codeine
would be affected by a ban on opium and opium derivatives. Two of the three
18
available narcotic antagonists are prepared from opium derivatives. These
are nalorphine (Nalline) and naloxone (Narcan), the other, levallorphan (Lor-
phan) is prepared synthetically. The properties and uses of nalophine and leval-
lorphan are similar and the latter could substitute for the former. However,
the actions of naloxone differ from those of the other two agents and is con-
sidered the drug of choice in treatment of overdosage of a narcotic. Even more
significant are the studies showing that naloxone has promise in the treatment
of heroin addiction : thus, to ban the source of this drug would deprive the
medical profession of a useful drug.
Cliairman Pepper. Mr. Mann, have you a question ?
Mr. Maxx. I am very much interested in tlie action of the Economic
and Social Council of the United Nations in almost outlawino- syn-
thetic narcotics. You imply here that the economic factor was the main
factor involved. What other motivating factors do you see in that
almost-action?
Dr. Seevers. Well, I don't really know. This got doAvn to a l^attle
between the producing and manufacturing nations and those that were
most interested in the synthetics. I don't know of any other, except
traditional. Many of these changes have been in this business for a long
time. Change would be resented in countries where producing has been
going on for a long time. There is a manpower problem as well as
substitution — finding some crop that would substitute for opium.
Mr. Mann. Do you think the medical community is prepared for
the legislative outlawing of morphine ?
Dr. Sefa'ers. I don't believe so. Although morphine, itself, isn't used
so much, I think the biggest rebellion is codeine. The reason I say that,
is because we have had a somewhat analogous situation with amphet-
amines. Amphetamines as a chass of drugs are, in my opinion, the most
dangerous drugs of all available for abuse. We know from a practical
point of view that the production of amphetamines greatly exceeds any
legitimate medical need. But if you pose this question to orgnnized
medicine, which w^e have had occasion to do, even in our committee —
I attended a meeting of the AMA committee in Chicago on Saturday
of last week — even among the committee there are questions as to
whether we could get along without these. I personally think we could.
But you will not find a consensus on these matters.
Chairman Pepper. Excuse me. Will the gentleman yield right at that
point ?
]Mr. Mann. Yes, sir.
Chairman Pepper. Doctor, this committee last year offered an amend-
ment in the House, which was later adopted by the Senate, proposing
that there be a production quota system for amphetamines imposed
by the Department of Justice on the recommendation of tlie Depart-
nient of Health, Education, and Welfare. Do you think that was a
l^roDer nroposal ?
Dr. Seevers. Well, it is in the right direction. I am not sure whether
it would accomplish the objective you seek.
The only country that has really been successful in controlling am-
phetamines, as I mentioned earlier, is Japan. Sweden has also adopted
a complete ban in the sense that even a medical use is restricted to a
few speci-^lists. Three of the Australian states have done this recently.
These nations have all done it in response to a rising and hazardous
abtise problem with amphetamines.
19.
I think a quota would be better than nothing, but I am not sure this
would really solve the problem.
Chairman Pepper. Mr. Mami, I interrupted you.
Mr. IVLvNN. No further question.
Chairman Pepper. Mr. Wiggins ?
Mr. Wiggins. Doctor, if Congress should ban the importation of
morphine, should that law have an immediate effective date or should
it have a delayed application ?
Dr. Seevters. Well, off the top of my head, I would say that time is
not very important. It might be delayed long enough to work out some
alternative, but I don't see that much would be gained by delay, except
possibly the codeine problem.
]\Ir. WiGGixs. Yes. You indicated that substitutes for morphine are
available. Are they available in sufficient commercial quantities to
meet the necessary commercial need or should the industry be per-
mitted a period of time to get into that kind of production?
Dr. Seevers. I think that would probably be wise, but we have
enough variety of these compounds of synthetic origin at the present
time that I don't think we would have any significant shortage, if
there was a reasonable time.
Mr. Wiggins. Are those synthetic substitutes typically manufac-
tured in the United States ?
Dr. Seevers. They are. The principal one is sold under the commer-
cial name of Demerol. I don't know what the current total consump-
tion or total use of this substance is in the United States, but at one
time about 50 percent of the strong analgesic was done with this drug.
It is comparatively simple to produce. I don't think there would be a
serious problem.
Mr. Wiggins. If Congress should enact a statute prohibiting the
importation of morphine could you suggest any exce]:)tion we should
make to that statute ?
Dr. Seevers. Not really.
Mr. Wiggins. Oft'hand, it occurs to me that you would like to con-
tinue your scientific studies and others doubtless would too.
Dr. Seevers. I think this could be done and it would be necessary.
Morphine is still used as a standard by which we compare all other
drugs. I think a certain amount of research should be carried on. But
as far as general medical use is concerned, I can't think, offhand, of
exceptions for medical use.
Mr. Wiggins. Is it your feeling that if we excepted necessary sci-
entific research we could impose an absolute ban on the importation
of morphine ?
Dr. Seevers. It would be possible. I am not sure it will solve your
problem.
Mr. Wiggins. Are the medical consequences tolerable ?
Dr. Seevers. From a medical point of view, I think the answer is
yes. _ ; '
Mr. Wiggins. That is all, Mr. Chairman.
Chairman Pepper. Mr. Steiger ?
Mr. Steiger. Thank you, Mr. Chairman.
Doctor, did Japan treat a marihuana problem? I guess first, do
they have a marihuana problem, and if they did, did they treat it?
20
Dr. Seevers. They have a rising marihuana problem. They have
never had much abuse of marihuana in Japan, although it grows wild
all over Japan. But they have become concerned about it now to the
point where one of the people in the Ministry said they are thinking
about cutting it off at the root right now, which implied there would
be stricter penalties rather than lesser penalties.
A good bit of this problem has been brought back into Japan by
returning American servicemen who are there for recreation. The
Ministry is frank enough to say this, but abuse of marihuana is also
spreading now to the younger people, and there have been a consider-
able number of seizures of smuggled hashish. Some of it is smuggled
in from Korea and other areas, and also from Vietnam. So they have
had an increasing number of users in the last couple of years.
Mr. Steiger. It is illegal ?
Dr. Seevers. It is illegal.
Mr. Steiger. Have we developed, or is there any research which
points to the potential development of any oral antagonists at this
point? They are all injected ?
Dr. Seevers. Practically all of them are injected. We have some that
can be used. The trouble with these antagonists, and this has been the
real problem, is that they produce unpleasant subjective responses,
much like the hallucinogens. Individuals have weird dreams, and
weird thoughts, and the like. This has been one of the principal ob-
jections to the use of the antagonist class of drugs.
Mr. Steiger. I should think that would help sell them.
Dr. Seevers. These effects are not sufficiently pleasant. Most of
them are the type of perceptive distortions that they leally don't want.
Mr. Steiger. Doctor, to your knowledge, how long have ampheta-
mines been in use medically, not the illegal use or the abusive use,
but how long have amphetamines been in use ?
Dr. Seevers. It is back to the early 1930's as I recall.
Mr. Steiger. That long?
Dr. Seevers. Yes.
Mr. Steiger. Do you know if our military still issues the morj^hine
ampules they used to issue to people in the field, or do we use Dem-
erol, or one of these others ?
Dr. Seevers. I don't know what the present state of the military
is in this respect.
Mr. Steiger. Thank you, Doctor.
Chairman Pepper. Mr. Winn ?
Mr. Winn. Thank you, Mr. Chairman.
Doctor, on page 6 you say : "Whereas we do have effective substitutes
for codeine which are safe, they have made relatively little inroads
in the prescribing of codeine."
yiy question is why ?
Dr. Seevers. I suppose it is natural conservatism of medicine.
Codeine has always been known traditionally as the weak analgesic.
It has become, by general use, to be a constituent of many mixture?
in small amounts, and medicine is one of the most conservative
professions.
If a drug gets off on the wrong foot, medicine just looses interest
in it. I refer to a compound we are all familiar with today, methadone.
21
When methadone was first introduced into the field by Lilly & Co.
it was introduced under the trade name of Dolophine. They thouojht
the drug was much more potent than it actually is. Dolophine was
introduced on a 3 -milligram dose basis whereas we know the drug
has about the same potency as morphine, and the average dose is 10 mil-
ligrams. Dolophine fell flat. If Lilly had introduced it at a 10-milli-
gram dose we might have had methadone substituting for morphme.
Methadone is one of the drugs that can satisfactorily substitute
for morphine.
Mr. Winn. How many years ago did Lilly come out with that, sir?
Dr. Seevers. That was the midfifties, as I recall, just around the
midfifties.
Mr. Winn. Would you encourage the pharmaceutical houses to get
a press campaign or campaign put together so that they can use the
substitutes for codeine ?
Dr. Seevers. That is a $64 question. I don't know whether I could
give an answer to that.
Mr. Winn. Well, I am saying do you think it would be wise to do
that.
Dr. Seevers. For them to initiate a campaign ?
Mr. Winn. Yes.
Dr. See\^rs. I don't know who would do the initiating, whether the
competitors would initiate or whether producers would do the initiat-
ing. I doubt the practicality.
Mr. Winn. Thank you, Mr. Chairman.
Chairman Pepper. ^Ir. Keating?
Mr. Keating. No questions, Mr. Chairman.
Chairman Pepper. Doctor, two questions. One, this committee has
had testimony from many sources that there are some 8 billion amphet-
amines produced and distributed in this country every year, and we
have been advised, as has the Committee on Interstate and Foreign
Commerce, Subcommittee on Health, that about half of those go into
the black market. Would you tell us what, in your opinion, is the
medical need, if any, for amphetamines in this country ?
Dr. Seevers. In my opinion the need is relatively small. I think this
is a concensus of most people who reviewed the problem. The biggest
use is in the treatment of obesity. At best, this use can be said to only
temporarily be effective. The reason for this is that tolerance develops
to its continued exposure. Bigger and bigger doses are necessary. With
susceptible individuals, but not in all cases, they are likely to become
dependent upon it.
Chairman Pepper. Would you put the need in hundreds, or thou-
sands, or millions ?
Dr. Seevers. Compared to 8 billion ?
Chairman Pepper. Yes.
Dr. Seevers. Well, that is pretty difficult. The only thing I can say
is that as far as I can determine, in Japan, Sweden, and the three
Australian States, medicine hasn't been hurt very badly.
Chairman Pepper. You would say the medical need is small ?
'' Dr. Seevers. Comparatively small.
Chairman Pepper. One other question. You have spoken about the
probable reluctance or probable tardiness of the medical profession in
accepting these synthetic substitutes for morphine and codeine. We all
22
recogrnize vre professional people are reluctant to change from a habit
or course that we have been foUowinir. But would it te desirable to put
in perspective the necessity of balancin<r the harm that this country
derives from the abuse of these drusrs, the heroin that is smugorled into
this comitry, the terrible cost in lives and other expenditures as distin-
guished from the inconvenience or perhaps some of the imperfection
in the use of these substitutes? Would it be desirable for the medical
profession to balance those two interests in making this decision?
Dr. Seevers. I think the answer to that question is a tangential one.
You would have to sell the profession on the notion that doing this
would accomplish the objectives that you seek. In other words, when we
have so many synthetic drugs available, if there is a market, for ex-
ample, suppose you abolish illegal heroin or illegal niorphine or wipe
out all morphine, we know that there are many places in the world that
have no respect for patents, they can make these synthetic compounds
with relative simplicity and they are equally subject to abuse. I think
the real question is whether you'^simply replace one bad situation with
another one.
I think it would be necessary to convince the profession as a whole
that the objectives that you seek would be accomplished.
Chairman Pepper. Doctor, we are profoundly grateful to you for
bringing your knowledge and experience to the benefit of this com-
mittee and helping our Congress and country try to find some solution
to this terrible narcotics problem.
I think counsel wants to put in the record your original finding
here.
Mr. Perito. Mr. Chairman, may we include in the record the cur-
riculum vitae of Dr. Seevers ?
Chairman Pepper. Without objection, it will be so received.
(Dr. Seever's curriculum vitae follows:)
[Exhibit No. 2]
Curriculum Vitae of Dr. Maurice H. Seevers, Chairman, Department of
Pharmacology, University op Michigan Medical School
Date of birth, October 3, 1901, Topeka, Kans.
Education :
Washburn College (Topeka. Kans.), 1920-1924 (A.B.)
University of Chicago, 1924-1928 (Ph. D., pharmacology)
University of Chicago (Rush Medical), (4 year certificate) 19.30; (M.D.)
1932
Internship, University of Wisconsin General Hospital, 1930-1932
Appointments :
Research fellow, pharmacology, Chicago, 1926-1928
Instructor, pharmacology, Loyola (Chicago), 1929
Assistant professor, pharmacology, Wisconsin, 1930-1934
Associate professor, pharmacology, Wisconsin. 1934-1942
Visiting associate professor, pharmacology (summer 1941), Chicago
♦Professor of pharmacology and chairman of the department of pharmacol-
ogy, the University of Michigan Medical School. 1942-
Associate dean, the University of Michigan Medical School, 1947-1950.
Memberships and committees :
♦National Research Council
Committee on Problems of Drug Dependence (formerly Committee on
Drug Addiction and Narcotics) 1946-1968: Consultant— 196&-
Subcommittee Anesthesiology (Committee on Surgery), 194»-1957
23
♦American Society of Pharmacology and Experimental Therapeutics, 1930-
Council, 1937; membership committee, 1942, 1943, 1944 (chairman);
president, 1946, 1947; nominating committee, 1949, 1950 (chairman)
♦American Physiological Society, 1933-
Federation of American Societies of Experimental Biology Executive
Committee, 1946, 1947 (chairman), 1948
Society for Experimental Biology and Medicine Council, 1950-1953
♦American Medical Association
Vice-chairman, Section of Experimental Medicine and Therapeutics
1951-1052
Chairman, 1952-1953
Member, Council on Drugs (formerly Council on Pharmacy and Chem-
istry) 1952-1962
* Member — Committee on Alcoholism and Drug Dei>endence — Council on
Mental Health, 1964-
♦Chairman — Committee on Research on Tobacco and Health AMA-ERF
1964-
Honorary memberships :
♦American Society of Anesthesiology.
♦Japanese Pharmacological Society.
Committees and consultantships :
Member — Board of Scientific Counselors, National Heart Institute, Na-
tional Institutes of Health, 1957-1960.
Member — Drug Abuse Panel, President's Advisory Committee — White
House Conference on Narcotic and Drug Abuse, 1962-1963.
Member — Surgeon General's Committee on Smoking and Health, Depart-
ment of Health, Education, and Welfare, 1962-1963.
Chairman — Committee on Behavioral Pharmacology — Psychopharmacology
Service Center-National Institutes of Health, 1964-1968.
♦American coordinator — U.S. Japan Cooperative Program on Drug Abuse —
National Science Foundation and Japan Society Promotion of Science,
since 1964.
♦Member — President's Commission on Marihuana and Drug Abuse, 1971-72
(established by Public Law 91-513) .
Editorial :
Board of publication trustees, American Society for Pharmacology and Ex-
perimental Therapeutics, 1948, chairman, 1949-1961.
Editorial board. Physiological Reviews, 1943-1951.
Editorial board. Proceedings Society for Experimental Biology and Medi-
cine, 1944-1959.
Editorial committee. Annual Review of Pharmacology, 1959-1962.
International :
♦WHO (United Nations) Expert Advisory Panel on Drugs Liable to Pro-
duce Addiction, 1951-
Second Medical Mission to Japan, May-June, 1951 Unitarian Service Com-
mittee and Department of the Army.
U.S. National Committee for International Union of Physiological Science,
Chairman American team— Conference on Physiologic and Pharmacologic
Basis of Anesthesiology— Japan, April-May 1956.
Consultant— Minister of Public Health of Thailand— Bangkok, May 2-17,
1959
♦Consultant, Minister of Health and Welfare of Japan, Tokyo, 1963-.
Awards :
Third Class of the Order of the Rising Sun 6f Japan, 1963.
Distinguished Service Award Washburn University Alumni Association,
1964. ^^ .„„_
Second Class— Order of the Sacred Treasure of Japan, 1967.^
Henrv Russell Lecturer— The University of Michigan, 196 (.
J Y. Dent Memorial Lecturer— Kings College-University of London, 1968.
Certificate of Commendation from Minister of State Director-Geneial,
Prime Ministers Office, Japanese Government, October 1969.
•Current appointments.
24
(The following letter was received for the record.)
[Exhibit No. 3]
Assistant Secretary of Defense,
Washington, D.C., June 28, 1971.
Hon. Claude Pepper,
House of Representatives,
Washington, B.C.
Dear Mr. Pepper : This is in reply to your letter of June 7 in which you re-
quested our views on the use of opium derivative drugs in the military medical
services and statistical data representing procurement and issues of these drug
items, as well as synthetic pharmaceuticals with similar effects.
"A consensus of military medical opinion on the need for opium derivative
drugs to treat casualties in the field and in hospitals." It is the consensus of
the Military Medical Departments that opiate drugs have an established place
in medical practice and cannot adequately be replaced by any other substances.
The need for opiate drugs is predicated on the pi-inciple that the highest pos-
sible quality of medical care should be rendered to military personnel and their
dependents. While it is true that there are many occasions when the synthetic
analgesic drugs would suffice, there is also a substantial number of indications
where the opiate drugs are clearly superior. For example, it has not been
demonstrated that the synthetic drugs are equal in efficacy to the opiates in
myocardial infarction, acute pulmonary edema, and in relief of pain in the
severely wounded.
"A consensus of military medical opinion on (a) the use of, and (b) the ef-
fectiveness of synthetic analgesic substitutes to treat casualties in the field and
in hospitals." The synthetic analgesics have a significant and increasing use-
fulness in treating casualties in the field and in hospitals. However, there re-
mains a substantial proportion of casualties in whom the opiate drugs are clear-
ly preferable. In addition, many of the synthetic analgesics have only a very
short period of experience with their use and it would be unwise to restrict
medical practice by relying solely on these newer compounds.
"A consensus of military medical opinion on the advisability of eliminating
opium derivative drugs and the substitution of synthetic analgesics." It would
be inadvisable to eliminate opiate drugs from medical and surgical practice. It
Is evident that the amount of opiate drugs used could be greatly curtailed by
substitution of the synthetic drugs. However, the total removal of opiates from
medical practice would result in less than optimum treatment of countless in-
dividuals having life-threatening diseases and injuries.
Statistical data representing procurements and issues of centrally managed
opium derivative drugs, as well as synthetic pharmaceuticals with similar ef-
fects, is attached as enclosure 1. This data represents the latest 4 complete fiscal
years. Data prior to fiscal year 1967 is not available. Miss Hastings of your
staff agreed to the submission reflecting this period of time.
Although most of the opium derivative drugs are procured and issued to the
military medical services by the Defense Supply Agency, larger medical facilities
locally procure nonstandard, slow moving opium derivative drugs. These facil-
ities are all registered with the Bureau of Narcotics and Dangerous Drugs.
Attached as enclosure 2 is a copy of the regulation "Safeguarding of Sensi
tive. Drug Abuse Control, and Pilferable Items of Supply" as per your request.
The Veterans' Administration does not procure these items from the Depart-
ment of Defense. The Veterans' Administration has its own procurement system
and buys these items directly from vendors.
There are no separate regulations or security precautions applicable to syn-
thetic analgesics versus opium derivatives. The governing factor in this instance
is whether the Bureau of Narcotics and Dangerous Drugs has classified the item
in one of five schedules for controlled substances. If so. security measures are
required ; however, these items are dispensed by prescription only.
I trust this information will be of assistance to you and the committee.
Sincerely,
Louis M. Roussei.ot, M.D., F.A.C.S.
25.
I'BOCUREMENT AND ISSUE DATA FOB CENTRALLY STOCKED OpIUM DERIVATIVE
Drugs and Synthetic Analgesics With Similar Effects
The information in tliis enclosure is qualified as follows :
1. Procurement quantities are indicated by the fiscal year in which contracts
w^ere awarded (or delivery orders processed). Actual delivery to DSA depots
and subsequent issue to DSA customers does not normally correspond to these
fiscal years. In addition tlo Army, Navy and Air Force units, the DSA has in-
teragency agreements to supply medical materiel directly to the following
Federal agencies : NASA, USAID, D.C. Government, U.S. Coast Guard, FAA and
GSA. Certain Army, Navy and Air Force units also supply directly to other Fed-
eral and foreign agencies. For example, the Republic of Vietnam Armed Forces
and USAID in Vietnam are supplied with medical materiel from the U.S. Army
Medical Depot in Okinawa.
2. In some cases, procurement and issue data do not appear to be related. This
can occur when items are being phased out of the distribution system or new
items are added to the armamentarium. Further, changing mobilization reserve
materiel objectives may be responsible.
3. Only those forms of propoxyphene containing at least 65mg are included.
4. Methadon is n(jt managed centrally as yet.
1967
Fiscal years —
1968
1969
1970
6505-114-8950— Codeine sulfate tablets, NF, 32 mg., 20's:
Procured by DPSC ^ 24,700
Issued to:
Army _ _ ._ 4,797
Navy 1,678
Air Force 640
IVIAP 20
Other = _.. 3
6505-114-8975— Codeine sulfate tablets, NF, 32 mg., lOO's:
Procured by DPSC 92,016
Issued to:
Army ^fek 9,525
Navy 9,420
Air Force. 9,088
MAP 9.803
Others 14,987
6505-615-8979— Codeine phosphate, USP, 1 oz. (28.35 gm.):
Procured by DPSC 2,502
Issued to:
Army 5,306
Navy - _. 1,752
Air Force 576
MAP...,. 144
Oth^ir 19
6505-864-8092— Codeine phosphate injection, USP, 30 mg.
cartridge-needle unit 1 cc, 20's:
Procured by DPSC i
Issued to:
Army.... 2,610
Navy.. 1,367
Air Force 1,071
MAP. L-. 0
Other 2 0
6505-864-8091— Codeine phosphate injection, USP, 60 mg.,
cartridge-needle unit 1 cc, 20's:
Procured by DPSC .^^..^ ic..: 4,230
Issued to: ^ ' =
Army 1,181
Navy 1,293
Air Force. 732
IVIAP . 0
Other 0
6505-929-8986— Hydromorphine, HOI injection, NF, 2 mg.
cartridge-needle unit 1 cc, 20's:
Procured by DPSC 10,200
Issued to:
Army _' 0
Navy 0
Air Force 19
MAP 0
Other 0
See footnotes at end of article.
3,638
1,818
1,454
297
203
22
366
126
52
4
7
474
1
7
3 15, 593
75,816
96,336 ..
47, 481
55, 344
14,811
8,980
9,405
8,470
9,514
10, 581
9,759
9,508
5,407
22,012
236
2,614
2,221
11,808
2,304 ..
5,016
2,043
4,111
1,126
1,312
664
1,753
2,106
1,433
21
25
85
76
109
27
9,600
11,430 ..
3,278
5,366
1,260
994
1,532
418
1,166
2,057
1,085
19
63
86
9
56
171
2,040
11,100...
1,542
1,410
840
1,482
2,009
771
882
1,211
889
14
40
25
14
0
56
59
2,520
1,483
1,160
927
586
1,274
800
750
1,196
1,440
0
1
0
9
24
15
60-296 — 71— pt. 1-
26
Fiscal year;
i—
1967
1968
1969
1970
6505-132-3030-Paregorlc, USP, 1 pt. (473 cc):
Procured by DPSC ' -
69,792 -.
39, 936
92, 776
3,715
5,706
3,556
424
64, 368
Issued to:
Army. - -
Navy
Air Force
25, 773
2,691
7,497
18,813
496
23, 598
4,499
6,484
4,017
339
3,960
2,618
4,658
MAP
Other 2 -
6505-129-5000— Morphine sulfate tablets, USP, 8 mg., 20's:
Procured by DPSC
7,658
168
Issued to:
Army ---
Navy -
Air Force -
MAP
Other -..- ------
6505-129-5500— Morphine sulfate tablets, USP, 16 mg., 20's:
Procured by DPSC ---
4,428
852
110
50
73
235
323
34
5
920
65 ...
21 ...
78 ...
4 ...
32 ...
Army -
Air Force - --
3,924
996
1,265
3,460
4,432
226,250 ..
663
233
793
1,772
20
3,181 ...
1,411 ...
318 ...
0 ...
4 ...
Other
6505-129-5517— Morphine injection, USP, 16 mg., 1.5 cc:
Prnnirori bv DPSC 1 ..
Army. _ - -
Navy - - -
Air Force -.
2,096
2,974
36, 206
0
2,500
258,500 ..
22, 782
11,601
6,019
12,921
1,483
25, 387
3,744
4,599
50
0
24, 805
4,057
604
6,023
949
39, 892
2,132
11,549
370
0
25, 193
12, 897
1,162
8,719
4,112
11.160
12,203
9,132
MAP.--.
Other' --
105
18, 000
6505-129-5518— Morphine injection, USP, 16 mg., 1.5 cc, 5's:
Procured bv DPSC
Army -
5,259
6,363
Air Force
292
MAP---
Other -
Procured bv DPSC
15,603
1,840
Army. - - -
Navy ---
Air Force
597
594
537
20
0
4,500
1,606
741
588
0
1
5,820
3,626
2,053
2,559
5
267
3,660
2,623
1,750
1,753
0
1
201
530
310
0
0
4,380
1,757
1,391
614
28
9
28, 335
11,737
3,592
3,257
4
185
9,420
3,734
2.300
2,139
20
92
178 ...
152 ...
191 ...
0 ...
0 ...
3,360
1,672
973
695
5
53
5,640 ...
Other. -
6505-864-7617— Morphine injection, USP, 8 mg., cartridge-needle
unit, 1 cc, 20's:
2,500
Issued to:
Navy --
905
618
784
MAP -
1
146
6505-864-7618— Morphine injection, USP, 15 mg., cartridge-needle
Procured bv DPSC - ..
Issued to:
Army -
Air Force
6,133
2,138
2,978
33
217
10,590
4,247
2,473
2,652
2
59
3,299
2,549
3,265
MAP
Other -
9
141
unit, 1 cc, 20's:
4,328
Issued to:
Navy
2,816
2,515
3,020
MAP
8
6505-435-8477— Pentazocine lactate injection. Equivalent of 30
mg. of pentazocine, 1 cc, syringe-needle unit lO's:
I Procured bv DPSC ' .
50
5,184
Army
3
13
k\T Torce _
2
2
other 2 - -
7
See footnotes at end of article.
27
Fiscal years—
1967 1968 1969 1970^
678
19, 789
179
18, 432
669
13,281
20
154
276
799
6505-689-5513— Pentazocine lactate injection. Equivalent to 30
mg. of pentazocine per cc, 10 cc:
Procured by DPSC... - - - 43,200 46,656
Issued to:
Army _ .-.
Navy._ - -
Air Force - --
MAP _ ..- - --
Other
6505-477-4655— Fentanyl citrate injection. Equivalent to 0.05
mg. of fentanyl per cc, 2 cc, 12's:
Procured by DPSC _ 1,296
Issued to:
Army _
Navy - - - _
Air Force -
MAP. - _
Other -
6505-477-4667— Fentanyl citrate and droperidol injection, 5 cc,
12's:
Procured by DPSC i 1,728
Issued to:
Army.. _
Navy ___
Air Force 14
MAP
Others _ _.. _ '
6505^84-6183— Fentanyl citrate and droperidol injection, 2 cc,
12's:
Procured by DPSC _ _ _ 1,728
Issued to:
Army _ _ ___
Navy _ _
Air Force _ _._ §
MAP
Other
6505-958-2364— Propoxyphene HCI capsules, USP, 65 mg., 500's:
Procured by DPSC 35,520 28,080 18,336 17,664
Issued to:
Army 9,741 13,841 12,629 11,865
Navy 3,303 4,953 5,758 8,304
Air Force 5,255 5,719 6,821 7,248
MAP 0 44 57 92
Other.... 98 161 348 165
6505-913-7907— Propoxyphene HCI, aspirin, caffeine, and
phenacetin capsules, lOO's:
Procured by DPSC 1 10,224 3,660 500
Issued to:
Army 2,994 49 904 2 749
Navy 129 213 30 188
Air Force 33 41 116 307
MAP 0 34 60 24
Others..-. 0 524 793 2,465
6505-784-4976— Propoxyphene HCI, aspirin, caffeine, and phen-
acetin capsules, 500's:
Procured by DPSC 78,048 158,208 131,688 27,792
Issued to:
Army 31,782 68,946 71,995 29,776
Navy... 14,392 23,853 31,896 28,162
Air Force 20,399 25,837 31,928 32,927
MAP 0 441 962 985
Other... _ 653 562 2,318 840
6505-082-2651— Meperidine HCI injection, NF, 75 mg., cartridge-
needle unit, 1 cc, 20's:
Procured by DPSC 4,680 7,380 2 640
Issued to:
Army 1,313 3,178 2,298 1,938
Navy 936 716 1,587 528
Air Force. 1,195 2,045 1,694 1,354
MAP- 0 11 36 15
Other...- _ 0 1 181 84
6505-082-2652— Meperidine HCI injection, NF, 75 mg.,cartridge-
.needle unit, 1 cc.,20's:
- Procured by DPSC 1 13,200 8,730 19,200 8,820
Issued to: ■,. , ,-
Army ..AQ..'il>.:'.'iil.:: - 2,401 4,986 7,151 6,346
Navy 1,505 2,362 2,900 3,355
AirForce. ■ 2,455 2,809 3,658 4,749
MAP 0 18 6 6
Others 225 167 102 133
See footnotes at end of article.
28
Fiscal years-
1967 1968 1969 1970
6505-126-9375— Meperidine HCI tablets NF, 50 mg., lOO's:
Procured by DPSC 13,536 5,904 6,480 7,920
Issued to:
Army --- - 4,052
Navy..-. 2,295
Air Force ---- 2,048
MAP 1,788
Other.. - ---- ---- 631
6505-126-9360— Meperidine HCI injection NF, 50 mg., per cc, cc:
Procured by DPSC .- 93,744
Issued to:
Army -...:. 20,298
|\|avy 24,448
Air Force 17,907
MAP - 4,392
Other 3,455
6505-864-8093— Meperidine HCI injection, NF, 100 mg., car-
tridge-needle unit, 1 cc. 20's:
Procured by DPSCi 3,830
Issued to:
Army... ---. 1.920
Navy.. 1.926
Air Force 1.558
MAP 0
Other 2 2
6505-854-8094— Meperidine HCI injection, NF, 50 mg., cartridge-
needle unit, 1 cc, 20's:
Procured by DPSC ..-- 21,270
Issued to:
Army --- 4,616
Navy - 2,715
Air Force --- 3,410
MAP 0
Other 157
6505-864-8095— Meperidine NCI injection, NF, 100 mg., cartridge-
needle unit, 1 cc, 20's:
Procured by DPSC. ^p '. .- 4,200
Issued to:
Army.-.. .--- 4,243
Navy .-- .--- 3,177
Air Force 2,825
MAP .-- 30
Other - 148
6505-864-8095— Meperidine HCI injection, NF, 50 mg., cartridge-
needle unit. 1 cc, 20's:
Procured by DPSC 11,340
Issued to:
Army 765
Navy.. 615
Air Force 855
MAP
Other 2 2
1,311
1,460
1,919
1,456
38
2,862
1.573
1,956
140
39
1,222
1,095
1,586
1,458
352
63,720
59,184 ...
34,803
16,144
12,305
5,378
128
24, 870
13,709
8,681
48
165
6,892
8,977
5,228
3,696
89
3,300
12,720
4,740
2,792
754
2,152
625
98
2,830
1,338
2,339
1,106
224
2,060
1,011
1,657
2,555
386
13, 860
27, 840
18,180
8,846
2,825
3,963
100
150
10,873
3,167
5,146
64
175
9,835
3,295
6,228
51
190
9,300
18, 540
8,888
7,654
3,399
2,830
119
138
5,305
2,980
3,714
8
60
5,817
3,244
4,066
1
44
4,260
10,020
4,140
3,651
1,269
2,383
339
136
4,481
1,289
2,240
7
132
1,139
1,396
1,977
65
147
» The difference between quantities procured and total issued is caused by the exclusion in this tabulation of the in-
ventory on hnnd (beginning FY 1957) and the inventory required to be retained as depot stocks at the end of FY 1970.
2 Other type customers are non-DoD. In order of user magnitude: AID and Public Health about the same. Coast Guard,
State Departnient. etc.
3 Item deleted May 1, 1970, This quantity transferred to property disposal.
(Enclosure 2 was retained in the committee files.)
Chairman Pepper. Our next Tvntness is a man so eminently qnalified
to spealv on the subject of drug abuse that I could spend a good i>art
of the rest of this hearing just listing his qualifications.
The committee is pleased and honored to welcome Dr. Nathan B.
Eddy.
Dr. Eddy holds a doctor of medicine degree from the Cornell Uni-
versity Medical School and an honorary doctor of science degree
from the University of Michigan.
29
Dr. Eddy began his career with the practice of medicine in New
Yoi-k City in 1911. Since then, he has been an instructor of physiology
;it McGili University; an assistant professor of physiology and phar-
macology at the University of Alberta; visiting investigator at the
department of pharmacology, Cornell University Medical School;
visiting investigator and lecturer, department of physiology, the Uni-
versity of Michigan: consultant biologist in alkaloids to the U.S.
Public Health Service; principal pharmacologist. National Institutes
of Health; chief of the Section of Anal<resics, Laboratory of Chemis-
try. National Institute of Arthritis and IMetabolic Diseases of the Na-
tional Institutes of Health. The last position he held before he sup-
posedly retired in 1960. Since his retirement, he has served as a con-
sultant on narcotics to the National Institutes of Health ; the Executive
Secretary and currently Chairman of the Committee on Drug Addic-
tion and Narcotics of the Medical Division of the National Research
Council ; consultant to the Bureau of Narcotics and Dangerous Drugs;
consultant to the New York State Narcotic Addiction Control Com-
mission, and consultant to the Le Dain Commission on Nonmedical
Uses of Drugs.
Dr. Eddy is a member of numerous honorific and professional asso-
ciations and has served on countless committees concerned with drug
addition, lioth in this country and for the United Nations.
Dr. Eddy's awards, all well deserved, are legion. Some of the groups
which have honored him are the U.S. Public Plealth Service, the
World Health Organization, the Eastern Psychiatric Research Asso-
ciation, and the American Social Health Association.
Dr. Eddy has authored and coauthored more than 150 books and
articles on a variety of subjects.
'^ Dr. Eddy, with his considerable experience in pharmacology and
physiology, will testify today on the present availability of synthetic
drugs to replace morphine and codeine.
It is indeed a great honor to have you with us today, Dr. Eddy,
Mr. Perito, our chief counsel, will inquire.
Mr. Perito. Dr. Eddy, I understand you have a prepared statement.
STATEMENT OF DS. NATHAN B. EDDY, CHAIRMAN. COMMITTEE
ON PROBLEMS OF DRUG DEPENDENCE, DIVISION OF MEDICAL
SCIENCES, NATIONAL ACADEMY OF SCIENCES-NATIONAL RE-
SEARCH COUNCIL
Dr. Eddy. Mr. Chairman, I prepared a statement for the committee
which might be called a series of thumbnail sketches of potential
alternatives to morphine and codeine.
I think it would take considerable time and be repetitious of a good
deal of technical detail to read that statement. With your permission,
I would prefer to make some pertinent statements of pertinent facts
and principles and afterward elaborate, if you wish, and answer ques-
tions so far as I can on points which have not been covered.
Chairman Pepper. Proceed as you will, Dr. Eddy.
Dr. Eddy. It is a privilege indeed to be here today and speak on the
question of the replaceability of the natural opiates direct and indirect.
By direct I mean, of course, morphine and codeine which occur natu-
30
rally in opium. By indirect, the substances which are derived from
morphine and codeine by modification of one sort or another, such
as hydrocodone, hydromorphone, oxymorphone, oxycodone, and
heroin, which, of course, is paramount in the problems of drug
dependence.
Let me start off by saying unequivocally that the natural opiates,
direct and indirect, can be replaced by synthetic substances presently
available. I am not alone in this belief. Dr. Seevers has already so
stated and I believe Dr. Brill will concur in this opinion. Also, as
Dr. Seevers indicated, the Committee on Drug Addiction and Narcot-
ics, now the Committee on Problems of Drug Dependence of the
National Research Council, has on at least four occasions adopted
resolutions, the sense of which is the same.
Referring to the descriptions which were in the statement prepared
for the committee on specific alternates, these cover a wide range, not
so wide strictij speaking from the chemical standpoint, but a wide
range in potency when we think in terms of dosage only. There are also
some variations in the surrounding j)roperties of the various com-
pounds. We have compounds which are several times — I am talking
about compounds which are presently available on the market — we
have compounds several times more potent than morphine; levor-
phanol, for example, which is like morphine in all essential
respects and equally dependence-producing. We have phenazo-
cine, somewhat different chemically, which is also several times more
potent than morphine and shows a slightly reduced dependence poten-
tial. It has not become very popular because the difference is not as
great quantitatively as hoped in the beginning.
We also have potential substitutes which are less effective dose wise
than morphine. The most popular of these is Demerol, or meperidine,
or pethidine. It has 40 or 50 different names around the world. It is
only about one-sixth to one-eighth as potent as morphine, thinking only
of dosage. It is equally dependence-producing. As a matter of fact, it is
my personal opinion relative to its pain-relieving properties it has a
greater dependence potential than does morphine itself.
Then we have pentazocine, which is quite different from Demerol
in its chemistry and belongs to a new class of compounds to be referred
to in somewhat more detail in a moment. It is about one-fourth as
potent as morphine. It has essentially no physical dependence potential
or such physical dependence potential as it possesses is of a different
type from that of morphine. It does have subjective effects which a
few people have found to their liking, especially if they have been
abusing other drugs and there are a small number of cases of abuse of
pentazocine reported. Pentazocine is being accepted to a verj^ consider-
able extent by the medical profession: its sale is increasing and it is
proving to be a quite effective compound.
There is a difference in these compounds with respect to their rela-
tive oral and parenteral use, oral and subcutaneous or intramuscular
use. The first I mentioned, levorphanol, is equally effective by mouth
as by injection. Practically all of the others are less effective by mouth
than by injection. Ppntazocine perhaps is another exception, the range
between its oral and parenteral dose is narrower than for most of the
other compounds.
31
I have been involved in this problem of trying to find, or trying to
disassociate, the dependence properties and the useful pain-relieving
properties of compounds which we could use in place of morphine for
some 40 years. It has been a most frustrating effort for most of that
time until we discovered, partly by accident, as the result of a sugges-
tion I made in another connection, that certain chemical modifications
of morphine-like substances produced at the same time the ability to
relieve pain or possessed at the same time the ability to relieve pain
and the ability under some circumstances to antagonize the effects of
morphine itself. The first of them was nalorphine. Many like com-
pounds, or many compounds in this class, have been made since then,
as Dr. Seevers pointed out. These antagonists, the compounds with
antagonistic potentiality, have little or no i^hysical dependence capac-
ity. Such physical dependence capacity as they possess is of a different
type from that produced by morphine. Their subjective effects are
different and in most people are exceedingly unattractive. We call these
compounds agonist-antagonists and pentazocine is an important
example.
To reiterate, I believe that it is possible to replace the natural opiates
with synthetic substances. The question is: Is it practical? At the
present time I think the answer has to be "no," because we have to
take so many other things into account other than the mere ability
to replace one compound with another without interfering with medi-
cal practice or without damage to the patient. As a matter of fact,
we might even, with some of these substitutes, improve the conditions
with respect to the patient.
Again, the answer is "no," if we are thinking simply in terms of
saying you cannot have the natural opiates, but must use the synthetics.
We banned heroin in this country from medical practice, but that did
not ban it from the illicit market. The illicit market in heroin is still
increasing.
As I said, I have been working in this held for 40 years, hoping that
some day we could say we can get along without opium. Today we
can say that, medically, we can get along without opium, but I am
not at all sure that we should say it in just that way, without qualifi-
cation. If I may make a suggestion, I think we can say to the world
at large, the time has come wlien we should be putting every effort into
economic and technical assistance to the opium farmer so that he can
live by the production of other crops and without the production of
opium. Meanwhile, we are going to continue to study the agonist-
antagonists because I think pentazocine can be further improved upon
and we are going to continue to pursue other lines of chemical investi-
gation, which in some instances already promise compoimds which are
not antagonists but which have reduced the dependence potential.
Some people like practically every drug, or for practically every
drug there are some people who like it, no matter how adverse it
seems to most of us. We call this craving or liking a psychic depend-
ence. I am very pessimistic about our ever eliminating completely
psychic dependence. We can and we have eliminated the ability — or
produced compounds which have eliminated the ability — to produce
physical dependence. We can do something about the individuals lik-
ing for other things, like his abuse of other things, and we can improve
the situations so far as drug abuse in medical practice is concerned.
32
We can, I think, most helpfully go back to the source, the opium
source, and try to do more than we have done about the overproduc-
tion, especially the illicit production, of opium to reduce the availa-
bility of compounds for abuse.
Chairman Pepper. Doctor, did I understand you to say tliat you
thought we could now scientifically develop an antagonistic drug to
heroin which would give, as Dr. Seevers indicated, a relative immunity
of sensation to tlie addict in the taking of heroin ?
Dr. Eddy. We already have such compounds.
Chairman Pepper. If that could be put into mass use, then that would
to a large degree remove the desire for the taking of heroin, I ])resume,
from the addict ?
Dr. Eddy. Well, the answer isn't quite as simple as that. We can
antagonize the effects of heroin. We can prevent the individual from
getting a response to his taking of heroin. We don't necessarily, by
the same token, remove his desire to take heroin. We can prevent the
heroin from having any effect upon him, but we don't necessarily, at
the same time, prevent him from wanting to have that effect.
Chairman Pepper. ]SIr. Wiggins wishes to ask a question.
Mr, Wiggins. Doctor, I am confused. Why would a person take two
drugs that would have the net effect of taking none? I gather that
there are antnironists that neutralize heroin?
Dr. Eddy. That is right.
Mr. WiGGixs. Which has the effect of not taking heroin.
Dr. Eddy. That is right.
IVIr. WiGGixs. So why not, just in terms of the logic of it, avoid tak-
ing heroin in the first instance?
Dr. Eddy. Well, they generally do. If you can persuade them to take
the antagonist even though they want the subjective effects of the
hei^oin or another opiate. The problem is to s:ei: them to take something
v/hich they know is going to prevent them from getting the kick they
want. The people who have been put on the antagonists, they don't
necessarily take your word for it that they are not going to get any
kick out of their heroin, and they may go back and try heroin until
they find that this is futile. If they have got any sense they are going
to say, "Well, I am throwing mj^ money away." And as long as you can
keep them on the antagonist they cannot get an effect out of heroin and
hence have no reason to abuse heroin or to go out on the street and
steal televisions and cars and the rest of it to buy heroin.
So you have improved the situation from that standpoint for them
and yourself. But you have to persuade them to take the antagonist.
Chairman Pepper. Excuse me. Could you add something to that
antag'onistic drug to cause the patient to get an unfavorable reaction
if, after taking the antagonistic dnig, he took heroin ?
Dr. Eddy. Well, you can do it the other way around. If he is taking
heroin and you give him the antagonist you certainly give him an mi-
pleasant reaction. I don't know any instance wheie he necessarily gets
an unpleasant i-eaction from the heroin he attempts to take after he
has taken the antagonist. He may get an unpleasant reaction from the
antagonist itself until you stabilize him on it.
Mr. Wiggins. Does the antagonist have any effect ?
Dr. Eddy. For a person dependent on an opiate, the antagonist pve-
cipitates withdrawal symptoms, very markedly so. It is the same as if
33
you had taken all of the heroin or opiate away from the addict, just'
like that. He goes into withdrawal when you give him an antagonist if
he is taking an opiate.
Mr. WiGGixs. How much success are you having in getting people to
do this voluntarily ?
Dr. Eddy. Well, it hasn't been tried too widely. There are two diffi-
culties, at least. One is that the most potent antagonist we have, which
has been tried, cyclazocine, is likely to produce unpleasant reactions
when you start to administer it. Dr. Seevers referred to these. They
are quite disagreeable. You have to proceed rather cautiously with
most people to stabilize them on the cyclazocine. They, too, become tol-
erant, accustomed to the drug so that these unpleasant reactions disap-
pear and you can stabilize them, keep them in a state where they can
take cyclazocine day by day and be free from any adverse symptoms.
You have got to completeh' withdraAv them from their heroin, dis-
continue their hei'oin administration completely for several days before
you start the antagonist.
That is one drawback for that particular antagonist. The other one
which has ]:)een used to the greatest extent is naloxone, which does not
produce any unpleasant reactions at all. It is as nearly as we know, a
pure antagonist. It has no morphine-like eifects whatsoever. Cyclazo-
cine does have morphine-like effects under certain circumstances. It is a
powerful analgesic. It is on the order of 40 times more potent as an
analgesic than morphine itself. But to attain its analgesia you are liable
to produce, with a great many people, these unpleasant side reactions.
So it is not a practicable analgesic.
Xaloxone is not an analgesic at all. It only produces antagonism.
It is quite effective when injected, but it is very poorly effective by
mouth and the doses required to stabilize the individual to a state
where he would not get a reaction from taking heroin requires very
large oral doses, and the duration of action is short.
But we have other antagonists in the offering, which we ho[)e to be
able to develop, of longer duration and hopefully as effective as cycla-
zocine, without the unpleasant reactions. This is the field in which a
great deal of effort is being put at the present time. Ideally, it would
seem to me the way to go about it. Practically, as I say, the difficulty is
to 2:)ersuade the patient to begin and to continue the administration of
the antagonist; but he must, initially, give up his opiate entirely and he
must take a compound which he knows is going to prevent him from
getting any of the reactions that he has been wanting. So far as this
can be done, the program is successful.
Chairman Pepper. Doctor, Mr. Perito has a question.
Mr. Perito. Dr. Eddy, do these antagonists have an opiate base?
Dr. Eddy. No.
Mr. Perito. They do not ?
Dr. Eddy. No; not necessarily.
The original, tlie first antagonist that we are familiar with, nal-
orphine, is a modified morphine. You can make similar modifications
in various of the synthetic bases which are used as analgesics, in levor-
phanol, for example. You can make a similar substitution in levor-
phanol and get a more potent antagonist than nalorphine. You can
similarly substitute in the synthetic phenazocine the same group and
get a very powerful antagonist with very intense subjective reactions,
34
so intense that we haven't done very much with it. Or you can modify
either of these bases in other ways and get lesser degrees of antagonism
with lesser subjective effects. Pentazocine is such a compound. It is,
at the same time, an agonist; that is, a morphine-like substance which
produces the morphine-like relief from pam and so on, as well as
being a mild antagonist. So that it can prevent the development of
morphine-like dependence or precipitate withdrawal phenomena if
given to a person dependent on morphine.
Mr. Perito. I assume the same would be true with cyclazocine and
naloxone.
Dr. Eddy. Cyclazocine is a modification of one of the synthetics.
Naloxone, on the other hand, is derived by modification of a morphine
derivative. Therefore, theoretically, we would require the availability
of opium in order to produce naloxone. Actually there is another
variety of poppy which produces one of the opium alkaloids in its
natural life history without producing morphine, and work is under-
way to develop this particular variety of poppy to get the starting
material to make naloxone without having, at the same time, an over-
supply of morphine.
Even though naloxone is morphine based, if I may put it that way,
it is theoretically possible to come to it without having to go through
morphine production.
Chairman Pepper. Doctor, if we could eliminate the legitimate need
for the growing of the opium poppy, and, if, as you suggested, we could
provide a comparable income to the grower of the opium poppy by
substituting some other crop that would not have these injurious
effects, do you think that would be in the public interest of this Nation
and the nations of the world ?
Dr. Eddy. Very definitely so. If you reduce the overall production
you must increase the trend toward the use of the substitutes.
If I might refer to the question that was asked of Dr. Seevers with
respect to the international situation when we came so close to ban-
ning the synthetics some years ago, it was largely an economic ques-
tion. The opium producing countries were afraid of the loss of their
income, of course, and they put forth the claim, or made the assertion,
that if we permitted the synthetics, we would develop a greater prob-
lem than we had in controlling opium, since we would develop the
opportunity for illicit production of the synthetics. Well, that prob-
lem has not developed and the manufacturing countries argued that
thev did not expect that it would develop.
Chemistry is not all that simple. If we were to cut off the supply
of opium completely we might be faced with some prol)lems along
those lines, because we know now that there are illicit manufacturers
of barbiturates and amphetamines in addition to the licit manufac-
ture. So we can't eliminate completely the possibility of illicit manu-
facture of synthetics if we turn to the synthetics in place of natural
alkaloids.
Chairman Pepper. Doctor, from your knowledge of the general field
and of the sums available for carrying on the very commendable re-
search in finding a synthetic substitute for morphine and codeine, and
also for the finding of an antagonistic drug to heroin, are the funds
presently available adequate to carry on the research programs that
vou think are desirable ?
35
Dr. Eddy. No.
Chairman Pepper. Therefore, Avoiild you think additional Federal
fluids would be in the public interest for these research programs ?
Dr. Eddy. Yes.
Chairman Pepper. Mr. Mann ?
Mr. Mann. Thank you.
Pursuing this economic problem just one step further, would there
be any allegation on the part of the opium-producing countries at this
point, or any justifiable allegation that the United States would have
any monopoly on the production of the synthetic drugs, or that the
cost of producing these synthetic drugs on a legitimate basis would
make the outlawing of opium economically bad for all other countries ?
Dr. Eddy. I don't think so, because the know-how is present in
other countries besides the United States. We do have a group of
manufacturing countries on the one hand and presently a group of
producing countries, if you want to call them that, the opium pro-
ducers, on the other hand. But my suggestion was that we put our
effort into giving the opium producers and producing countries, eco-
nomic and technical assistance so they can live without opium. We
can't expect to do this at their cost solely. We have got to do some-
thing about getting them to grow alternative crops. But once you have
done that I don't see that they have any allegation that we are taking
the bread out of their mouth.
Mr. Mann. Nothing further.
Chairman Pepper. Mr. Wiggins ?
My. Wiggins. Doctor, do you generally concur in the observations
made by Dr. Seevers that if the Congress were inclined to prohibit the
importation of morphine that such a statute should have immediate
effect? i- ■ }\ >''
Dr. Eddy. Well, I don't know — I am not sure that I know what
you mean by immediate. As of now, no. You couldn't do it quite that
quickly.
There is reluctance on the part of the physicians to use the syn-
thetics, justifiably so. They have been fooled more than once. Heroin
was introduced as a nonaddicting substance 75 years ago. It was
promptly proved to be — that was promptly proved to be — erroneous.
Demerol was introduced 30 years ago as a nonaddicting substance, even
though at the time that it went on the market we had evidence that it
was as dependence-producing as morphine itself. The producer dis-
agreed and claimed for a number of years, 6 or 8 years, that we were
wrong, that it did not produce morphine-like dependence. Later, they
did admit that we were right, that it did produce physical dependence,
and the}' have changed their advertising. It is now under narcotic
control — they advertise it now as a morphine-like substance.
Mr. Wiggins. Doctor, we both understand that if Congress were to
await a medical concensus that we would not act at all, just because the
doctors are, as has previously been testified to, an independent lot.
Nothwithstanding that, if Congress should make a determination that
it is in the public interest to prohibit the importation of morphine do
you know of any reason why that statute should not be made operative
as of its effective date, or would it be in the public interest to delay it
a month, 6 months, a year, 2 years, something on that order ?
Dr. Eddy. Well, physicians, usually physicians are not all that
familiar with new products. I think there should be some reasonable
delay in order to familiarize them with the substitutes. As I said
earlier, we banned heroin from the medical practice without too much
resistance, partly because we kept morphine, which in many instances
was advantafjeous over heroin and heroin was not all that popular in
the United States. When the attempt was made to ban heroin in Great
Britain there was a tremendous furor and the Home Office eventually
withdrew the ban and heroin is still permissible in Great Britain.
If we were to attempt to ban, by congressional action, the use of
morphine in clinical medicine I think there would very justifiably be
a fjood deal of resistance on the part of physicians. The natural opiates
are what they are accustomed to and you would have to give them an
opDortunity to become accustomed to things to be used alternatively.
Mr. WkvOtxs. I have difficulty in reconciling your statement that
medical resistance would be iustified in view of your earlier statement,
there are adequate substitutes for morphine now existing.
Dr. Eddy. Well, those substitutes are there, but not all of the physi-
cians in the country are aware of them and familiar with their use.
They would say: "Well, what am I going to do for John Jones for
whom I must have morphine in order to get him through this opera-
tion or to handle his broken leg or something else. I don't know any-
thing about this compound. I have never heard of it." You have got to
give him an opportunity to familiarize himself, carry on some sort of
campaign to get them to accept the alternative.
I was very active, took a very great interest in the introduction of
pentazocine. It was quite slow m coming on the market for reasons I
don't need to go into. I was particularly interested because it appeared
to be completely free of physical dependence factors, and it is reason-
ably so. We did not expect any abuse of it at all. There has been a
very small amount of abuse because a few people who have abused
other drugs have found the reactions of it pleasant to them and have
gone on to use excessive amounts, but the number is very small. It
does have antagonistic properties if given to a person already depend-
ent on morphine. It was likely the withdrawal phenomena would be
precipitated and would probably make him sick and probably very
angry with his doctor if the doctor w^as not aware of what was going
on. But the reaction to it has been exceedingly good. It is an agonist-
antagonist and physicians are accepting it, and I think we can get
them to accept it and other compounds of this sort to a sufficient ex-
tent so that medical practice would not suffer for lack of the opiates.
But this takes a little time.
Mr. Wtootns. I would like to ask two additional questions. Doctor.
How would you describe the ease of manufacturing the existing sub-
stitutes for morphine? That question is really aimed at whether or not
we can expect a lot of backyard or backroom clandestine laboratories
turninir out the substitutes if the United States were to prohibit the
use of morphine.
Dr. Eddy. Well, none of the synthetics are all that easy to produce.
It would require a very skilled, very well-equipped technical chemical
laboratory to produce them. It isn't anything like the ease with which
heroin is obtained from morphine. You can cook up hei-oin in your
37
kitchen from morpliine if you have a morphine supply. You can ex-
tract morphine from opium without very much difficulty.
Mr. Wiggins. Is it as easy as manufacturing LSD or more difficult?
Dr. Eddy. Well, given a supply of lysergic acid for the production
of LSD, the development of the synthetics in place of the natural opi-
ates would be much more difficult.
Mr. Wiggins. What would be the price for synthetics versus price of
morphine?
Dr. Eddy. Presently the price to the patient is practically the same
per dose for all the compounds we have been considering. We have al-
ready looked into that.
Mr. Wiggins. Thank you, Doctor.
Chairman Pepper. Mr. Steiger ?
Mr. Steiger. I have no questions.
Chaii-man Pepper. Mr. Winn ?
Mr. Winn. Thank you, Mr. Chairman.
Doctor, you have a statement here which says you believe drug de-
toxification has no effect on a person's craving for drugs. You spoke to
that a minute ago, and this same statement says that is what you re-
ferred to as the lesson of Lexington. Could you speak to that a little
bit more?
Dr. Eddy. Well, perhaps I can answer your question this way : So
far as we know, putting a patient through cold turkey, which means
withdrawing from opiate without any treatment at all, does not deter
him from relapse, relapse to the use of opiate once he is free of the
treatment as against treating him as humanely as possible. So there is
no point — there is no justification — for cold turkey treatment of a
drug-dependent person.
]\Ir. Winn. What you are saying, which you referred to a little while
ago, is that there would be no difference in the psychic craving ?
Dr. Eddy. That is right.
Mr. Winn. And not a physiological craving ?
Dr. Eddy. We can handle the physical dependence side of it without
difficulty, because we know how to take the person through withdrawal
so he does not suffer, to all intents and purposes, take him through
withdrawal with reasonable comfort.
But that doesn't necessarily affect his remembrance of the effects
that he got from the heroin he took or the oj^iate that he took previ-
ously or his desire to reexperience those effects. That is psychic
dependence.
Mr. Winn. Are you doing anything, or is anything being clone, to
offset this psychic dependency.
Dr. Eddy. Yes; of course. Any treatment program should include
psychotherapy to try to help the man to understand and meet his prob-
lems Avithout resort to drugs to convince him that the subjective effects
which he obtained were not essential to him, that life without drugs is
possible and reasonable and more productive, more rewarding.
Mr, Winn. Thank you very much, sir.
Thank you, Mr. Chairman.
Chairman Pepper. Doctor. I understand that in Britain, one way of
handling heroin addiction is to authorize the prescription of heroin
to addicts. Would you recommend that course in this country ?
38
Dr. Eddy. No.
Chairman Pepper. Now, would you care to comment about the use of
methadone as a drug in the treatment of heroin addiction?
Dr. Eddy. In the use of methadone you use, or you accustom, the
individual, you stabilize the individual on a dosage level which,
through the mechanism of cross-tolerance, prevents him from getting
anj' acute reaction to the methadone which he is taking or a dose of
heroin which he might take. Therefore, you stabilize him in a state
where he is in a stable mood so far as drug use is concerned and is of a
mind to turn his attention to other things rather than simply to his
previously drug-seeking behavior. Therefore, he no longer needs to go
out in the street and steal cars and televisions and so on to buy his
heroin. Ke has an opportunity to concern himself with getting a job
,and supporting his family.
Mr. Pepper. How do you think methadone should be furnished to
the addict?
Dr. Eddy. Through a team effort to help handle all of his problems,
not just simply to supply him with drugs, because you must have the
psychotherapy, the vocational assistance, the job help and housing
help, perhaps, and all this while he is stabilized on methadone. Other-
wise he has other reasons for trying to go back to other drugs, even
though he is not getting any satisfaction out of his heroin.
Chairman Pepper. In other words, a prescription of methadone by a
physician is not the answer to the problem alone ?
Dr. Eddy. Very definitely not. Theoretically, in a very rare instance,
it would be possible for a private physician with very close rapport
with his patient to put that patient on methadone and keep close con-
tact with him and treat him satisfactorily. But practically, writing pre-
scriptions for drug-dependent people for methadone, letting them go
to tlie drugstore and buy it without doing anything else for him, is
not the answer at all. You just give him the opportunity to use exces-
sive amounts of methadone or to sell some of it to somebody else, go to
another doctor and get some more. You have no control over the prop-
osition at all. You have not accomplished what you have set out to do.
Chairman Pepper. Doctor, one other question.
What is your opinion as to the medical need for amphetamines^
Dr. Eddy. The legitimate need is very small indeed.
Mr. Wiggins. Doctor, what is the difference between methadone
maintenance or stabilization and heroin maintenance or stabilization,
assuming the heroin was made available at no cost or minimum cost
to the patient ?
Dr. Eddy. Theoretically, none when you supply the heroin. If you
are going to be successful you have got to supply him \yith enough
heroin to maintain him in a reasonably stable state. Practically, there
are differences because at the present time they are still^ sujiplying
heroin in England to be taken by injection, which maintains the
ritual of heroin abuse which the individual has been subject to pre-
viously. In the methadone maintenance program the drug is given by
mouth and therefore you upset the ritual, which goes along with his
dependence, and probably is a very significant factor in the mainte-
nance of dependence.
Put more than that, you can build up to a dose of methadone which
will maintain the individual in the stable state throughout the 24-
39
hour period. It is exceedingly difficult to do that with heroin because
heroin is so short acting and particularly ineffective by mouth. Meth-
adone is nearly as effective by mouth as it is by injection. Heroin is
much less effective by mouth. That is why they stick to the injection
route, and it would be exceedingly difficult to stabilize a person on
heroin given by mouth, almost impossible.
But theoretically in both instances you are simply maintaining the
individual's dependence by giving him another opiate.
Chairman Pepper. Any more questions ?
Mr. Steiger. Just one.
Dr. Eddy, in your work with Dr. Seevers in his primate laboratory
did you see any symptoms of the psychic dependence, or is there any
method of observing that ?
Dr. Eddy. There are programs going on in a number of laboratories
directed toward that very thing. As a matter of fact, we are very
hopeful that in the not too distant future we will have techniques for
measuring drug seeking behavior through offering the drugs to the
primates for self-administration. This is a very promising line of re-
search that is going on in Dr. Seevers' laboratories and other labora-
tories as well. It is a different approach from what he described where
we were attempting to assess the dependence liability of compounds
sent to him under code designation.
Mr. Steiger. Is there any investigation in which we are attempting
to support psychic independence by chemical means? Has that been
explored? Is it not conceivable? Is that a part of what you just
described ?
Dr. Eddy. I am not sure what you mean.
Mr. Steiger. In which we can reach the psychic dependence chemi-
cally or by
Dr. Eddy. Well, you do. In methadone maintenance or heroin main-
tenance you are administering the same type of drug upon which the
individual is dependent psychically and physically, so you satisfj'^ his
psychic as well as physical craving.
]Mr. Steiger. I understand that. Is there any attempt to find a chem-
ical which will allow the patient to overcome the psychic dependence
without the need for all of the social requirements that we now have ?
Is that not achievable, in your opinion ?
Dr. Eddy. Perhaps. Dr. Keats once said when he first began study-
ing the antagonists — Dr. Keats is a very skilled person in clinical
medicine and very much involved with some of the new compounds —
he once said that perhaps the solution to our problem was to develop
a compound which made the individual uncomfortable and yet re-
lieved his pain. If he could be persuaded to take cyclazocine as an
analgesic in the ordinary clinical situation he would probably at some
times, at least, be pretty uncomfortable. He wouldn't like it very
much. But if he got sufficient relief of pain he might be able to tolerate
the unpleasantness until tolerance to it developed. The pharmaceutical
houses have not been willing to take that gamble.
There is a related compound, one of the synthetic groups, actually
as potent as cyclazocine. I discussed with the manufacturer the possi-
bility of pursuing it as a drug for clinical medicine, hopefully that
there would be enough difference between the dose level for the dis-
agreeable side effects and for the pain-relieving effect so that we could
40
get away with it as Dr. Keats suggested. The company did make a
brief trial but the results were even worse than with cyclazocine and
they would have nothing further to do with it.
But something along those lines may be possible. Pentazocine in
some circumstances, and in some individuals, has had disagreeable
side effects though to a lesser degree then cyclazocine, but it is being-
accepted by physicians and patients at the present time. So in a sense
we have accomplished w4iat we are striving for.
Mr. Steigek. Thank you, sir.
Chairman Pepper. ]\Ir. Keating ?
jMr. Keating. No questions.
Chairman Pepper. Mr. Perito, do you have anything to put in the
record or any other questions ?
Mr. Perito. Yes, Mr. Chairman, I would like to offer for the recoi-d
the prepared statement and curriculum vitae of Dr. Eddy.
Chairman Pepper. Without objection they will be received.
Dr. Eddy, we wish to than you very much for coming here and giv-
ing us from your vast knowledge and experience the encouraging testi-
mony you have given us this morning.
Thank you very much.
Dr. Eddy. It has been a privilege and a pleasure to talk with you.
(The material referred to follows :
[Exhibit No. 4(a)]
Prepared Statement of Dr. Nathan B. Eddy, Chairman, Committee on Prob-
lems OF Drug Dependence, Division of Medicax Sciences, National Academy
OF Sciences-National Research Council
The Select Committee on Crime has seen the resolutions of the Committee on
Drug Addiction and Narcotics, Division of Medical Sciences, National Research
Council, the earliest of which has been quoted by Dr. Seevers today. These resolu-
tions maintain that medical practice, and the patient, would suffer no loss if the
natural alkaloids of opium, and substances derived from them, were not available.
All medical indications for morphine and/or codeine, as well as for substances
semisynthetically derived from them, can be met by substances of wholly synthetic
origin. Adequate substitution is possible. Is it practical or advantageous? Many
considerations must enter into the answer to this question. Dr. Seevers and Dr.
Brill have, or will, discuss some of them. Obviou^^ly the advantages and disad-
vantages of potential substitutes are important, so I offer for the record brief
summaries of some replacements already on the market. The presentation is in
approximate chronological order.
Pethidine (meperidine, Demerol®) was the first wholly synthetic morphine-
like analgesic, the characteristics of which were discovered only incidentally.
Close scrutiny, however, revealed that its structure corresponded ro an internal
part of the morphine molecule, hence, presumably, its morphine-like properties.
As with heroin 40 years earlier, pethidine was introduced as not dependence-
producing, a claim which undoubtedly was of great importance in building the
drug's popularity and is in vogue among many physicians even today. Fortunately
we liavc not again been so far off the mark. The optimal analgesic dose of pethi-
dine, effective against many types of pain, is 100 nig. approximately equivalent
to 10 mg. of morphine when each is given intramusculary. Pethidine is available
for oral administration, usually in combination with aspirin, but its effective-
ness by this route is not as great as the small dose in the cominerical preparation
seems to indicate. The use of pethidine is accompanied by the same sort of side
effects as are associated with the use of morpliine witli only minor quantitative
differences. Sleepiness and constipation may be less frequent, a feeling of well-
being more frequent. It produces respiratory depression, relative to its analgesic
action, at least as great as that following morphine, and is probably more likely
to cause a fall in blood pressure. Pethidine has been used widely in obstetrics
41
and may facilitate dilation of the cervix, but it may also decrease uterine con-
tractions and it does not necessarily shorten labor. Pethidine has a significant
effect on the infant, increasing the frequency of delay in first breath and cry.
This depression is less than when the barbiturates are used and i)rol)abIy less
than with administration of morphine, but it is definite and should not be re-
garded lightly. From the very first tests for determination of the possibility,
pethidine has been shown to be dependence-producing and many cases of de-
pendence on it, of morphine type, have been reported, especially among medical
and ancillary personnel. The euphorigenic and dependence-producing dose of
pethidine is close to its optimal analgesic dose, so that its dependence liability
relative to its analgesic action is much like that of morphine.
Methadmie (Dolophine®), though apparently dissimilar to morphine in struc-
ture, can produce qualitatively essentially all of moi-phine's actions and in many
respects is quantitatively equivalent. It is more effective than morphine when
taken by mouth and its euphorigenic action persists longer vphether the oral or
parenteral route is employed. Tolerance, cross-tolerance, and dependence develop
as with morphine and the side effects of methadone and morphine are similar.
The withdrawal syndrome after chronic administration of methadone develops
more slowly, is less intense, and is longer in duration than the morphine absti-
nence syndrome. Methadone is a good enough suppressant. There should be no
difficulty in using methadone wherever morphine is indicated but its abuse
liability is as great as with morphine.
Normethadonc is closely similar to methadone in structure and action, but
has been used only in a mixture as a cough suppressant. The addition of the
other active constituent in the marketed mixture, Ticarda : namely Suprifen,
does not reduce abuse liability and may indeed increase it because of its am-
phetamine-like stimulant subjective effects. Cases of dependence in clinical prac-
tice have been described. While at least as effective as codeine, according to the
usual therapeutic doses, for cough relief, the abuse liability or normethadone
is greater.
Levorphanol (Dromoran®) is a result of attempts to synthesize morphine in
the laboratory and has the structure minus three chemical features. It is
morphine-like in its action in all respects and dosewise is several times more
powerful. It is particularly effective when taken by mouth. Again it could be
used for all morphine indications, but there would be no reduction in dependence
liability.
Dea:ftrometh orphan (Romilan®) is structurally related to codeine as levorpha-
nol is related to morphine, but it is qualitatively different in some respects. It
does not have pain-relieving potency, but is as effective as codeine for the relief
of cough. It will not support an established dependence of morphine-type but
the sul)jective effects of large doses, mainly psychotomimetic rather than mor-
phine-like, are appreciated by some subjects and a few cases of abuse have
been encountered. Preparations of dextromethorphan are available over the
counter.
Phenazocine (Prinadol®, Narphen®) is a result of further simplification of the
morphine molecvile, or of less-advanced synthesis toward the morphine molecule.
It is a basic structure present in morphine and levorphanol and represents fur-
ther deletion of certain chemical features. It is qualitatively similar to morphine
in its action but shows some quantitative differences. Analgesic potency is pres-
ent in phenazocine about on a par with that of levorphanol, that is, several times
greater than with morphine. Side effects are similar with all three drugs. De-
pendence capacity is reduced definitely, as measured by animal experiments,
but little as judged by quantitative comparisons in man. Phenazocine is effective
orally, often nearly as effective as after parenteral injection, and therein may lie
its greatest u.sefulness. Oral phenazocine has been well received in England' and
other countries : it has not been marketed for oral use in the United States.
Propoxyphene (Darvon®) is structurally related to methadone and has en-
joyed wide popularity as a mild oral analgesic, especially ia combination with
APC (aspirin, phenacetin, and caffeine). An intensive review of manv studies,
comparing the drug w^ith codeine, or with aspirin, or APC, concluded that even
the mixture with APC hardly equaled the oral effectiveness of codeine and
certainly did not surpass it. Propoxyphine can produce morphine-like subjective
effects, supports an established morphine dependence poorly, but has measurable
dependence-producing capacity. Cases of abuse have been reported. However,
after 5 years of marketing experience, the abuse liability of propoxyphene as a
60-296— 71— pt. 1 i
42
public health hazard was judged not to warrant narcotics control, nationally or
internationally.
Caramiphen (Parpanit®) is not related chemically to any of the compounds
which have been described. It was introduced as a relaxant and later shown
to have cough-suppressant action, but there have been few controlled studies
comparing it with codeine. Few side effects have been reported and no case of
dependence or abuse.
Benzonatate (Tessalon®) is also unrelated to the morphine structure, but is
claimed to have a suppressant effect on cough reflexes both at the site of irrita-
tion peripherally and at the responding center in the nervous .system. Again
there have been few carefully controlled .studies. The recommended therapeutic
dose is at least three times larger than for codeine and tolerance to the cough-
relieving action may occur.
Pentazocine (Talwin®) is a member of the benzomorphan series of which
phenazocine was the first marketed example, and illustrates our most promising
leads for opiate substitution. These constitute two underlying basic principles :
(1) Animal experiments have shown consistently greater dissociation of pain
relief and dependence capacity among the benzomorphans, which represent only
partial synthesis toward morphine, than in any other chemical group. This
ti'end has been partially confirmed in studies in man; (2) Whether the basic
structure is morphine, morphinan, or benzomorphan, certain modifications have
led to the appearance of specific antagonistic properties simultaneously with
the retention of some morphine-like action. Compounds displaying such a com-
bination of effects are classified as agonist-antagonists and pentazocine is in
this group. It relieves pain satisfactorily, given orally or parenteral] y at a dose
about four times greater than for morphine. Side effects with therapeutic doses
are morphine-like. Pentazocine is also a weak morphine antagonist and will not
support an established morphine dependence. Chronic administration of pentazo-
cine causes the appearance of some dependence and a mild abstinence syndrome
when the drug is abruptly withdrawn. Both the dependence and the abstinence
syndrome are partly like, partly unlike, these phenomena with morphine. There
is less drug-seeking behavior. The clinical effectiveness of pentazocine is being
well received by physicians and patients. A few cases of abuse have been re-
ported, very few in relation to the total doses prescribed. The drug has not
been subjected to narcotics control.
The foregoing descriptions confirm, I think, that we can do without morphine
and codeine but the book on opiate substitution is not closed. Not only is the
agonist-antagonist group undergoing and worthy of much further study, but
there are other compounds of diverse structure in development, following fur-
ther dissociation of dependence capacity and therapeutic action.
[Exhibit No. 4(b)]
Curriculum Vitae of Dr. Nathan Browne Eddy, Chairman, Committee of
Problems of Drug Dependence, Division of Medical Sciences, National
Academy of Sciences-National Research Council
Date and place of birth : Glens Falls, N.Y, August 4, 1890.
Family: Wilhelmina Marie Aherns (wife); Charles Ernest Edjdy (son), de-
ceased.
Education and degrees : 1911 — Cornell University Medical School — M.D. : 1963 —
University of Michigan — D. Sc. (honorary).
Special training or experience :
1911-16 — Practice of medicine. New York City.
1916-20 — Instructor of physiology, McGill University ; teaching and research.
1926-28 — Assistant professor, physiology and pharmacology, T^niversity
of Alberta — teaching and research.
1928-30 — Associate professor of pharmacology, University of Alberta, teach-
ing and Research.
1927 (May-September) Visiting investigator. Department of Pharmacology,
Cornell University Medical School.
1928 (May-September) Visiting investigator and lecturer. Department of
Physiology, University of Michigan Medical School.
1929 (May-September.) Visiting investigator and lecturer, Department of
Physiology, University of Michigan Medical School.
43
1930-39 — Research professor in pharmacology, University of Michigan —
rGSGcircli.
1980-39 — Consultant Biologist in Alkaloids, U.S. Public Health Service.
1939-49 — Princii)al Pharmacologist, National Institutes of Health.
1949-60 — Medical Officer, General, National Institutes of Health.
1951-60 — Chief, Section on Analgesics, Laboratory of Chemistry. National
Institute of Arthritis and Metabolic Diseases, National Institutes of Health
—retired August 31, 1960.
1960 — Consultant on Narcotics, National Institutes of Health.
1961-67 — Professional Associate, designated Executive Secretary, Com-
mittee on Drug Addiction and narcotics, Medical Division, National Re-
search council.
1968 Consultant, Bureau of Narcotics and Dangerous Drugs.
1969 Consultant New York State Narcotic Addiction Control Commission.
1970 Consultant Le Dain Commission on Nonmedical Use of Drugs.
Membership in professional organizations :
Society of Pharmacology and Experimental Therapeutics.
American Association for the Advancement of Science.
Society for Experimental Biologyand Medicine.
Sigma Xi.
Editorial board, Excerpta Medica ; editorial advisory board "Voice of
America".
Society for the study of addiction to alcohol and other drugs.
Washington Academy of Sciences.
American College of Clinical Pharmacology and Chemotherapy.
Institute for the Study of Addiction.
College of Neuropsychopharmacology.
Eastern Psychiatric Research Association.
Committee appointments, etc. :
Committee on Drug Addiction and Narcotics (Problems of Drug Depend-
ence), National Research Council, Secretary 1947-61; chairman 1970.
U.S. Public Health Service Drug Addiction Committee (resigned).
U.S. Public Health Service Post Office Advisory Committee, (resigned).
Bureau of Narcotics Advisory Committee on Oral Prescription bill. Ad hoc.
Advisory Committee under Narcotics Manufacturing Act of 1960.
Chairman, 1961.
Expert Panel on Addiction-Producing Drugs, World Health Organization ;
member of each expert committee chosen from this panel ; chairman of
Committee on first, second, eighth, ninth, 12th, 13th, and 16th sessions.
Technical Adviser, U.S. Delegation to United Nations Commission on Nar-
cotic Drugs. 1947, 1948, 1957, and 1958.
Technical Committee, United Nations Plenipotentiary Conference on Single
Convention on Narcotics Control, 1961.
Special Consultant to Addiction-Producing Drugs Section, World Health
Organization, 1954, 1955, 1956, 1959, and 1961.
Consultant to Army Chemical Center.
American Social Health Association Advisory Committee on Narcotic Addic-
tion.
Delegate and Panelist, Wliite House Conference on Narcotic and Drug Abuse,
September 27-28, 1962.
Alternate delegate for ASHA National Coordinating Council on Drug
Abuse Information and Education.
Honors and Awards :
Corecipient, First Annual Scientific Award, American Pharmaceutical
Manufacturers Association, 1939.
Guest speaker, Royal Canadian Institute, Toronto Ontario, Canada, March
28, 1953.
Lister Memorial Lecture, October 1, 1959, Edinburgh, Scotland.
Public Health Service Superior Performance Award for Sustained Outstand-
ing Service, August 31, 1960.
Delegate and gue.st speaker, Los Angeles Conference on Narcotic and Drug
Abuse, April 27-28, 1963.
Guest speaker, Hawaiian Pharmaceutical Association, Honolulu, May 4, 1963.
D. Sc (honorary) University of Michigan, 1963.
Dent Lecturer, Society for the Study of Addiction, London, 1967.
WHO Medal for Distinguished Service, 1969.
Snow Medal of American Social Health Association, 1969.
Gold Medal of Eastern Psychiatric Research Association, 1970.
44
Bibliography
(1
(2
Med. Assn., 60 : 1296, 1913.
(3> Ardrey W. Downs and Nathan B. Eddy. "The influence of secretin on
number of erythrocytes in the circulating blood." Am. J. Physiol., ^3 :
415-428, 1917.
"Secretin : II. Its influence on the number of white corpuscles in
(4
(5
(6
(7
(8
(9
(10
(11
(12
(13
(14
(15
(16
(17
(18
(19
(20
(21
(22
(23
(24
(25
(26
(27
Nathan B. Eddy. "A case of arrested development of pancreas and intes-
tine." Anatomical Record, 6 : 319-323, 1912.
"Recovery in brain syphilis after the use of salavarsan." J. Am.
circulating blood." Am. J. Physiol., 45 : 294-801. 1918.
"Secretin : III. Its mode of action in producing an increase in the
number of corpuscles in the circulating blood." Am. J. Physiol.. 46
209-221. 1918.
'Secretin : IV. The number of red and white corpuscles in the cir-
culating blood during digestion." Am. J. Physiol., -)? : 399-403, 1918.
"Secretin and the change in the corpuscle content of the blood dur-
ing digestion." J. Fla. Med. Assn., 5 : 101-106, 1916.
Nathan B. Eddy. The role of the thymus gland in exophthalmic goitre."
Canadian Med. Assn. J., 9 : 203-213, 1919.
Audrey W. Downs and Nathan B. Eddy. "The influence of internal secre-
tions on the formation of bile." Am. J. Physiol., 48 : 192-198, 1919.
"The influence of spenic extract on the number of corpu.s'cles in
the circulating blood." Am. J. Physiol., 51 : 279-288, 1920.
"Effect of subcutaneous injections of thymus substance in young
rabbits." Endocriu., 4 : 420-428, 1920.
"Extensibility of muscle : The effect of stretching upon the develop-
ment of fatigue in a muscle." Am. J. Physiol., 56 : 182-187, 1921.
"Extensibility of muscle: The production of carbon dioxide by a
muscle when it is made to support a weight." Am. J. Physiol.. 56 : 188-
195, 1921.
Nathan B. Eddy. "The internal secretion of the spleen." Endocrinologv.
5 : 461-475, 1921.
"A simple device for the demonstration of heart block in the
student laboratory." J. Lab. and Clin. Med., 6 : 635-638, 1921.
Ardrey W. Downs and Nathan B. Eddy. "Secretin. V. Its effect in anae-
mia with a note on the supposed similarity between secretin and vitamin
B." Am. J. Physiol., 58 : 296-300, 1921.
"Further observations on the effect of the subcutaneous injection
of spenic extract." Am. J. Physiol., 62 : 242-247, 1922.
"Some unusual appearances of nucleated erythrocytes in the cir-
culation following repeated injection of splenic extract." Am. J. Phvsiol..
63 : 479-483, 1923.
"Secretin and a suggestion as to its therapeutic value." Endocrin-
ology, 7 : 713-719, 1923.
Nathan B. Eddy. "The action of preparations of the endocrine glands
upon the work done by skeletal muscle." Am. J. Phvsiol., 69 : 430-440,
1924.
Ardrey W. Downs and Nathan B. Eddy. "Secretin : VI. Its influence on
the antibodies of the blood." Agglutinin. Am. J. Physiol., 77 : 40-43, 1924.
Ardrey W. Downs, Nathan B. Eddy, and Robert M. Shaw. "Secretin :
VII. Its inflence on the antibodies of the blood." Complement. Am. J.
Physiol., 71 : 44-45, 1924.
"Secretin: VIII. Its influence on antibodies of the blood: Haemolv-
tic amboceptor." Am. J. Physiol., 71 : 46-48. 1924.
Nathan B. Eddy and Ardrey' W. Downs. "Blood regeneration." Canadian
Med. Assn. J., 16 : 391-396, 1926.
"Secretin : IX. Its relation to the activity of skeletal muscle." Am.
J. Physiol., 7.^ : 489-490, 1925.
Nathan B. Eddy. Studies on hypnotics of the barbituric acid series."
J. Pharmacol, and Exper. Therap.. 33 : 43-68. 1928.
Nathan B. Eddy and Ardrey W. Downs. "Tolerance and cross-tolerance
in the human subject to the diuretic effect of carreiue. theobromine.
and theophylline." J. Pharmacol. & Exper. Therap., 33: 167-174. T92S.
45
(28) Nathan B. Eddy and Robert A. Hatcher. "The seat of the emetic action
of the digitalis bodies." J. Pharmacol, and Exper. therap., 33 : 295-300,
1928.
(29) Ardrey W. Downs and Nathan B. Eddy. "Morphine tolerance: I. The
acquirement, existence and loss of tolerance in dogs." J. Lab. and Clin.
Med., 13 : 739-745. 1928.
(30) "Morphine tolerance: II. The susceptability of morphine tolerant
dogs to codeine, heroin and scopolamine." J. Lab and Clin. Med., 13 :
745-749, 1928.
(31) Ardrey W. Downs, Nathan B. Eddy, and John P. Quigley. "Morphine
tolerance : III. The effect of cocaine upon dogs before, during and after
habituation to morphine." J. Lab. and Clin. Med.. 13 : 839-842, 1928.
(32) Nathan B. Eddy. "The regulation of respiration: XXVII. Tlie effect upon
salivary secretion of varying the carbon dioxide and oxygen content of
of the inspired air." Am. J. Physiol., 88: 534-545, 1929.
(33) "The effect of the repeated administration or diethyl barbituric
acid and of cyclohexenylethyl barbituric acid." J. Pharmacol. & Exper.
Therap., 37: 261-271, 1929.
(34) "The excretion of diethyl barbituric acid during its continued ad-
ministration." J. Pharmacol. & Exper. Therap. 37; 273-282, 1929.
(35) Ardrey W. Downs and Nathan B. Eddy. "The influence of Tyramine on
the number of red corpuscles in the circulating blood." Proc. Soc. Exper.
Biol. & Med., 27: 405-407, 1930.
(36) Nathan B. Eddy. "Antagonism between methylene blue and sodium cya-
nide." J. Pharmacol. & Exper. Therap., 39: 271, 1930. (Proc.)
(37) "Regulation of respiration. The effect upon salivary secretion of
the intravenous administration of sodium bicarbonate, sodium carbon-
ate, sodium hydroxide, sodium chloride, and sodium sulphate." Quart.
J. Exper. Physiol., 20: 313-320, 1930 (8 plates).
(38) "Regulation of respiration. The effect upon salivary secretion of
the intravenous administration of lactic acid, sodium lactate, and hydro-
chloric acid." Quart. J. Exper. Physiol., 20: 321-326. 1930 (5 plates).
(39) —"Regulation of respiration. The effect upon salivary secretion of
the intravenous administration of ammonium chloride and ammonium
carbonate." Quart. J. Exper. Physiol., 20: 327-332, 1930 (5 plates).
(40) "Regulation of respiration. The effect upon salivary secretion of
an increased oxygen content of the inspired air and of forced venti-
lation." J. Pharmacol. & Exper. Therap., 4I: 42.3-433, 1931.
(41) "Regulation of respiration. The effect upon salivary secretion of
the intravenous administration of sodium sulphide, sodium cyanide and
methylene blue." J. Pharmacol. & Exper. Therap.. 4I: 435-447, 1931.
(42) "Regulation of respiration. The antagonism between methylene
blue an dsodium cyanide." J. Pharmacol. & Exper. Therap., 4i-' 449-464,
1931.
(43) "The action of the codine isomers and some of their derivatives."
J. Pharmacol. & Exper. Therap., 45: 236, 1932. (Proc.)
(44) "A comparison of phenanthrene and some 2-, 3-, and 9-monosubsti-
tution products." J. Pharmacol. & Exper. Therap., 45: 257, 1932. (Proc.)
(45) Nathan B. Eddy and A. Kenneth Simon. "The measurement of the de-
pressant action of the codeine isomers and related substances by the
use of mazetrained rats." J. Pharmacol. & Exper. Therap., 45: — , 1932.
(Proc.)
(46) Hugo M. Kreugar and Nathan B. Eddy. "A study of the effects of codeine
and isomers on the movements of the small intestine." J. Pharmacol. &
Exper. Therap., 45: 266, 1932. (Proc.)
(47) Nathan B. Eddy. "Studies of morphine, codeine, and their derivatives:
I. General Methods." J. Pharmacol. & Exper. Therap., 45: 339-359, 1932.
(48) "Studies of morphine, codeine, and their derivatives: II. Isomers
of codine." J. Pharmacol. & Exper. Therap., 45: 361-381, 1932.
(49) Ardrey W. Downs and Nathan B. Eddy. "Influence of barbital upon
cocaine poisoning in the rat." J. Pharmacol. & Exper. Therap., 45: 383-
387, 1932.
(50) "Effect of repeated doses of cocaine on the dog." J. Pharmacol. &
Exper. Therap., 46: 195-198, 1932.
(51) "Effect of repeated doses of cocaine on the rat." J Pharmacol. &
Exper. Therap., 46: 299-200, 1932.
46
(52) Nathan B. Eddy. "Dilaudid." J. Am. Med. Assn., 100: 1031-1035, 1933.
(53) Gerald G. Woods and Nathan B. Eddy. "Some new alkamines of the
tetrahydronapthalene series." J. Pharmacol. & Exper. Therap., 48: 175-
181, 1933.
(54) Nathan B. Eddy. "Studies of phenanthrene derivatives : I. A comparison
of phenanthrene and some 2-, 3-, and 9-monosubstitution products." J.
Pharmacol. & Exper. Therap., 48: 183-198, 1933.
(55) "Studies of the relation of the hydroxyl groups of morphine to its?
pharmacological action." J. Pharmacol. & Exper. Therap., 48 : 271, 1983.
(Proc.)
(56) "Studies of morphine, codeine, and their derivatives : III. Morphine
methochloride and codeine methocloride." J. Pharmacol. & Exper.
Therap,. 49: 319-327, 1933.
(57) "Studies of morphine, codeine, and their derivatives: IV. Hydro-
genated codine isomers." J. Pharmacol. & Exper. Therap., 51: 35-4:4,
1934.
(58) "Studies of phenanthrene derivatives: II. Monosubstitution prod-
ucts, first variations. The effect of muzzling the hydroxyl group of 2- or
3-hydroxyphenanthrene." J. Pharmacol. & Exper. Therap., 51: 75-84,
1934.
(59) Charles W. Edmunds and Nathan B. Eddy. "Some studies on the drug
addiction problem." Michigan Alumnus Quarterly Review, 4^: 250-257,
1934.
(60) Charles W. Edmunds, Nathan B. Eddy, and Lyndon P. Small. "Studies
on morphine addition problem." J. Am. Med. Assn.. 103: 1417, 1934.
(61) Nathan B. Eddy. "Studies of phenanthrene derivatives: III. Di-subst.
'f>= products." J. Pharmacol. & Exper. Therap., 52 : 275-289, 1934.
(62) Nathan B. Eddy and John G. Reid. "Studies of morphine, codeine, and
their derivatives: VII, Dihydromorpliine (paramorphan), dihydro-
morphinene, (Dilaudid), and dihydrocodeinone (Dicodide)." J.
Pharmacol. & Exper. 52 : 468-493, 1934.
(63) Nathan B. Eddy and Homer A. Howes. "Studies of morphine, codeine,
and their derivatives : VIII. Monoacetyl- and diacetylmorphine and
their hydr. derivatives." J. Pharmacol. & Exper. Therap., 53: 430-439,
1935.
(64) Nathan B. Eddy. "Phenanthrene studies. The effect of different nitric-
taining side-chains." J. Pharmacol. & Exper. Therap., 54 : 149, 1935.
(65) A. Kenneth Simon and Nathan B. Eddy. "Studies of morphine, codeine,
and their derivatives : V. The use of maze-trained rats to study the effect
on central nervous system of morphine and related substances." Am. J.
^7 : 597-613, 1935.
(66) Nathan B. Eddy and Bertha Aheens. "Studies of morphine, codeine, and
their derivatives : VI. The measurement of the central effect of codeine,
hydrocodeine, and their isomers bv the use of maze-trained rats." Psy-
chol., ^7 : 614-623, 1935.
(67) Nathan B. Eddy. "Studies of morphine, codeine, and their derivatives:
Methyl ethers of the morphine and codeine series." J. Pharmacol. &
Therap., 55 : 127-135. 1935.
(68) Nathan B. Eddy and Homer A. Howes. "Studies of morphine, codeine,
and their derivatives : X. Desoxymorphine-C, desoxycodeine-C and their
hydro derivatives." J. Pharmacol. & Exper. Therap., 55 : 257-267, 1935.
(69) Natpian B. Eddy. "Studies of phenanthrene derivatives: V. Homologous
and aldehvdes and some of their derivatives." J. Pharmacol. & Exper.
Therap., 55 : 354-364, 1935.
(70) "Studies of phenanthrene derivatives : VI. Amino alee of the ethan-
olamine and propanolamine type." J. Pharmacol. & Exper. 55 : 419-429,
1935.
(71) "Studies of morphine, codeine, and their derivatives: The isomers
of morphine and dihydromorphine." J. Pharmacol. «& Exper. 56' : 429-431,
1936.
(72) "Studies of phenanthrene derivatives: 'SMI. A comparing analogous
phenanthrene and dibenzofurau derivatives." J. Pharmacol. Exper.
Therap., 58 : 159-170, 1936.
(73) ^"Drug Addiction. Pharmacological Studies." Hosp. New 34, 1936.
47
(74) Nathan B. Eduy and C. K. Himmelsbach. "Experiments on the tolerance-
and addiction potentialities of dihydrodesoxymorphiue-D ("Desomor-
phine")." Suppl. No. 118 to the U.S. Public Health Reports. 33 pp.. 1936.
(75) Nathan B. Eddy. "Analgesic and other effects of some carbazoles." J.
Pharmacol. & Exper. Therap., 60: 105, 1937 (Proc.)
(76) "The search for more effective morphine-like substitutes." Am. J.
Med. Sc, J97 : 464^79, 1939.
(77) Lyndon F. Small, Nathan B. Eddy, Erich Mosettig, and C. K. Himmels-
bach. "Studies on drug addiction. With special reference to chemical
structure of opium derivatives and allied synthetic substances and their
physiological action." Suppl. No. 138 to U.S. Public Health Reports, 143
pp., 1939.
(78) Nathan B. Eddy. "Studies of carbazole derivatives: I. Amino-carbazoles."
J. Pharmacol. & Exper. Therap., 65 : 294-307, 1939.
(79) "Studies of carbazole derivatives: II. Amino alcohols and deriva-
tives of tetrahydrocarbazole." J. Phai-macol. & Exper. Therap., 65 : 308-
317, 1939.
(80) "Studies of morphine, codeine, and their derivatives: XIV. The
variation with age in the toxic effects of morphine, codeine, and some
of their derivatives." J. Pharmacol. & Exper. Therap.. 66 : 182-201, 1939.
(81) Nathan B. Eddy and Margaret Sumwalt. "Studies of morphine, codiene,
and their derivatives : XV 2,4-Dinitrophenylmorphine." J. Pharmacol,
& Exper. Therap., 67 : 127-141, 1939.
(82) Nathan B. Eddy. "Pharmaceutical education and the public health." Am.
J. Pharmaceut. Ed., 181-186, 1942.
(83) Hugo Krueger, Nathan B. Eddy, and Margaret Sumw^alt. "The Pharma-
cology of the Opium Alkaloids." Suppl. No. 165 to the Public Health
Reports, 1448 CXL pp., 1943.
(84) Nathan B. Eddy. "4,4-Diphenyl-6-dimethylamino-heptanone-3 : A new syn-
thetic morphine-like analgesic." Soc. for Exper. Biol. & Med., Washing-
ton Section, April 1947.
(85) "Metopon hydrochloride." J. Am. Med. Assn., 134: 219-292, 1947.
(86) Harris Isbell, Abraham Wikler, Nathan B. Eddy, John L. Wilson, and
Clifford F. Moran. "Tolerance and addiction liability of 4,4-diphenyl-
6-dimethylamino-heptanone-3 (Methadone)." J. Am. Med. Assn., 135:
883-894, 1947.
(87) Nathan B. Eddy. "Metopon." J. Am. Pharmaceut. Assn., Pract. Pharmac.
Education, 8 : 430-433, 1947.
(88) "A new morphine-like analgesic." J. Am. Pharm. Assn., Pract.
Pharm. Ed.. 8 : 536-540, 1947.
(89) "Analgesic drugs in cancer therapy." Fourth International Cancer
Research Congress, St. Louis, Sept. 5, 1947. Acta L'Union luteruat.
Cong. Cancer, 6 : 1379-1385, 1950.
(90) "Metopon." Am. Soc. Anesthesiologists — Symposium on New Drugs,
New York, Dec. 5, 1947.
(91) "Progress in Drug Therapy of Pain." Am. Pharmaceut. Monuf.
Assn., Annual Award Meeting, New York, Dec. 16, 1947. Am. Prof.
Pharmacist, 14 : 252-253, 1948.
(92) "Metopon hydrochloride." Canad. Med. Assn. J. January 1947.
(93) "Metopon hydrochloride (Methyldihydromorphinone hydrochlo-
ride)." Report to the Council on Pharmacy and Chemistry of the AMA
by the Committee on Drug Addiction and Narcotics of the National Re-
search Council. J. Am. Med. Assn., 137 : 365-367, 1948.
(94) "Newer analgesics in the control of pain in cancer patients." Post-
graduate symposium on Cancer, Medical College of Virginia, Rich-
mond, Va. Mar. 25, 1948. Unpublished.
(95) "Newer preparations for pain relief." Read Apr. 16, 1948. George
Washington University Medical School. Postgraduate course. Unpub-
lished.
(96) "Progress in drug therapy of pain." Adapted from No. 91. Read
at Staff Meeting of Arlington Hospital, Arlington, Va. May 6. 1948.
Unpublished.
(97) "Pharmacology of Metopon and other new analgesic opium deriva-
tives." New York Academy of Science. May 14-15, 1948. Ann. N.Y.
Acad. Science, 51 : 51-58, 1949.
48
(98) "The New Narcotics, Post-graduate Course in Internal Medicine
of tlie American College of Physicians, May 22, 1948." Am. Practitioner,
3 : 37^2, 1948.
(99) "Cooperation on Narcotics." Drug & Allied Indust., 5: 8-11, 1949.
(100) . "Metopon hydrochloride. An Experiment in Clinical evaluation."
U.S. Public Health Reports, 64 : 93-103, 1949.
(101) - — —"Progress in drug therapy of pain." Am. Professional Pharmacists,
14 : 2.52, 1948.
(102) "The relation of chemical structure to analgesic action." J. Am.
Pharmaceut. Assn., Sc. Ed., 39 : 24.5-251, 1950.
(103) Nathan B. Eddy, Caroline Fuhrmeister Touchberrt, and Jacob E.
LiEBERMAN. "Synthetic analgesics. I. Methadone isomers and deriva-
tives." J. Pharmacol. & Exper. Therap., 98 : 121-137, 19.50.
(104) Nathan B. Eddy. "Methadols and acetylmethadols." Read Lilly Research
Laboratories, May 24, 1951 : Pharmacological Institute, Basle, Switzer-
land, Nov. 15, 1951. Unpubli.shed.
(105) Nathan B. Eddy, Evekette L. May, and Erich Mosettig. "Chemistry and
pharmacologv of the methadols and acetylmethadols : XII." Interna-
tional Cong. Chem., New York, Sept. 7, 1951 : J. Org. Chem., 17 : 321-326.
1952.
(106) Nathan B. Eddy. "N-Allylnormorphine." Comm. Drug Addiction & Nar-
cotics. Jan. 21, 1952. Unpublished.
(107) "Drugs liable to produce addiction (The work of the World Health
Organization Expert Committees)." Public Health Reports, 61: 362,
1952.
(108) Nathan B. Eddy and Everette L. May. "The isomethadols and their acetyl
derivatives." J. Org. Chem., 17 : 210-215, 1952.
(109) Nathan B. Eddy, G. Robert Coatney, W. Clark Cooper and Joseph
Greenberg. "Survey of antimalarial agents." Public Health Monograph,
No. 9 : .323 pp. U.S. Govt. Print. Off., Washington. D.C. 1953.
(110) Nathan B. Eddy and Dorothy Leimbach. "Synthetic Analgesics: II. Di-
thienvlbutenyl- and dithienylbutylamines." J. Pharmacol. & Exper.
Therap. 107 : 385-393, 19.53.
(111) Nathan B. Eddy. "Heroin (diacetylmorphine). Laboratory & clinical
evaluations of its effectiveness and addiction liability." Bull. Narcotics,
5:39-44,1953.
(112) "Symposium on drug addiction: Foreword." Am. J. Med. 14'- 537,
1953.
(113) — "The hot plate method for measuring analgesic effect in mice." Na-
tional Research Council Bull. Drug Addiction & Narcotics, 603-612,
19.53. Unpublished.
(114) "Drug Addiction: Fact and Fancy." Royal Canadian Institute,
Toronto. Canada, Mar. 28, 19.53. Pro. Roval Canad. Inst., 18: 44, 19.53:
Health Ed. J., 17 : 1, 11 ; 17 : 2. 14-19, 19.53.
(115) Dorothy Leimbach and Nathan B. Eddy. "Synthetic analgesics: III.
Methadols, Isomethadols and their acvl derivatives." J. Pharmacol. &
Exper. Therap., 110 : 135-147, 19.54.
(116) Nathan B. Eddy. "The Phenomena of tolerance." Symposium on Drug
Resistance, Washington, D.C, Mar. 26, 1954. Published by Academic
Press — "Origins of Resistance to Toxic Agents." pp. 22.3-243* 1955.
(117) "The Committee on Drug Addiction and Narcotics." News Report,
National Academy of Sciences ; ^ : 93, 1954.
(118) Olav J. Braenden, Nathan B. Eddy, and H. Halbach. "Synthetic sub-
stances with morphine-like effect. Relationship between chemical struc-
ture and analgesic action." Bull. World Health Organization, 13: 937,
19.55.
(119) Nathan B. Eddy. "Addiction liability of nlagesics: tests and results."
Read, Symposium on alagesics, American Theraueptic Society, June 3,
19.55, Atlantic City, N.J. J. Am. Geriatrics Society, 4: 177, 19-56.
(120) "The search for new analgesics. Part of Symposium, Pain and its
relief." J. Chronic Dis., //.- 59, 1956.
(121) Nathan B. Eddy, II. Haibach, and Olav J. Brafndex. "Synthetic sub-
stances with morphine-like effect. Relationship between analgesic action
and addiction liability, with a discussion of the chemical structure of
addiction producing substances." Bull. World Health Organization, 14:
.353. 1956.
49
(122) Nathan B. Eddy. "Synthetic narcotic drugs." Union Signal, 82: 7, 19r.5.
(123) Theodore D. Perrine and Nathan B. Eddy. '"The preparation and anal-
gesic activity of 4-carbethoxy-4-pheuyl-l-(2-phenyIetliyl) -piper idine and
related compounds." J. Org. Cheni., 21: 12.j, ID.jH.
(124) Nathan B. Eddy. "Habit-forming drugs." Bull. Drug Addiction & Nar-
cotics, p. 1494. 195«;.
(125) "The history of the development of narcotics." Law and Contempo-
rary Problems, 22: 3, 1907.
(12G) "Addiction-producing versus habit-forming." Guest editorial J. Am.
Med. Assn., 163: 1G22, 1957.
(127) "New developments in analgesics." Read, Bahamas Medical Con-
ference, Nassau, Apr. 25, 1957. Unpublished.
(128) "Addiction — ^the present situation." Read, Bahamas Medical Con-
ference, Nassau, Apr. 25, 1957. Unpublished.
(129) Nathan B. Eddt, H. Halbach, and Olav J. Braenden. "Synthetic sub-
stances with morphine-like effect. Clinical experience : Potency, side
effects and addiction liability." Bull. World Health Orgn., 27; 569, 1957.
(130) Nathan B. Eddy, James G. Murphy, and Everette L. May. "Structures
related to morphine : IX. Extension of the Grewe morphinan synthesis
in the benzomorphan series and pharmacology of some benzomorphans."
J. Org. Chem., 22: 1070, 1957.
(131) Nathan B. Eddy, Red wig Besendorf, and Bela Pellmont. "Synthetic
Analgesics : IV. Aralkyl substitution on nitrogen of morphinan. "U.N.
Bull. Narc. 10: (No. 4) , 23, 1958.
(131a) Lyndon F. Small. Nathan B. Eddy, J. Harrison Ageu. and Everette L.
May. "An improved synthesis of N-phenethylnormorphine and analogs."
J. Org. Chem., 23: 1387, 1958.
1 132) Nathan B. Eddy and Lyndon E. Lee, Jr. "The analgesic equivolence to
morphine and relative side reaction liability of oxymorphone (14-hy-
droxy-dihydromorphinoue)." J. Pharmacol. & Exper. Therap., 125: No. 2,
February 1959.
(133) Nathan B. Eddy, Lyndon E. Lee, Jr., and Cari. A. Harris. "The rate of de-
velopment of physical dependence and tolerance to analgesic drugs in
patients with chronic pain : I. Comparison to morphine, oxymorphone
and anileridine." Bull. Narc, 11: Nos. 1, 3, 1959.
(134) Nathan B. Eddy and Harris Isbell. "Addiction liability and narcotics
control." Public Health Reports, 7.J; 755, September 1959.
(135) Nathan B. Eddy. "Chemical structure and action of morphine-like anal-
gesics and related substances." Sixth Lister Memorial Lecture. Chem. &
Indust., 47.- 14H2 November 1959.
(136) Nathan B. Eddy, Lyndon E. Lee, Jr., and Carl A. Harris. "Dependence
physique et tolerance vis-a-vis de certains analgesiques chez des malades
souffrant de douleurs chroniques. Comparison entre la morphine, I'oxy-
morphoneet I'anileridine." Bull. Org. Sante, 20: 1245, 1959.
(137) Nathan B. Eddy, Modeste Piller, Leo A. Pirk, Otto Schrappe, and
SiGUARD Wende. "The effect of the addition of a narcotic antagonist on
the rate of development of tolerance and physical dependence to mor-
phine." Bull. Narc, 12: No. 4, 1959.
(138) Everette L. May and Nathan B. Eddy. "A new potent synthetic anal-
gesic" J. Org. Chem., 2J,: 294, 1959.
(139) Everette L. May, and Nathan B. Eddy. "Structures related to morphine:
XII. ( ± ) -2'-Hydroxy-5,9-dimethyl-2-phenethyl-6,7-benbomorphan ( NIH-
7519) and its optical forms." J. Org. Chem., 24: 1435-1437, 19.59.
(140) Paul A. J. Janssen and Nathan B. Eddy. "Comiwunds related to pethi-
dine : IV. New general chemical methods of increasing the analgesic
activity of pethidine." J. Med. Pharmaceut. Chem., 2: 31. I»i0.
(141) J. R. Nicholls and Nathan B. Eddy. "The assay, characteristics, compo-
sition and origin of opium. No. 97. Analysis of samples of opium of
unknown origin." United Nations, ST/SOA/Ser. K/97, February 19,
1960.
(142) BENJAJfiN J. CiLiBEKTi AND Nathan B. Eddy. "Preanesthetic medication:
morphine, anileridine, oxymorphone, and placebo." Bull. Narc, 13 : Nos.
3, 1, 1961.
(143) Everette L. May and Nathan B. Eddy. "The assay, characteristics, com-
position, and origin of opium. No. 111. The analysis of authenticated
opium samples bv means of direct absorption spectrophotometry." United
Nations, ST/SOA/Ser. K/Hl, October 6, 1961.
50
<144) Nathan B. Eddy, H. M. Fales, E. Haahti, P. F. Highet, E. C. Horning,
E, L. May, and W. C. Wildman. "The assay, characteristics, composi-
tion, and origin of opium. No. 114. Identification and analysis of opium
samples by linear-programed gas chromatography." United Nations,
ST/SOA/Ser.K/114, Oct. 6, 1961.
(145) Maxwell Gordon, John J. Laffebty, David H. Tedeschi, Nathan B.
Eddy, and Everette L. May. "A new potent analgetic antagonist." Na-
ture, 192 : 1089. 1961 .
(146) Maxwell Gordon, John J. Lafferty, Blaine M. Sutton, David H.
Tedeschi, Nathan B. Eddy and Everette L. May. "New benzomorphan
analgetics." J. Med. Pharmaceut. Chem., 1962. In press.
(147) Nathan B. Eddy and Hans Halbach. "Synthetic substances with mor-
phine-like effect: V. Tests for addiction." Bull. World Health Organi-
zation, 1962. In press.
(148) Nathan B. Eddy and Everette L. May. "Synthetic Analgesics, Part 2, B.
Benzomorphans" Pergamon Press, 1962. In press.
(149) H. Halbach and Nathan B. Eddy. "Tests for addiction (chronic intoxi-
cation) or morphine type." Bull. World Health Organization, 1963,
28 : 139
<150) Nathan B. Eddy. "Statement on Relative Safety of Codeine Prepara-
tions." Read, Senate Committee on Judiciary, California Senate, Sacra-
mento, Calif., Mar. 8, 1963.
(151) — ^ "The role of the National Academy of Sciences and the National
Research Council." Proceedings White House Conference on Narcotic and
Drug Abuse, Washington, D.C., Sept. 27-28, 1962, p. 136.
(152) "The chemo-pharmacological approach to the problem of drug ad-
dition." Read, Conference on Drug Addiction, University of California
at Los Angeles, Apr. 27-28, 1963. U.S. Public Health Report (1963) 78:
673. Proceedings of the conference. McGraw-Hill (1964). In press.
(153) Nathan B. Eddy, B. Ciliberti, and Phyllis F. Shroff. "Preanaesthetic
medication." Bull. Narcotics (1964) 16 : No. 2, 41.
<154) Nathan B. Eddy. "Drug addiction and the law." Britannica Book of the
Year (1964), 291.
(155) "The search for a nonaddicting analgesic." Proc. of symposium on
history of narcotic drug addiction problems. Mar. 27-28, 1958. Public
Health Service publication No. 1050, U.S. Gov. Print. Off. (1963).
Chairman Peppp:e. We will now take a 5-minute recess.
(A brief recess was taken.)
Chairman Peppee. The committee will come to order, please.
Dr. Brill, would you please come forward.
Our next witness today is Dr. Henry Brill, ca distinguished psychia-
trist and hospital administrator.
Dr. Brill, a graduate of Yale College and Yale Medical School,
served his internship at Pilgrim State Hospital in New York, the
same facility that he now serves as director.
Dr. Brill is a diplomate of the American Board of Neurology and
Psychiatry, a fellow of the American Psychiatric Association, and a
certified mental hospital administrator.
He has served as assistant commissioner for research and medical
services of the New York Department of Mental Plygiene : and vice
chairman of the New York State Narcotic Addiction Control
Commission.
PTe has been director of Pilgrim State Plospital, with time out for
some of his other appointments, since 1958.
Dr. Brill has served as clinical professor of psychiatry at Albany
Medical College and as professional lecturer at Upstate Medical Cen-
ter in Syracuse, N. Y.
He is presently a lecturer in psychiatry at Columbia Uiiiversity-s
College of Physicians and Surgeons, and clinical professor of psychia-
try at the New York School of Psychiatry.
51
In the past, Dr. Brill has served as president of both the American
College of Neuropsychopharmacology and the Eastern Psychiatric
Research Association. He is currently president-elect of the American
Psychopathological Association.
In addition to serving on the editorial boards of four scientific jour-
nals, Dr. Brill is a member and past chairman of the American Medi-
cal Association's Committee on Drug Dependence and Alcoholism; a
member and past chairman of the National Research CounciFs Com-
mittee on Drug Dependence, and was recently appointed to the Presi-
dent's Commission on Marihuana and Drug Abuse.
In 1965, Dr. Brill was chairman of the methadone maintenance
evaluation advisory committee of the Columbia School of Public
Health.
I have taken the time to list but a few of Dr. Brill's many profes-
sional appointments and accomplishments. I will not detail the over
100 papers in the field of psychiatry, administration, somatic theory,
and drug dependence he has authored.
Dr. Brill, we are greatly honored that you have taken time from
your busy schedule to share your immense knowledge with us.
Mr. Perito, would you make the inquiries ?
Mr. Perito. Thank you, Mr. Chairman.
Dr. Bril], I understand you have a prepared statement ?
STATEMENT OE DE. HENEY BRILL, DIRECTOR, PILGRIM
STATE HOSPITAL, NEW YORK, N.Y.
Dr. Brill. I have.
Mr. Perito. Would you care to read that statement or just sum-
marize it?
Dr. Brill. I would like to skip through it because much of it re-
peals what you have already heard this morning.
Chairman Pepper. Doctor, without objection, your full statement
will appear in the record, and you may give such summary of it as you
will.
Dr. Brill. Thank you, sir.
I think what I would like to stress here is that the question before
your committee, as has been mentioned, was already brought up in
1051, but it is different in one important respect. In 1951, the question
was asked what would happen in a state of national emergency when
stocks of opiuni derivatives were exhausted and not to be replenished.
Now, today this Nation is in a secure position with respect to such an
emergency, and I think that you already have heard that we haA-e good
substitutes under such circumstances so there would be no emergency
in the medical practice if the supplies were cut off.
I would also like to point out that this is, to a significant degree, the
direct result of a major coordinated research in which the iSTational
Academy of Medicine-National Research Council Committee played
an important role under the leadership of Dr. Nathan Eddy, who was
its chairnian for most of the time, since 1951, and I might also add that
another important element was the work of Dr. Maurice Seevers, whom
you have heard this morning.
You now, as I understand it, are interested in the situation with re-
spect to a complete substitution in a nonemergency situation, and this
52
entails the consideration of additional important factors, factors in
jiddition to those coiisidered in response to the first question: That is
the established patterns of medical and pharmaceutical practice, and
I might add. it also relates to the habits of the public with respect to
the medication they take, because one of these medications- codeine,
is extensively self-administered for the treatment of cou^h.
From all ])ersonal experience, I am led to believe that tlie synthetics
are playing a large and growing role in the practice of medicine, yet
it appears the natural opium products and their derivatives are still
extensively used in spite of the availability of heavily advertised syn-
thetic rei)lacements, and these synthetics are being heavily advertised
in the medical press at least. The TT.N. publication "Statistics on Nar-
cotic Drugs for lOGO." table o, indicates that the amou.nt of morphine
converted into '^odeine actually rose worldwide from 112.350 kilo-
grams in 1905 to 146,000 kilograms in 1969, and the corresponding
U.S. figures rose from 20,000 kilograms to 28,000 kilograms, v.-hir>h
points to a marked public acceptance of the use of codeine in current
practice.
The increases were irregular, but the figures seemed to show that
the natural products, and especially codeine, continue to play a very
large role in world medicine and in the United States, and that the
U.S. share is significant but by no means decisive in the overall figures.
It would thus seem that in a plan to influence the dru<i' dependence
field by terminating the use of natural products would call for re-
orientation of this aspect of medical practice within the Ignited States
and in other countries as well. Quantitativelv the story relates to co-
deine. The issue which would have to be considered includes the relative
costs of the natural and synthetic products and the relative familiarity
of public and the health professions with the many characteristics of
each of the various drugs because in practice few drugs are entirely 07-
essentially identical. They tend to vary among themselves as to speed
and duration of their primary action and the relative intensity and
timing of their many other properties. From all available information,
it would seem that a replacement is technically feasible Init it would
also appear that this would call for full considtation with organized
medicine and pharmacy. In order to be fully accepted, such a transition
would require further research to explore the many pharmacological
characteristics of the substitute drugs — and this includes the question
of teratogenicity, which is a thorny question at the present moment,
the capacity to create deformities in unborn children — in the multi-
plicity of clinical situations and the many conditions under which the
drugs are used and this would call for extensive laboratory studies
and clinical investigations. Because when a drug comes out of a labora-
tory and comes into clinical practice there is a large empirical element
that must enter into it, because no laboratory can ever go into all the
various complex situations that are liable to be faced in actual mcMlical
practice. They can approximate it, but they can't totally reproduce it.
I appreciate the opportunity to appear before this body and realize
that there is room for nnich clifference of opinion on all these matters
but have sought to identify the prol)loms which would seem to require
solution in connection with the proposal which is before you. Under
emergency conditions the synthetic drugs which we now have would
fully replace the natural products in control of i^ain and for other
53
indications but under nonemergency conditions it would seem that
the immediate reorientation of medical and pharmaceutical procedures,
on the scale implied in the U.S. figures, would require a major effort,
although there are strong indications that the long-term trend lies in
this direction, that is, in the direction of the gradual substitution of
he natural products by the introduction of synthetics.
Thank you, sir.
Chairnian Pepper. Doctor, what needs to be done, in addition to what
has already been done, to justify Congress in prohibiting the impor-
tation of any deri^'ati\'GS of opium so as to lead to the stoppage of the
growing of the opium poppy ? Do you think additional research is nec^
essary, and if so, are additional funds required ? What more needs to
be done^
Dr. Brill. I would say yes to both counts. For example, a synthetic
way of producing codeine which hasn't yet been achieved or a synthetic
which will substitute completely for codeine — and we do not have a
drug which is exactly like codeine — both of these would be well worth-
while in connection with the proposal, and they call for research.
In addition, if I may, there is a large amount of investigation that
needs to be done and has not been done in connection with many, many
interesting products that have been tested and are available for fol-
lowup but have not been thoroughly investigated because of a lack of
funds.
Chairman Pepper. Doctor, what do you consider the state of develop-
ment of antagonistic drugs to heroin addiction?
Dr. Brill. I think we are at the beginning, sir. Naloxone is one drug
which is quite acceptable to those patients who are willing to take the
antagonist and the supply is as yet not extensive. I think that this is
now being developed, but we need a substance which will have a longer
action tlian naloxone has. But I must also point out that many pa-
tients will refuse to take, many addicts will refuse to take, antago-
nists. This is from my personal experience.
Chairman Pepper. Are you informed about the methadone experi-
ment in New York '?
Dr. Brill. , Yes.
Chairman Pepper. "Would you comment on the use of methadone in
the treatment of heroin addiction?
Dr. Brill. When methadone is used along the lines that Dr. Eddy
outlined, when it is properly used in a program of treatment, it can
produce results which I think are better than any other techniques
that I know for a certain number of addicts whose condition is intrac-
table to any other procedure. But when methadone is used by other
methods, by other techniques and in other ways, it can become a pub-
lic health hazard and the essential difference between the medical use
of methadone and the abuse of methadone is that the medical use of
methadone provides physical saturation, saturation of the physical
need but it produces no mental effect. "Whereas, if the drug is used in
such a way as to produce mental effects it produces all the harm of ad-
diction as we know it. It produces mental effect when it is injected in-
travenously and when it is taken orally by beginners on an irregular
basis.
54
Chairman Pepper. Have you found tliat the use of methadone in the
New York experiment with which you are familiar has reduced the
amount of crime committed by the heroin addict treated ?
Dr. Brill. In the cases that are under treatment, the statistics are
quite spectacular. The amount of crime was reduced by over 85 per-
cent. But I cannot say that there was an impact on the overall crime
statistics, althou<ili I knoAv how difficult it is to eA^aluate overall
crime statistics. But among the population that followed the metha-
done treatment, the reduction in crime is spectacular.
Chairman Pepper. Mr. Perito, do you have any questions of Dr.
Brill?
Mr. Pertto. a couple of brief ones, Mr. Chairman.
Dr. Brill, how would it be best to coordinate the eflForts of or-
ganized medicine to move toward the use of synthetic analgesics ?
Dr. Brill. You mean to advance the use of existing synthetics or
new synthetics ?
Mr. Perito. Existing synthetics.
Dr. Brill I think an educational program would be useful. I think
there is relatively little problem, as Dr. Eddy pointed out, in connec-
tion with the use of synthetics for the control of pain in connection
with operations and major surgery or major accidents and this kind
of thing.
The real problem is in the use of codeine as an analgesic and an
antidepressant for the control of cough. Hero the drug has a combi-
nation of qualities that are not easily mimicked.
Mr. Perito. Would you acquiesce in the judgment of Dr. Eddy that
methadone should not be distributed by private physicians but should
only be distributed in a coordinated clinical atmosphere with proper
support services?
Dr. Brh^l. Most certainly.
Chairman Pepper. Mr. Mann.
Mr. Mann. No questions, Mr. Chairman.
Chairman Pepper. Mr. Wiggins?
Mr. Wiggins. Doctor, your testimony indicated that one of the
problems with the synthetics is that they have not been thoroughly
tested to know fully their impact in general clinical use. But isn't
it so. Doctor, that many of these substitutes are now in clinical use ?
Dr. Brill. Yes, sir ; they are. Unfortunately, it takes years of clinical
use before all the ramifications of a drug can be identified. For exani-
ple, we take one of the commonest drugs in clinical use, and that is
tobacco. It was in clinical use for hundreds of years before anyone
suspected that it might possibly lead to pathologies in the lungs and
so on. So the same has happened over and over again with ncAvly
introduced drugs. After they have been on the market for a while,
questions have been raised.
Antidiabetic drugs recently had questions raised about them which
are not fully answered as yet. It is a controversial subject, as you know.
So the fact that a drug is in clinical use is reassuring, but not totally
reassuring.
Mr. Wiggins. Doctor, simply because questions exist and probably
will always exist, are you satisfied that those questions standing alone
are sufficient reason not to warrant a statute which would outlaw
morphine and thereby force the general clinical use of the substitute ?
55
Dr. Brill. I think there would be less difficulty with a statute out-
lawino: morphine than with a statute outlawing all opium products.
I think it would be relatively simple to outlaw morphine, although
there would be, as has been brought out here, professional questions
raised both on the grounds of familiarity with the morphine and on
the grounds that there is a reluctance to have such things legislated.
But this is not, as I see it, the major problem.
Mr. Wiggins. The point was made by Dr. Eddy that the medical
profession would require a period of orientation and education. How
long do you suppose would be appropriate for that purpose?
Dr. Brill. If I might add to that question, it might be well to allow
organized medicine to come in and make its comments.
Mr. Wiggins. They will be invited to do so.
(See Exhibit 1.)
Dr. Brill. Yes.
Chairman Pepper. Yes.
Dr. Brill. I hesitate to speak for organized medicine, but it cer-
tainly couldn't be done in less than several years to the satisfaction of
most people.
Mr. Wiggins. That is all the questions I have.
Chairman Pepper. Mr. Steiger?
Mr. Steiger. Thank you, Mr. Chairman.
Doctor, the summation of your testimony and that of Dr. Eddy and
Dr. Seevers is that there is no medical reason for retaining the natural
analgesic, whatever the medical term is. Now, Doctor, as a layman, it
occurs to me that we have had painted here this morning a rather un-
flattering picture of the medical profession, because we say we arrive
on a conclusion based on a question posed in 1951, the conclusion being
that in a physical emergency in which opium was not available the
medical profession could readily adjust. Now, we understand, and
rather thoroughly, from the testimony that it would be, one, inconven-
ient and it would be what is termed justifiable for natural resistance
to any change, it would be difficult to stop cough.
Now, I think, it seems to me unfair to the medical profession — I
wouldn't want to just leave it lying there — that the inconvenience, the
comfortable familiarity with the existing natural opiates, all of these
things of themselves are so important that the evils that the opiate
now represents are going to be somehow set aside. It would be easy for
those of us in the political arena — and I am sure some of us will — to
call this an emergency situation. We truly have an emergency. There
are many areas in which the emergency is very genuine. The chairman,
I think, defined it pretty well at the outset.
I would hope that possibly — obviously the most comfortable thing
for us, and we are interested in our comfort, too — would be for the
medical profession to come forth and say now is the time and for the
medical profession to declare this an emergency and for the medical
profession to say these synthetics work, they will use them, those who
have coughs will perhaps have to cough a little.
I don't honestl}'^ know what the clinical situation is. But I know
that, again, just having heard this and having considered myself a
friend of medicine, I think we are painting medicine accurately, per-
haps, but unfairly nevertheless.
56^.
I wonder would you care to comment, and I suspect it is rather un-
fair, but on the likelihood of the medical profession feeling the need
to come forward and say let's do this thing.
Dr. Brill. I think that the real issue is the feeling of the public. The
medical pi-ofession can only represent the patient in this area, because
the doctor deals with a patient, and the indications for the use of
codeine, for example, are not indications of life and death. They are
relatively minor indications.
But I think all any technical person can do is to venture an opinion
as to whether a drug can be fully substituted to the satisfaction of the
patient or whether the substitution will not be equally satisfactoiy to
the patient. I think it would be misleading, from my point of view, if
I were to say that in my opinion drugs wdiich would replace codeine
would be just as satisfactory to the patient as codeine now is, particu-
larly keeping in mind that much of the codeine is over the counter
where the physician doesn't enter into it at all.
But the bar is not an absolute bar. It is a question of cost-benefit
ratios, and T am not in a position to judge the benefits. I think these
benefits have to do with traffic and so on, which I don't know anything
about.
Mr. Steiger. I understand. All right.
Medically, Doctor, on a scale of 1 to 10, how effective — and putting
codeine at 10 — how effective are the known codeine substitutes for
cough suppressants on this scale of 1 to 10, and would that be sufficient
to make the abolishment of opium and Avhatever benefits would derive
on a national basis? Really, I guess that is what we are faced with.
Obviously we don't want to impose a genuine hardship on the public.
By the same token I have great faith in the medical profession being
able to convince the public that what we are prescribing for them is
good for them, even though that may not always be the case.
On that 1 to 10 ratio, what would you say ?
Dr. Brill. Well, as a rough guess I would say two or three.
Mr. Steiger. So in your opinion that is where the gap lies, then ?
Dr. Brill. There is a possible difference, and there also is a possible
difference between the usefulness of codeine as an analgesic in many
cases and the usefulness of the competing analgesics. I think it is
less clear cut. These are matters of judgment and opinion and not
easily measured. But I think there is that difference.
But I must again say that much of this codeine, I don't know what
proportion — you easily can find out — much of the codeine used has
no medical intervention at all. This is a matter of public habit.
Mr. Steiger. I must say is not used medically ?
Dr. Brill. There is abuse of the cough mixtures. That is true. There
also is abuse of synthetic cough mixtures. So that is an even tossup.
Mr. Steiger. I thank you.
Chairman Pepper. ^Ir. Blommer, any questions?
Mr. Blommer. No, Mr. Chairman.
Chairman Pepper. Mr. Winn?
Mr. WixN. None, Mr. Chairman.
Chairman Pepper. INIr. Keating?
Mr. Keating. None, Mr. Chairman.
57
Chairman Pepper. Dr. Brill, I think you have given us extremely
valuable testimony this morning. You know, sometimes we can be
pushed a little bit to get to the conclusions that we want to reach.
I very much sympathize with what was suggested by Mr. Steiger.
Is codeine used largely in the suppression of cough?
Dr. Brill. Suppression of cough and for the control of minor pains
and minor discomforts. It is an analgesic.
Chairman Pepper. Yv e hope to iiear later from the medical associa-
tion and the whole medical profession on this subject. We w^ould cer-
tainly hope that they would take the lead in trying to move as rapidly
as possible, because Congress is faced with such a terrible problem in
heroin addiction. I believe we all agree that it is growing worse;
isn't it i (See Exhibit No. 1 for AMA views.)
Dr. Brill. Yes, sir ; it is.
Chairman Pepper, ilie problem is so serious, and it seems impossible
to stop it by law enforcement, which catches only 20 percent of the
heroin being smuggled into this country. That method seems so im-
probable of success that we have to turn to alternatives to see what
else we can do.
Dr. Brill. I agree.
Chairman Pepper. That is the reason we are trying to get teclmical
information, scientific knowledge that would guide the Congress in
seeing whether or not we may safely and properly move in this direc-
tion of stopping importation of opium. If we could stop the legal
growing of the opium poppy it would be easier to police a ban. We
could catch it, then.
Dr. Brill. Thank you.
Chairman Pepper. Mr. Perito has one more question?
Mr. Perito. Dr. Brill, have you had an opportunity, in your pro-
fessional practice, to treat and evaluate addicts who have been given
antagonists ?
Dr. Brill. Yes.
Mr. Perito. What is your professional opinion about the possibili-
ties of developing antagonists to the point w^here they will become an
effective weapon o^ the clinician in the treatment of drug-dependent
persons ?
Dr. Brill. I think it is a very good possibility and a very excellent
lead to follow. I wouldn't want to leave the impression that this is a
panacea, but the antagonists certainly are one of the best leads that
I know of.
Chairman Pepper. Are more funds necessary, in your opinion, to
carry on the developmental work in the finding of these solutions for
opium derivatives and finding antagonistic drugs to heroin addiction ?
Dr. Brill, Yes, sir; to my personal knowledge many of the most
important research activities in the country today in this field are
feeling the pressure of shortage of funds, and I think that this is
something that I have to call to your attention.
Chairman Pepper. The Federal Government might well interest
itself in providing more funds ?
Dr. Brill. I think so.
Chairman Pepper. Anything else ?
Mr. Perito. Mr. Chairman, may we have incorporated in the record
Dr. Brill's prepared statement; also, Dr. Brill's curriculum vitae.
60-296 O — 71— pt. 1 5
58
Chairman Pepper. Without objection, they will be admitted.
Thank you very much Doctor, for coming today.
(The material referred to follows :)
[Exhibit No. 5(a)]
Prepared Statement of Dr. Henry Brill, Director of Pilgram State
Hospital, New York, N.Y.
On the feasibility of replacing natural opium products with totally
synthetic substances in medical practice.
Mr. Chairman and Members of the Committee: I am Dr. Henry Brill of
Brentwood, N.Y., and a member of the committee on alcoholism and drug de-
pendence of the American Medical Association and the Committee on Problems
of Drug Dependence of the National Research Council. I am also immediate past
chairman of both committees and a member of the World Health Organization
Expert Committee on Drug Dependence. However, my statement here today is
made in a purely personal capacity and I am not here as a representative of any
group or organization.
I believe you already have testimony to the effect that as long ago as 19ol, the
Committee on Drug Addiction and Narcotics (now the Committee on Problems
of Drug Dependence), National Academy of Science-National Research Council
was questioned about the possibility of completely replacing natural opium
products with synthetic substances in the practice of medicine. The answer at
that time was a qualified affirmative and, as you know, the answer today has
become an unqualified aflSrmative. With this I fully concur and agree that from
the scientific and pharmacological point of view, such a substitution is entirely
practicable.
The question now before your group is different from that which was posed
in 1951. That question related to a state of national emergency in which it was
assumed that stocks of opium were exhausted and irreplenishable. Today this
Nation is, I believe, in a secure position with respect to such an emergency and
this improvement is to a significant degree the direct result of a major coordi-
nated research effort in which the National Academy of Medicine-National Re-
search Council Committee played a prominent role under the leadership of Dr.
Nathan Eddy who was its chairman for most of that time.
You are now interested in the situation with respect to a complete substitu-
tion in a nonemergency situation and this entails consideration of an important
factor in addition to those considered in response to your first question and I
refer to the established patterns of medical and pharmacological practice.
From all personal exi^erience, I am led to believe that the synthetics are play-
ing a large and growing role but yet it appears that the natural opium products
and their derivatives are still extensively used in spite of the availability of
heavily advertised synthetic replacements. The U.N. publication "Statistics on
Narcotic Drugs for 1969," table 5, indicates that the amount of morphine con-
verted into codeine actually rose worldwide from 112,350 kilograms in 1965 to
146,084 kilograms in 1969 and the corresponding U.S. figures rose from 20,089
to 23,084 kilograms. The increases were irregular but the figures seem to show
that the natural products continue to play a very large role in world medicine
and in the United States and that the U.S. share is significant but by no means
decisive in the overall figures.
It would thus seem that any plan to influence the drug dependence field by
terminating the use of natural products would call for reorientation of this
aspect of medical practice within the United States and in other countries as
well. The issue which would have to be considered includes the relative costs
of the natural and synthetic products and the relative familiarity of public and
the health professions with the many characteristics of each of the various
drugs because in practice few drugs are entirely or e.'^sentially identical. They
tend to vary among themselves as to speed and duration of their primary action
and the relative intensity and timing of their many other properties. From all
available information, it would seem that a replacement is technically feasible
but it would also appear that this would call for full consultation with organized
medicine and pharmacy. In order to be fully acceptable, such a transition
would require further research to explore the many pharmacological character-
istics of the substitute drugs in the multiplicity of clinical situations and the
59
many conditions undef which the drugs are used and this would call for ex-
tensive laboratory studies and clinical investigations.
I appreciate the opportunity to appear before this body and realize that there
is room for much difference of opinion on all these matters but have ;;ought
to identify the problems which would seem to require solution in connection
with the proposal which is before you. Under emergency conditions the synthetic
drugs which we now have would fully replace the natural products in control
of pain and for other indications but under nonemergency conditions it would
seem that the immediate reorientation of medical and pharmaceutical procedures,
on the scale implied in the U.N. figures, would require a major effort although
there are strong indications that the long-term trend lies in this direction.
[Exhibit No. 5(b)]
Curriculum Vitae of Dr. Henry Brill, Director, Pilgrim State
(N.Y.) Hospital
1906 Born Bridgeport, Conn.
1928 Graduate Yale College.
1932 Graduate Yale Medical School.
1932-34 Medical intern Pilgrim State Hospital (recognized as basis
for Nat. Board Part III).
1934 Licensed New York State (28727) .
1938 Diplomateof National Board (by exam) (6160).
1938 Qualified psychiatrist, New York State.
1940 Diplomate of American Board of Neurology and Psychiatry.
1951 Fellow American Psychiatric Association.
1957 Certified Mental Hospital Administrator (412) .
1934-50 Resident, Senior Psychiatrist, Clinical Director and Associate
Director, Pilgrim State Hospital.
1950-52 Director, Craig Colony and Hospital (epilepsy) .
1952-59 Assistant Commissioner for Reserach and Medical Services,
Department of Mental Hygiene, New York.
1958-64 (Director, Pilgrim State Hospital — on leave).
1959-64 Deputy and First Deputy Commissioner, N.Y. State Depart-
ment of Mental Hygiene (Special reference to Research
Training and Medical Services).
1964-66 Director Pilgrim State Hospital.
1966-68 Vice Chairman NY State Narcotic Addiction Control Com-
mission (Director — on leave — P.S.H.).
1968 to date Director Pilgrim State Hospital.
teaching
1955-64 Associate Clinical Professor and Clinical Professor — Psychia-
try— Albany Medical College.
1958-64 Professional lecturer — Upstate Medical Center, Syracuse.
1958 to date Lecturer — Psychiatry — College of Physicians and Surgeons,
Columbia University.
1959 to date Clinical Professor of Psychiatry, New York School of Psy-
chiatry.
1964-68
ORGANIZATIONAL
Past President of American College of Neuropsychophar-
macology and of Eastern Psychiatric Research Association.
Currently President-Elect American Psychopathological
Association.
Elected to Council of American Psychiatric Association;
Council Representative to Committee on Mental Hospital
Standards and Practices.
EDITORIAL BOARD
1948 to date Psychiatry Quarterly.
1968 to date International Journal of Addictions.
1969 to date Psychopharmacologia.
1971 to date Comprehensive Psychiatry.
60
1958-68
1959-«4
1969
1962-64
1962
1969
1965
1970
1971
COMMITTEES
Member and Chairman of Advisory Committee Clinical Psy-
chopharmocolgy NIMH.
Member and Chairman A.P.A. Committee on Nomenclature
and Statistics (DSM II).
Chairman of American Psychiatric Association Task Force
on Nomenclature and Statistics.
Member of Subcommittee on Classification to U.S. Surgeon
General.
Consultant to World Health Organization — Statistics and No-
menclature (Psychiatry).
Member and past chairman of A.M.A, Committee on Drug De-
pendence and Alcoholism.
Member and past chairman of National Research Council —
Committee on Drug Dependence.
Member W.H.O. Expert Committee on Drug Dependence.
Chairman — Methadone Maintenance Evaluation Advisory
Committee Columbia School of Public Health.
Member of NY State Regents Committee on Continuing Edu-
cation
Member of Presidential Commission on Marihuana and Drug
Dependence
On various Advisory Committees — Department of Justice,
FDA, and NIMH.
1970
1970
PUBLICATIONS AND HONORS
Author of over 100 papers in the field of Psychiatry, Admin-
istration, Somatic Therapy and Drug Dependence.
Member of Sigma XI and Phi Beta Kappa.
Recipient Hutchings Award.
Listed in current "Who's Who in America."
Chairman Pepper. Secretary Rossides, please.
The committee is pleased to call now the Honorable Eugene T. Ros-
sides, Assistant Secretary of the Treasury for Enforcement and
Operations.
Mr. Rossides serves as the principal law enforcement policy advisor
to the Secretary of the Treasury. His responsibilities include provid-
ing policy guidance for all Treasury law enforcement activities, as
well as direct supervision of the Bureau of Customs, the U.S. Secret
Service, the Bureau of the Mint, the Bureau of Engraving and Print-
ing, the Consolidated Federal Law Enforcement Training Center, the
Office of Operations, the Office of Tariff and Trade Affairs, and the
Office of Law Enforcement.
Mr. Rossides also serves as U.S. Representative to Interpol, the in-
ternational criminal police organization, and was elected one of three
vice presidents of Interpol in October 1969.
From 1958 to 1961, he served as Assistant to Treasury I'nder Secre-
tary Fred C. Scribner, Jr. Early in his law career, Mr. Rossides served
as a criminal law investigator in the rackets bureau on the staff of Xew
York County District Attorney Frank S. Hogan. For 2 years, he was
an assistant attorney general for the State of XeAv York, assigned to
the bureau of securities to investigate and prosecute stock frauds. A
former legal officer for the Air Materiel Command, Mr. Rossides holds
the reserve rank of Air Force captain.
A native of New York, Mr. Rossides received his A.B. degree from
Columbia College and his law degree from Columbia Law School.
61
Mr. Rossides is a vice president of the New York Metropolitan
Chapter of the National Football Foundation and Hall of Fame and
a director of the Touchdown Club of New York.
Mr. Rossides, it is indeed a pleasure to have you with us today. Al-
though your responsibilities are widespread, I understand that you
are going to limit your testimony today to the role of the Bureau of
Customs in controlling the illicit flow of heroin into the United States
and your support for this committee's proposal for an international
ban on opium cultivation.
Mr. Perito, will you inquire ?
Mr. Perito. Secretary Rossides, I understand you have a prepared
statement ?
STATEMENT OF EUGENE T. KOSSIDES, ASSISTANT SECRETARY OF
THE TREASURY, ENFORCEMENT AND OPERATIONS
Mr. Rossides. Yes ; I do.
Mr. Perito. Would you care to present that to the committee ?
Mr. Rossides. Mr. Chairman, members of the committee, it is a great
pleasure to appear again before this committee.
I think this committee has done some of the most significant work
that has been done in Congress in this area of narcotics — in the total
area of the narcotics problem.
I am pleased to be here today. I will summarize my statement and
read the key paragraph regarding the committee's inquiry.
Mr. Chairman and members of the committee, I am pleased to be
here at the request of the committee to give my views on a narrow but
significant question ; namely, what would be the enforcement effect if
there were an adequate supply of synthetic substitutes for opium and
substances derived from opium. Put another way, would it be helpful
in preventing the illegal growth and diversion of opium and the prod-
ucts of heroin and its smuggling into the United States. As back-
ground, let me say that there are at least five critical points in the ille-
gal narcotics traffic:
( 1 ) The growth of opium poppies ;
(2) Illegal diversion of opium;
(3) Illegal production of morphine and heroin ;
(4) Smuggling into the United States ; and
(5) Distribution within the United States.
I have testified before this committee regarding the President's six-
point action program. I think the President has by his personal inter-
vention and initiatives elevated the drug problem to a foreign policy
level. His White House conferences and other efforts devoted to this
problem have alerted not just the international community but the
national community as well. His efforts have stimulated debate, re-
search, education, and enforcement and have recognized the role of the
States and the role of the private community in dealing with the nar-
cotics problem. The private community under discussion here today,
and the medical profession particularly, have an enormous role to play
in this whole problem.
This doesn't mean more should not be done. But I do feel, and it is
my own personal judgment, that the President's action program has
alerted the international community to the global problem of drug
62
abuse and has brought about the action needed to combat it; and on
the national scene, has arrested our incredible downward slide into
drug abuse.
As I have testified before, however, let there be no false optimism.
This simply means we have stopped the downward trend, turned it
around, and have a long way to go to come back to the level at which
we would like to be.
I am confident we Avill meet that challenge, because it has become a
national bipartisan effort. The Congress has an essential role as does
the executive in this entire area. The private community has a role.
The States have the central role in law enforcement, in the distribu-
tion of needed information, in education, and indeed they might do
more in research.
With this background, Mr. Chairman and members of the commit-
tee, I would answer the committee's inquiry by stating that in enforce-
ment terms the ban on opium production as a legal item would be a
definite plus. When there is no legal growth of poppies permitted, the
enforcement officials will clearly have a much easier time in locating
illegal acreage.
Secondly, when there is no legal acreage, the grower does not have
a legal supply of opium from which to withhold and divert to the
illegal market. It is as simple as that, Mr. Chairman.
It would be a definite plus, a definite step forward.
Thank you.
Chairman Pepper. Mr. Perito, will you inquire ?
Mr. Perito. Secretary Rossides, in 1969 the General Assembly of
Interpol took a position in reference to this. What was your position
at that time representing the U.S. Government ?
i\Ir. Rossides. We were for a complete ban on legal production of
opium worldwide.
Mr. Perito. Is that still the position of the U.S. Government ?
Mr. Rossides. Let me qualify that to this extent : Yes ; from the en-
forcement point of view we were stating that obviously and clearly it
would be of substantial help to the enforcement community — the var-
ious police forces, the various customs forces throughout the world —
if no legal production of opium poppy was allowed. That is still the
position of the Government.
That is not to say, though, that there may not be other factors in-
volved in the timing and phasing of this proposal. This is the push
that we would want. There would be no reason not to still have that
position.
Mr. Perito. There seems to me to be some reluctance expressed inso-
far as the codeine aspect of the ban was concerned. Do you have at
your disposal any more additional facts medically which would dis-
abuse some of the people who felt that we could not move on it insofar
as the synthetics for codeine were concerned ?
Mr. Rossides. Well, it would be the testimony— and this has to be
up to the medical profession— it Avould be the testimony that this
committee has heard today. I want to be very clear in the fact that as
a lawyer and as a person with responsibilities of enforcement at the
Department of the Treasury, and within the administration's enforce-
ment community, we do not try to intrude \ipon the medical judg-
ment. I recall, while working on the task force of Operation Inter-
63
cept, thereafter called Operation Cooperation, we pinned down
the doctors and said all right, what is the harm? Obviously, harm
you compare with the harm regarding heroin, because an estimated
15 percent of heroin is grown illegally and produced— from the
poppies — in Mexico and converted to morphine and heroin and smug-
gled in. But the other operation of Intercept was regarding mari-
huana.
What is the medical testimony? The medical evidence? We cross-
examined them and pushed them as this committee is pushing, and
rightly so, and they came back with the comment that there is no
known good for marihuana, it can lead to serious mental health prob-
lems, and taken in conjunction with other drugs it can have a more
serious effect. So we had to base it on the medical evidence and went
accordingly. Research since then has tended to confirm the problem
of marihuana.
Getting back to the specific point, that has to be up to the doctors,
but I concur, in listening to the testimony and the chairman's ques-
tions and Mr. Steiger's questions,; that the medical profession has
clearly ^ot to move ahead and rapidly. There is no simple answer to
the heroin problem. It requires a multidimensional approach.
I think the President has recognized this from the outset. This
committee has, and it is moving ahead on many fronts in education
and enforcement, for example. If I had a dollar to spend— well, I
would have spent, before these recent hearings, 90 percent on educa-
tion, maybe a little less on education, a little more on research, but
enforcement is just one of the elements in the effort.
I am convinced that the youth have acquired great concern about
heroin and some of the other dangerous drugs. They are not nearly
as convinced about marihuana yet, but every little bit helps and
every little bit of pressure helps, and particularly from the Congress.
Chairman Pepper. Mr. Secretarv, you heard the testimony of Dr.
Eddy, and I believe Dr. Brill. Both said that heroin addiction in this
country is growing. We have had testimony from the Bureau of
Customs and the Bureau of Narcotics and Dangerous Drugs that with
all of the splendid efforts they are putting forth and the millions of
dollars of money that Congress has made available to you, the
hundreds of new agents that you have been able to put on the job, yet
the problem is so colossal that you are able to seize only about 20
percent of the heroin coming into this country.
Now, here at home we have thousands of dedicated law enforce-
ment officers trying to stop the distribution of heroin in this country.
There is no foreseeable date, it seems to me, when by law enforcement
alone we are going to be able to stop heroin from getting into the
hands and the veins of the addicts of this country.
Do you generally agree to that ?
Mr. RossmES. The last statement I agree to — the last part of your
statement, Mr. Chairman — that law enforcement alone cannot do the
job. That is an absolute principle as far as I am concerned. I cannot
agree with certain of the other comments regarding statistics. No one
fully knows. Statistics in this crime area are not quite that reliable
because we don't have a scientific way of gathering them.
The heroin area and crime is one of the most unusual, because you
do not have a victim in the criminal sense as you do when there is a
64
bank robbery or an assault. You do not have the heroin addict coming
forward and complaining. He is trying to find where he can get
some more heroin.
I do feel the total effort which has been made in the last 2 years
has stemmed the tide. You can feel it when you are talking to some
of the college students and others. That doesn't mean we are still not
in a crisis situation.
Chairman Pepper. You mean, sir; we are not in a crisis situation
with respect to heroin use in this country ?
Mr. RossiDEs. I said that we are. We have done an enormous amount,
in my judgment, in the combined Federal and State establishment in
the last 2 years, and we have arrested a downward slide, in my own
personal judgment. I get this from many different people — from en-
forcement people, from students, and others.
But that doesn't mean we are not still in a crisis. We are; obviously
we are. But it took 10 years to get to this stage and the trip back may
take a long time.
Chairman Pepper. What we are trying to do is supplement the
splendid effort you law enforcement people are making by seeing if
it wouldn't be possible to stop the growing of opium. But you have
to stop the legitimate demand. In order to do that you have to have
effective substitutes,
Mr. RossiDES. From the enforcement point of view, this is essential.
Chairman Pepper. That is why I feel, and I hope this belief is
shared by the committee, that more money spent in research to find
these synthetic substitutes, and more money spent in trying to find
antagonistic drugs so that the pusher's market would be diminished,
would help law enforcement in the country.
Mr. RossiDES. No question whatsoever, Mr. Chairman.
I used to stress that out of the dollar I would want most of it going
for education. I have changed in the last year to now add the need
for research. I do want to point out the President has substantially
increased funds for research and education. But that doesn't mean more
may not be needed. That is up to the Congress and the executive to
work out.
Chairman Pepper. Mr. Blommer ?
Mr. Blommer. No ouestions, Mr. Chairman.
Chairman Pepper. Mr. Mann ?
Mr. Mann. Recognizing that the abolition of legal growing of the
opium poppy would necessarily be pursuant to an international agree-
ment, almost worldwide, what good would it do for the United States,
through the Congress, to take unilateral action to abolish the importa-
tion of opium ? What good would it then do you in trying to negotiate
an international agreement with other countries?
Mr. RossiDES. I would say, without commenting fully on the pre-
mise— because it can be done unilaterally by each country
Mr. Mann. Yes.
Mr. RossiDES. (continuing). The will of the Congress spoken after
hearings, after testimony, after review and analysis — that this is the
judgement of the Congress of the United States, would have, in my
judgment, a very salutary effect throughout the world, throughout the
nations that are members of the TTnited Nations, and it would be a
plus.
65
Mr. Manist. But without other sanctions we have merely cut off our
trading point as far as the control of the market is concerned if you
say, "Well, we don't need your poppy any more." Why should this
cause them to stop growing it ?
Mr. RossiDES. When you say sanctions, you are talking about nego-
tiation and added factors are involved ; this is another step in the ne-
gotiation process. I think, for the first time, the United Nations has
been galvanized to do something following the President's speech last
October, and our own contribution of $1 million out of a $2 million
pledge. I think other nations are coming forward. A conference on
the revisions of the 1961 Single Convention on the Control of Drugs
is planned, hopefully, for early next year with proposals for construc-
tive amendments bemg considered.
Now, all of this is helpful. I happen to feel that the publicity value
of public opinion, hearings, and of statements and of positions are
helpful. It is no panacea, but it is a step and it is a helpful step.
Mr. Mann. Thank you
No further questions.
Chairman Pepper. Mr. Wiggins ?
Mr. Wiggins. Yes, sir ; I would like to continue with the questions
started by my colleague, Mr. Mann.
The United States constitutes a major portion of the world demand
for the lawful manufacture of morphine, and accordingly, if we were
to stop our importation of it, it would have more than publicity impact
on those supplying countries ; wouldn't it ?
Mr. RossiDES. Yes, Mr. Wiggins ; I should have added that. It cer-
tainly would. The countries that are selling to us would not have the
market. So that they would then be possibly more inclined to look for
other crops.
Mr. Wiggins. We have observed in Turkey, for example, the elimi-
nation of provinces where the growing of poppy was permitted law-
fully. I think we are down to about six or seven now, as against a high
of more than 20 not too long ago.
Can you comment on the enforcement within the nation of Turkey
as to the illicit growing of poppy in those provinces where it has been
discontinued ?
Mr. RossiDES. Yes. Our reports are that it has been quite successful
in the provinces where it has been discontinued. It was up to 21 prov-
inces and is now down to seven. Reports that we receive are that in
those provinces in which growth has been lawfully discontinued, en-
forcement has been quite successful.
The. main growing areas are still in the seven provinces. But at least
the enforcement effort has been successful in the provinces.
I might conimend the Turkish Government for these efforts, and
they are devoting more manpower to this problem, and I might quote
the new Turkish Government's public comment recently made by the
Prime Minister, Mr. Erim :
Our Government believes that opium smuggling, which has become a terrible
disaster for the youth of the vporld, is hurting above all our humanistic senti-
ments : therefore due importance will be attached to this problem. Opium pro-
ducers will be provided with a better way to make a living.
That is a step forward. Everybody, including the United States,
has to do more, as this committee is pointing out.
66
Mr. Wiggins. Would the stopping of the importation of lawful
morphine into the United States, in your opinion, tend to stimulate
the Government of Turkey to accelerate its program of cutting down
these provinces where the opium poppy is lawfully grown ?
Mr. RossiDEs. I would have to pass on that. Congressman. I would
have to check with the State Department and get back to the commit-
tee. I just don't know. I am not m a position to know. (See exhibit 6.)
Mr. Wiggins. Well, let us suppose that there is no more lawful opium
poppy grown in Turkey. What impact would that have on organized
criminal activities in the United States ?
Mr. RossiDEs. Well, the impact would be significant, in my judg-
ment, and they would look to other sources, Southeast Asia, other
possibilities in the Near and Middle East. But clearly you have made
a major advance because you have disrupted a known pattern of
trade, of illegal activity.
One of the things that we are doing, we are making strenuous
efforts to analyze, review and do something about the situation in
Southeast Asia, even though the percentage, we estimate that the per-
centage of opium coming from there is quite small. There is an enor-
mous amount grown in Burma and Thailand, and most of it is used
in the area, but we are trying now for the first time to be ahead of
the game instead of our just reacting. In fact, the organized criminals
are not going to stop when they see a profit. We have to have a total
fight. It has to include enforcement, education, research; every possi-
ble way.
As I say, I think we have done a good job. I really do. But more
["» Q o "t c\ hf* ri on (^
Mr. Wiggins. It is generally known that the largest opium pro-
ducers in the world are India and the Soviet Union with Turkey
third. It is usually stated, however, that there is minimal diversion
from India and from the Soviet Union.
Do you think if we were to ban the lawful importation of morphine
that we run the risk of development of an illicit market in these two
areas ?
Mr. RossiDES. I do not.
Mr. Wiggins. Well, now let's turn to Mexico. Usually the figure is
5 to 15 percent, something of that range, is attributed to Mexico as a
source of heroin. It is not grown lawfully in Mexico at all. Mexico is
not one of the — what is it, seven — countries that may lawfully grow
poppies ?
Mr. RossiDES. Correct.
Mr. Wiggins. What impact do you think it would have, if any, in
Mexico ?
Mr. RossiDES. None — no real impact in Mexico — because it is already
illegal there as is the growing of hemp. The problem in IVIexico is that
the growth is in the mountains — very difficult areas to detect — and in-
accessible areas where it is quite difficult to prevent the growth. The
Mexican Government, however, has made many strenuous efforts and
has had some success. But a great deal more needs to be done and is
being done.
We have just concluded the fourth or fifth meeting with our col-
leagues from Mexico, and I commend the efforfs of the Mexican Gov-
ernment and the public condemnation by the Mexican Government of
67
the traffickin<2: in heroin and marihuana. They are doinji: better. Again,
it is an intei-national problem. We cannot be satisfied. We cannot say
that anyone is doing adequately, except maybe Japan, which took care
of the lieroin problem by tlie strictest kind of enforcement, moral and
cultural, and public effort. Every one of the policemen in Tokyo is a
narcotics expert, and with their tough customs efforts, Japan has done
the job. What I am saying is that I don't want to point a finger at any
one country, because we are all guilty. But no matter how much more
we are doing, we are not nearly at the point Avhere we can even think
of seeing the end of the road, and we are just going to have to redouble
our efforts.
Mr. WiGGixs. I would like to conclude, Mr. Chairman, with just a
brief comment.
I don't think any of us have ever felt that the prohibition against
the importation of morphine in this country would be in and of itself
a panacea. But there are many incidental fallout benefits for doing so.
One of them is the disruption of the organized criminal infrastructure
involved in the importation of heroin in this country. It took many,
many years to develop the chain from Turkey into the Port of New
York. That in and of itself is a substantial achievement.
Chairman Pepper. If you Avill excuse me just a minute, while you
are on that subject, there are two things I want to ask the Secretary.
One is, can you tell us what is the extent of the involvement as you
have found it of what we call organized crime in the importation of
heroin into the United States ? How deeply is organized crime involved
in the importation of heroin ?
Mr. RossroES. Mr. Chairman, practically every bit of heroin brought
into the United States is brought into the United States by organized
crime. The heroin traffic is a highly organized criminal conspiracy.
Now, what is the definition of organized crime ? That is where peo-
ple may disagree. My first law enforcement came while working under
Mr. Hogan, probably the greatest district attorney that the Nation has
had. He would never allow his assistants to use the word "Mafia," be-
cause it gave the false impression that the Mafia was the only part of
organized crime.
Organized crime is a criminal conspiracy of a continuing nature, I
would say this, that there have been more members of certain of the
IVIafia families involved before — probably less now — but the groups
that are involved now in the heroin traffic are of all ethnic groups, all
religious groups, and all racial groups. The key groups outside the
country are the French Corsicans. Certain of the families — the Mafia
families — are still involved at the importation level. They take their
cut on getting it in. They do not have, as they do in their other enter-
prises, the distribution system up and down the line. In gambling, for
instance, they will take care of someone that is pulled in, provide him
with counsel and take care of the family. That is not necessarily the
problem here.
You have a different distribution system. It is in the ghetto. The
blacks are profiting from it, the Puerto Ricans, ethnic, Irish, Italian,
Greek, every group.
My only point is that organized crime is involved, but we cloud the
issue when we try to equate organized crime with the Mafia.
My point is that organized crime is far broader.
68
Chairman Pepper. Can you give us an estimate as to the number of
people who make up that organized crime group responsible for the
importation of heroin into this country ?
Mr. EossroES. I would not have that at my fingertips, nor would we
have a firm figure of the number of persons involved.
Let me review that with my staff, Mr. Chairman, and try to supply
the committee with an estimate of the number of persons that you
are talking about.
Chairman Pepper. We would appreciate it if you would get us
that information.
The reason I ask particularly is because Mr. William Tendy, for-
merly of the U.S. attorney's office in Xew York, told our committee
that, as I recall it, 10 to 15 organized crime figures were responsible
for most of the heroin smuggled into the United States.
Mr. Rossides. I believe they meant syndicates. I would agree with
that figure. I would agree you are talking about probably up to 15
at a maximum of significant criminal conspiracies, of organized crime,
of all types, natures, and backgrounds.
Chairman Pepper. One other question. Do you have any estimate or
could you get us one as to how much all the growers of the opium
poppy in the world — I mean, growing it in any appreciable quantity —
are making from that production.
Mr. Rossides. I don't have it now. I will try and supply it, Mr.
Chairman.
(The information requested was not available at time of printing.)
Chairman Pepper. If we and others working with us were to give
every opium poppy grower in the world the same amount of income
that he is now deriving from the growth of the opium poppy, how much
would it cost the participating nations in such a program ?
Mr. Rossides. I will try and find out, Mr. Chairman, but I would
like to go on record as strongly opposed to any concept of preemptive
buying. It would simply stimulate production and it would take away
the responsiblity of each nation to handle the problem as part oP the
international community. I just want to make sure of that.
Chairman Pepper. I don't think anybody on this committee would
follow that will-o-the-wisp of wanting to start the United States in
buying all the opium production in the world. I am not talking about
that.
I am talking about if you got them to grow soybeans, wheat, or
something else, if they had the guarantee of the same income from the
growing of legitimate products, how much would the financial burden
be upon the nations including the nation where the growing occurs ?
Mr. Rossides. I would answer that. I will find out the figure, if it
is available. There would be no financial burden because what you
would be doing is substituting a crop. So really you would be making
an investment, a capital investment for the group.
Chairman Pepper. Yes.
(The information requested was not available at time of printing.)
Chairman Pepper. Mr. Steiger?
Mr. Steiger?
Mr. Steiger. I yield to Mr. Wiggins.
Mr. Wiggins. I have just one more question, Mr. Rossides. There is
the possibility that if effective synthetics are mandatory in this coun-
try that they in turn would be widely abused and diverted. Let's sup-
pose that happens. Has your experience indicated that the organized
69
criminal groups within this country have been in the business of di-
verting amphetamines, for example?
Mr. RossiDES. Oh, yes.
Mr. Wiggins. Do we change the nature of the enemy in any way ?
I would like you to comment on the ease or difficulty of controlling
diversion from lawful manufacturers in the United States as dis-
tinguished from lawful producers of natural poppy elsewhere.
Mr. RossiDES. I would refer the diversion problem to the Bureau of
Narcotics and Dangerous Drugs, which has the responsibility for pre-
venting illegal distribution of dangerous drugs. (See testimony of
John Ingersoll, Director, BNDD, on Jmie 2, 1971.)
There is no question that there are efforts by organized crime to
steal the pills, and one of the reasons for the Drug Abuse Act of 1970
was that before there were not the proper controls on the manufacture
and distribution in following production down the line so that you had
a controlled system. It was a simple thing to sell a million pills to a
post office box number in Tijuana and then smuggle them back into
the United States. It was really very simple.
My own feeling is if we are able to be more successful in stopping
heroin from coming in, organized crime would naturally try to divert
to dealing in pills. But again it is a manageable problem. It is some-
thing we are trying to do in the area of cargo theft. It is not that
difficult to develop a system at the ports of entry.
Mr. Wiggins. Is it more manageable than the difficulty you are
experiencing in preventing the importation of heroin ?
Mr. RossiDES. I haven't looked at it enough. In my judgment it
would be. But you have got to remember that a lot of pills are pro-
duced. I hadn't thought of the comparison of the problem, but it is
not — let me put it a different way. I would rather face the problem
of increased effort to divert the pills that would come from a sucess-
ful effort to prevent the heroin being smuggled into the United States,
I think that is far more manageable and we can move in that area by
careful controls by the manufacturers themselves in many ways.
Chairman Pepper. Mr. Steiger ?
Mr. Steiger. Yes, Mr. Chairman.
Mr. Secretary, you have been very candid, and I appreciate it. In
your relations with Interpol and with other enforcement people from
these other countries, as a cold, practical matter if there were to be —
somehow we could achieve international agreement that would ban
the poppy, how rigid do you think the internal enforcement would be,
say, in Turkey, and I might add that the seven privinces which now
produce, which Turkey has reduced the legality of the poppy, it is
my understanding and you indicated the same thing, that still had
about 90 percent of the existing poppy production. So it really sounds
good to go from 20 to seven, but we haven't reduced the production
by 30 percent.
In those areas of five or 10 poppy producers, as a practical, political
matter, how tough would their enforcement be ?
Mr. RossiDES. Well, even on the question — if it were made illegal ?
Mr. Steiger. Yes ; how tough would the Turkish police be on their
people ?
Mr. RossiDES. I think we have to commend the new Turkish Gov-
ernment for its forthright statement. The first time that a public
statement has been made, and I do commend them for that.
70
The problem then would be the will of the Government of Tur-
key, and I am convinced that they would be able to handle it.
Mr, Steiger. Well, of course, you know, we talk about preempted
buying. One area this country has expertise in is in paying people not
to grow things. We have a great, long history of that. I am con-
vinced, as apparently the chairman is, that we could produce a viable
plan in which we could augment the poppy growers' income to the
point where he wouldn't have to grow poppies at a fraction
Mr. KossiDES. Crop substitution is the answer. I don't consider that
to be preemptive buying.
Mr. Steiger. But we are dealing with a very real problem as we un-
derstand it, the guy wants to grow poppies, he has grown poppies
forever, and his folks before him, and that is something a little tough
for us to understand. I am asking you how valid is this desire to grow
poppies on the part of the seven Turkish provinces and how emo-
tional an issue is it within those provinces.
Mr. RossiDES. I would pass and let the State Department come up
with the analysis of the psychology of the Turkish farmer.
(The analysis referred to above follows :)
[Exhibit No. 6]
Department of State.
Washington, B.C., July 2, 1971.
Hon. Claude Peppeb,
Chairman, Select Committee on Crime,
House of Representatives.
Dexar Mr. Chairman : I refer to your letter of May 27, requesting informa-
tion about Turkey and opium.
As you may know, on June 30 that country's government showed a strong
sense of international responsibility in taking the diflBcult decision to ban further
opium cultivation to be effective approximately 1 year from now. Under Turkish
law farmers must be given 1 year's notice before opium poppy planting can
be prohibited in areas where cultivation has been permitted. Nonetheless, in
his statement explaining the opium ban, the Prime Minister has said that he
wU take every measure to eliminate smuggling and he will undertake a program
to induce farmers, who are legally permitted to plant in the fall of 1971. to
voluntarily abstain from planting. Beginning in the fall of 1972 opium poppy
will be banned throughout Turkey.
We have also been encouraged by other recent evidence of the Turkish
Government's intention to prevent Turkish opium from entering illicit channels.
On June 18, a strict opium licensing and control bill was reported out of com-
mittee; it was passed by the National Assembly of the Parliament on June 21.
The bill is now under consideration in the Turkish Senate. We anticipate that
the legislation will pass before the end of the session, now scheduled for July 30.
In addition, measures which the Turkish Government has taken to insure
collection of the total production from this year's harvest will result, we
believe, in a much improved performance. Among these new measures are :
training of additional agents ; an increase in the purchase price of the opiiuu
gum ; provision for advance cash payments to the farmers ; collection of the
gum at the farm immediately after harvest; and improved coordination of
tlie elements involved in the collection. Moreover, enforcement efforts arc also
showing improved results.
The amount of opiates seized during tlie first 4 montlis of 1971 (equivalent
to 574 pounds of pure heroin, which would have been worth about $00 million
in the IJ.S. market) is more than double that seized during the entire year of
1970. It is also more than the total amount seized by U.S. enforcement agencies
within the United States and at our borders during these same 4 months.
With regard to substitute crops, none have been identified tliat can replace
opmm pQppy in all the provinces where it is grown. Tlie Turkish Ministry of
Agriculture is conducting research into this problem witli assistance provided
under an AID loan. However, agricultural research by its very nature is a
71
slow prcx?ess. Some possible alternative crops have been identified and further
investigations are being conducted. The Turkish Agricultural Extension Service
is working with farmers in those areas where production has been banned teach-
ing the farmers ways of increasing their yields of such crops as sunflower seeds,
vetch, various fruits and vegetables and new varieties of wheat.
Prime Minister Erim recognized that the cost and diflBculties of controlling
opium cultivation were greater than the economic importance it has for the
Anatolian farmer, great as that is. His courageous and statemanlike action
will greatly help to reduce and to disrupt the existing pattern of illicit inter-
national traflBcking, and it will provide an example for other countries. I en-
close a translaton of Prime Minister Erim's statement explaining his Govern-
ment's reasons for terminating opium production and a copy of the Turkish
Government's decree.
I hope this information will be helpful. Please do not hesitate to call on us
when ever you feel we might be of assistance.
Sincerely yours,
David M. Abshire,
Assistant Secretary for
Congressional Relations.
(Enclosure 1)
Statement of Prime Minister Erim. — June 30, 1971
In recent years the abuse of narcotics in the world has assumed a very seri-
ous and dangerous condition. This situation has been described by the United
Nations as almost an "exp'osion." Several times more production is made of
narcotic drugs than is needed for legitimate and medical needs. For this reason,
the lives of millions of persons who use narcotics end. In some countries, this
deadly disaster is spreading rapidly, particularly among youth. It is noted that
even 12-year-old children are drawn to drugs. Countries which never used drugs
10 years ago are now its victim. The tragedy has spread even as far as the
African countries. Furthermore, addiction has begun to threaten all the mem-
bers of the community. Youth in particular must be protected from this addiction
as a great duty for the sake of mankind.
We have seen what a great danger the world is facing. We touched on this in
the Govenment program which our Parliament passed : "And indicated that
the problem of opium smuggling, which has become a destructive tragedy for
all young people in the world, will be seriously undertaken by the Government,
which believes before all else that this harms sentiments of humane considera-
tion. Opium growers will be given support by showing them a better field for
earning their living."
Indeed. Turkey has not remained a stranger to the development of the prob-
lem of narcotic drugs, to the international agreements made in this matter since
the beginning of the 20th century, and to the work of the United Nations. On
the contrary, she has joined in the agreements and has taken decisions to end
this disaster.
Turkey has participated in all the international agreements made on the sub-
ject of narcotics beginning with the Hague Agreement of 1912 ; those concluded
agreements in 1925, 1931, 1936, 1946. 1948, 1953 and 1961.
An important provision of the 1961 Narcotics Single Convention, signed by 78
nations, is the article which binds the production of opium to the permission
of the Government.
Governments coming before us have fulfilled their commitments to interna-
tional agreements and furnished all types of statistical information to the
authorized organs of the U.N. However, the need law establishing a licensing sys-
tem for planting in Turkey, which is the key point of this agreement, for some
reason was not passed until this year. Our state was continuously asked by inter-
nationally authorized organs to fulfill this commitment. This shortcoming was
criticized in the parliaments of many countries and by their public opinion. The
U.N. Secretary General in the report he presented on this subject in 1970, based
on these criticisms, said that an extensive amount of smuggling was being made
from Turkey.
After this, matters took a rapid turn. In the summer of last year the matter
was first taken up at the U.N. Economic and Social Committee. The Committee
on Narcotic Drugs was called to an extraordinary meeting. There, the critical
situation in the world was taken up and it was decided to start a struggle by
72
taking exceptional measures in the three stages of the problem : Production,
supply and demand, and smuggling. It was stipulated that a fund was to be
established to assure the financial means for this purpose. The subject was agreed
upon at the General Council meeting of the U.N. too.
In a law passed by the Turkish Grand National Assembly in 1966, Turkey
ratified the international agreement signed in 1961. In this way, international
commitments became a part of our national law. Accordingly, "In the event
one of the parties fails to implement the provisions of the agreement and through
this, the object of the agreement is seriously harmed, the control body will ask
that the situatiotrbe corrected and can go so far as to set up an embargo against
this country.
Smuggling made from our country in recent years has become very distressing
for us. Governments, whicli were unable to prevent smuggling, decreased the
number of provinces where poppies were planted from 1960 on and gradually
moved to the planting of opium from regions close to the border to the center
of Anatolia. Now planting has been decreased to four provinces. In this way it was
hoped to prevent smuggling.
However, imfortunately, this system did not give results. During 1970 many
things developed in favor of the smugglers. Although the soil products oflSce
obtained 116 tons of opium from the poppies planted in 11 provinces in 1969,
in 1970 the opium which reached the oflSce from nine pro\ances was only 60 tons.
The whole world is asking where the difference is going. The contraband opium
seized by our security forces, which we learn about in radio and newspaper
reports, shows everyone the extent of the problem.
It is certain that a smugglers' gang organized on an international scale, consti-
tutes a political and economic problem for Turkey. They will not be i^ermitted to
play around with the prestige of our country any further.
This horrible network of smugglers fools our villagers either with the wish
to make extra money or by force and it tries to use them for their own ends.
Of the tremendous sums which revolve around these transactions, the poor
hard-working Turkish villager actually does not get much. The smugglers pay
400 or 500 liras for an illegal kilo of opium to the villagers whom they force to
break the law. By the time this opium reaches Turkey's borders, the smugglers
have made a profit many times multiplied. After it leaves our country and
throughout its route, the value of the drug becomes augmented more and more ;
in the end it reaches an unbelievable price. International smugglers are earning
millions from the raw opium produced by the villagers, but the Turkish farmer
gets only a paltry sum. In countries where health is endangered through this
opium, because smuggling cannot be prevented in Turkey, anti-Turkish opinions
are created.
The Turkish villager also naturally feels bitter against this problem created
by the smugglers who make millions from the back of our farmers. All I'urkish
citizens also feel a moral pain that our country is blamed for smuggling which
is poisoning world youth.
The measures to be applied to control smuggling are extremely expensive. In
general, poppies are planted in one corner of the field. For this reason, it is
necessary to establish an organization which can control an area 10 times that
of a total poppy farming area of 13,000 donums which may actually be planted.
Vehicles, gasoline, personnel and their salaries must not be forgotten. Smugglers
on the other hand, it must be remembered, will resort to any means. Until now,
foreign assistance was obtained for control purposes; even an airplane was
obtained for our organization. But, unfortunately, the matter was imiK>ssible to
control by these means, in spite of all the efforts which were made. Our nation,
which is known for its honesty and integrity, is now under a grave accusation.
The time when we must end the placing of blame for deaths in other countries
on T'nri.-aT- is lori"' ovptIik^.
We cannot allow Turkey's supreme interests and the prestige of our nation
to be further shaken. Our government has decided to apply a clear and firm
solutioii. ii forbids completely the planting of poppies; they have already been
reduced to four provinces. The agreement ratified in 1966 also stipulates this
arrangement.
Poppies will not be planted in Turkey beginning next year. However, we have
given careful consideration to the fact that the farmers have until now obtained
a legitimate and additional source of income from the phinting of ix>ppies. For
this reason, in order that the poppy growers will not incur a loss in any way, the
necessary formula has been developed. This formula is: in order to make up
73
for the income farmers who are planting in provinces at present will lose, they
will be given compensation beginning from the coming year. This compensation
will work this way : the basis will be the value on the international market
of the whole produce, such as opium, seeds, stems, etc., that the planters will sell
to the soil products office this year.
Furthermore, in order to replace the income lost by farmers by other means,
and to provide them other means or earning a living, long-term investments will
be made in the region. Until these investments give fruit, villagers will continue
to be given comi>ensation. From among those who would normally plant this
year, those who voluntarily give up planting in the coming Autumn will be given
compensation on the same basis.
I am now addressing my villager citizens, in order that this plan may be
successful and that it will be possible to establish real values for future year
compensations and the criteria for investment, please turn over all your produce
to the Soil Products Office. You will receive the necessary assistance in this
respect We have also raised our purchasing price. The larger the amount turned
over to the office by all the poppy producers, the larger the compensation they
will receive in the coming years without planting. Bes(ide.s, by selling all his
produce to the TMO, the producer will prove he is not the tool of the smuggler,
that the Turkish farmer at no time had the object of poisoning the whole world,
nor that he encouraged this knowingly. Dear Farmer Citizens, you will be the
ones to save the prestige of our nation. The Government will also henceforth
give special importance to your problems. Our Government has taken precau-
tions in order that, in the end. not a siingle farmer family will incur a loss. Your
income will be met without allowing any room for doubts; at the same time,
it is planned to establish necessary installations to open new sources of income
in the region. I ask you to carry out this plan and to .sell all your opium products
for this year to the Office at the high price established last month, thereby you
will give this program a good start.
(Enclosure 2)
Turkish Opitjm Decree, June 30, 1971
On the basis of the letter of the Ministry of Agriculture dated June 26, 1971,
No. 02-16/1-01/342 ; per law 3491 as amended by law 7368, article 18 ; and per
article 22 of appendix agreement dated December 27, 1966, to law 812, the
Council of Ministers has decided on June 30, 1971 : Definitely to forbid the
planting and production of poppies within the borders of Turkey beginning
from the autimm of 1972. This Will be done by specifying the provinces shown
on the lists attached hereto.
1. To forbid poppy planting and opium producing in provinces where warning
is given as of the autumn of 1972 — Afyon, Burdur, Isparta, Kutahya.
2. To forbid popipy planting and opium producing in the provinces where a
warning has been g*iven from the autumn of 1971 — Denizli, Konya, Usak.
3. To give a suitable compensation as proposed by the Ministry of Agriculture
and by decision of the Council of Ministers to the planters in these seven prov-
inces where poppy planting and production have been forbidden. This Will be
on the basis of the opium they deliver this year to the Soil Products Office and
on the ba.sis of other poppy byproducts so that the farmers will not incur any
loss of income.
4. To grant to the planters in the areas indicated in paragraph 1, who volun-
tar'ily give up planting in the autumn of 1971, the right to benefit from the
compensation set forth in paragraph 3.
C. SUNAY,
President of the Republic.
Mr. RossiDES. But I only IPass in a sense. I don't want to duck any
question, because I keep coming back to what I think was a tremendous
statement by the new Government of Turkey, which I think they
should be commended for. The Prime Minister's statement, Mr. Erim's
statement, to the effect that the contraband trade in opium, which has
assumed the aspect of ovei- whelming blight for the youth of the whole
world, is offensive on humanitarian grounds. The Government will
60-206 O— 71— pt. 1 6
74
pay serious attention to this problem. Turkey's opium growers "will
be shown a way to earn a better living.
We should commend the Turkish Government for this statement.
I know what you are saying. The tradition of hundreds of years
and
Mr. SteiCxER. My only point in this whole line of questioning. Mr.
Secretary, and you obviously realize it, but I think it is important that
we understand it, as I think we do, is that it is obviously a positive
step, it is obviously appropriate, but we mustn't be deluded into think-
ing it is any kind of panacea and actually the difficulties that you are
now experiencing will not be alleviated completely. There will still be
attempts made by this organized crime organization if they have to go
somewhere else. It took them a long time to work up their Turkish-
American lines, but they now know how to do it and there are lots of
places they can go, as you indicated, and as Mr. Wiggins replied, there
is a question about Mexico.
I think it might be worthwhile if you could help the committee in
finding out what the Japanese customs did, for example, that enabled —
aside from the educational program they went through as described —
what actual
Mr. RossiDES. Correct. I will be happy to submit a statement that
the committee would hopefully consider whether it wanted to include
it as part of the record. I was not aware of the enormous success of the
Japanese until last year. It was a total effort by the Government and
was effective as a result of their cultural heritage, which provides
other avenues for relief of tensions. But their national police and their
customs police did a tremendous job, and they don't have a heroin
problem. In fact, they get upset when there is a seizure of marihuana,
as being a very dangerous thine, and thev are concerned about this
Nation's efforts to ease the penalties in marihuana.
We have a difficult problem. I think the easing of penalties was good
on the first offenders.
Chairman Pepper. Excuse me. You say you have that report?
Mr. RossroES. I will submit a statement regarding it.
Chairman Pepper. We will incorporate it with your testimony.
Mr. RossiDES. I will commend the Washinirton Post on this, because
it was their article last fall which was practically a full page article.
( The statement referred to above follows : )
Japanese Customs' Successful Curbing of Heroin Traffic
According to reports in the past few months, Japanese Customs have success-
fully curbed the importation of heroin into Japan. Much of this success was based
on tightened surveillance of incoming traffic — especially ships.
The customs officials were supported in their effort by strict enforcement of
narcotic laws by police who were well trained in narcotic enforcement, a hard
hitting press-TV campaign, and the cooperation of the Japanese people.
Chairman Pepper. Any other questions ?
Mr. Steiger. No.
Chairman Pkppfj?. Mr. Winn ?
Mr. Winn. Thank you, Mr. Chairman.
Mr. Secretary, two questions. Do you consider the college students
who bring heroin into the United States a part of organized crime ?
75
Mr. RossiDEs. I do not consider it a part of organized crime when a
college student goes overseas and purchases some heroin, or into Mexico
and brings it back and sells it to some of his fellow students. The
amount of this that goes on, in my judgment, is minimal, a very small
percentage. I don't even know if it is 1 percent. There are far more who
bring marihuana and hashish into the country, and they are quite
organized. In the New England area 600 pounds was seized. That
effort was highly organized and the marihuana and hashish were going
to be sold to fellow students.
Mr. Winn. My next question Avas what percentage and I think you
answered that. That may be 1 percent.
Mr. RossiDES. Yes ; a very small amount regarding heroin.
Mr. Winn. Do college students work with organized crime? They
may not be considered a part of it, but they are working with the
criminals to make
Mr. RossiDES. Sometimes, they are used as ducks or couriers. But do
not assume anyone who is bringing in heroin is an unsophisticated,
naive college student. I think very few are involved in heroin smug-
gling. Marihuana and hashish, moreso — and they are making a lot of
money on their fellow students.
Mr. Winn. Thank you.
Chairman Pepper. Mr. Keating ?
Mr. Keating. No questions.
Chairman Pepper. Any other questions ?
Mr. Mann ,• No ; thank you.
Chairman Pepper. Mi-. Secretary, we thank you very much for your
valuable contribution this morning.
We want to keep in touch with you and cooperate Avith you in any
way we can.
■ Mr. RossiDES. Thank you, Mr. Chairman.
Mr. Perito. Mr. Chairman, may the curriculum vitae of Secretary
Rossides be incorporated in the record.
Chairman Pepper. Without objection, it is so ordered.
(The curriculum vitae of Mr. Rossides follows:)
[Exhibit No. 7]
Curriculum Vitae of Eugene T. Rossides, Assistant Secretary of the
Trbiasury for Enforcement and Operations
As Assistant Secretary of the Treasury for Enforcement and Operations, Mr.
Rossides' responsibilities include direct supervision of the Bureau of Customs,
the U.S. Secret Service, the Bureau of the Mint, the Bureau of Engraving and
Printing, the Consolidated Federal Law Enforcement Training Center the Office
of Operations, the Office of Tariff and Trade Affairs, and the Office of Law
Enforcement.
Mr. Rossides serves as the principal law enforcement policy advisor to the
Secretary of the Treasury. His responsibilities include providing policy guid-
ance for all Treasury law^ enforcement activities, including those of the Internal
Revenue Service.
Mr. Rossides is responsible for the administration of the antidumping and
countervailing duty laws.
Mr^ Rossides serves as U.S. Repre.sentative to Interpol (International Crimi-
nal Police Organization) and was elected as one of three vice presidents of
Interpol in October 1969.
^ ^^,>'- I^ossides, 43, had been a partner in the law firm of Royalls, Koegel, Rogers
& ^\ells (now Royall, Koegel & Wells) of New York City and Washington, D.C.
76
From 1958 to 1961, he served as Assistant to Treasury Under Secretary Fred C.
Scribner, Jr., before returning to the practice of law in New York City.
Early in his law career, Mr. Rossides served as a criminal law investigator in
the rackets bureau on the staff of New York County District Attorney Frank S.
Hogan.
For 2 years, Mr. Rossides was an assistant attorney general for the State of
New York, having been appointed by the then Attorney General Jacob K. Javits,
who assigned him to the bureau of securities to investigate and prosecute stock
frauds.
A former legal officer for the Air Materiel Command, U.S. Air Force, Mr. Ros-
sides holds the reserve rank of Air Force captain.
A native of New York, Mr. Rossides graduated from Erasmus Hall High School,
Brooklyn, and received hi'* A.B. decree from Columbia College in 1949. He re-
ceived his LL.B. degree from Columbia Law School in 1952. He is a member of
the Columbia Co lere Coun'^-il, n director of the Co umt>ia College Alumni Associ-
ation, and a member of the Columbia College Varsity "C" football club.
A member of the Greek Orthodox Church, he serves on the church's highest rul-
ing body, the Archdiocesan Council of the Greek Orthodox Church of North and
South America, both as treasurer and member of the coimcil's policy committee.
He is a vice president of the New York Metropolitan Chapter of the National
Football Foundation and Hall of Fame, and a director of the Touchdown Club
of New York.
He is a member of the American, Federal, and New York State bar associations,
and New York State District Attorneys Association, the American Political Sci-
ence Association, and the Academy of Political Science.
He is married to the former Aphrouite Macotsin of Washington, D.C. They
have three children Michael Telemachus. 8; Alexander Demetrius, 6; and Eleni
Ariadne, 3. Mr. Ros.sides has another daughter. Gale Daphne, by a previous
marriage.
Chairman Pepper. I would just like to announce before we break
up that these are the witnesses for tomorrow: the MITRE Corp.
representatives: Mr. David Jaffe, department staff; William E.
Holden, department head, resources planning department; Dr. Walter
F. Yondorf , associate technical director.
Then next is Dr. Frances R. Gearing, associate professor, Division of
Epidemiology, Columbia University School of Public Health and Ad-
ministrative Medicine.
Next is Dr. Jerome H. Jaffe, director, Illinois Drug Abuse Program ;
Wayne Kerstetter, University of Chicago Law School Research Center.
Next is Dr. Robert L. DuPont, director, Narcotics Treatment Ad-
ministration for the District of Columbia.
If there is nothing further, we will recess until 10 o'clock tomorrow
morning in this room.
Thank you.
(Whereupon, at 1 :1T p.m., the committee adjourned, to reconvene
on Tuesday, April 27, 1971, at 10 a.m.)
NARCOTICS RESEARCH, REHABILITATION,
AND TREATMENT
TUESDAY, APRIL 27, 1971
House or Representatives,
Select Committee on Crime,
Washington^ D.C.
The committee met, pursuant to notice, at 10 :05 a.m., in room 2359,
Rayburn House Office Building, Hon. Claude Pepper (chairman)
presiding.
Present: Representatives Pepper, Eangel, Mann, Brasco, Waldie,
Wiggins, Steiger, Winn, and Keating.
Also pr(;sent : Paul Perito, chief counsel ; and Michael W. Blommer,
associate chief counsel.
Chairman Pepper. The committee will come to order, please. We are
very pleased to see in the audience this morning a large niunber of
young ladies and gentlemen. We hope you will find something of
interest in the hearings we are holding today.
Yesterday, the Crime Committee heard testimony from three
uniquely qualified and eminently distinguished scientists and medical
researchers. Doctors Seevers, Eddy, and Brill all agreed that we now
have sufficient synthetic substitutes for morphine and codeine ca-
pable of satisfying the painkilling and cough suppressing needs of our
Nation.
For those who were not here yesterday, let me say that the Select
Committee on Crime is trying to find some way to diminish the menace
of heroin addiction in this country. We have already heard evidence to
show that in spite of all the efforts of the Federal Government and
all those agencies cooperating with the Federal Government, we seize
only about 20 percent of the heroin that is smuggled into this country.
The other 80 percent comes into this country to be the largest single
cause of death of young adults in some of our largest cities.
Last year, in Dade County, Fla., my congressional district, we had
41 deaths from heroin. We have already had nine this year. The num-
ber is in the several hundreds in the United States each year.
So in view of the difficulty of stopping heroin from coming in, we
are looking at some options, or some alternatives, as it were. If we
could just stop the worldwide cultivation of the opium poppy alto-
gether, that would, of course, eliminate that problem. It would make
it unnecessary to spend so much money trying to intercept the opium
smuggled into this country in the form of heroin.
But in order to do that, we have to eliminate a very large legitimate
need for derivatives of opium, because doctors use morphine and co-
(77)
78
deine in painkilling drugs. So if we cannot eliminate that legitimate
need for the growing of the opium poppy, it will continue to be grown
and the farmer, at least according to the pattern of the past, will con-
tinue to divert a part of his crop into the black market maintained by
the international organized crime syndicate.
In order to eliminate the necessity for importing certain derivatives
of opium for medicinal purposes, we are asking the scientific com-
munity of our country if there caimot be developed synthetic substi-
tutes for morphine and codeine so there wouldn't be a legitimate need
for the growing of the opium poppy anywhere in the world.
The other aspect of this hearing is to find blockage drugs which
will prevent the addict taking heroin from experiencing any sensa-
tion from it. So if you take that blockage drug, you might as well not
take the heroin, because you don't derive any sense of satisfaction from
the taking of it. That is the reason we are engaged in this scientific
inquiry into these areas.
We have received testimony from Assistant Secretary of the Treas-
ury Eugene T. Rossides, who told us that the total eradication of opium
cultivation, accompanied by domestic reliance upon synthetic sub-
stitutes, would be a definite plus to the law enforcement community
charged with the responsibility of policing our borders. Mr. Rossides
further told us that the switch from the natural opiates to the syn-
thetics might well cause a disruption in the organized criminal con-
spiracies which are responsible for bringing most of the heroin into
the United States.
Today, we will hear testimony from scientific researchers concern-
ing the possibilities of policing a worldwide opium cultivation ban.
The first three witnesses, from MITRE Corp., will tell us about the
possibility of using our satellite capabilities to police an international
treaty banning opium cultivation. We will also hear testmony about
the role which the scientific and engineering community can play in
the international addiction crisis.
We then will move into the second phase of our hearing. In this
segment we will attempt to determine whether methadone mainte-
nance is efficacious in reducing the number of arrests and illegal activ-
ities of addicts under such treatment.
It is generally said that it costs between $50 and $75 a day to main-
tain heroin addiction once a person becomes thoroughly addicted to
that drug. Well, not many people can afford $50 or $75 a day. Those
who cannot afford it have to go out and illegally get possession of
goods, which, when sold to a fence, will yield the amount of money
they must have to sustain their addiction.
It is estimated bv Dr. DuPont, who is in charge of the Narcotics
Treatment Administration here in the District of Columbia, that
each addict in the District of Columbia gets illegal possession of about
$50,000 worth of goods a year in order to sustain his addiction. With
some 16,000 addicts in the District, it is no wonder we have so many
robbery, burglaries, and muggings on the street.
Our next witness. Dr. Frances R. Gearing, is eminently qualified to
give us an analytical and statistical survey of Dr. Vincent Dole's meth-
adone maintenance program that will help us in determining the ef-
ficacv of the methadone maintenance approach.
79
We then will hear from Dr. Robert L. DuPont, Director of the Nar-
cotics Treatment Administi-ation, who has compiled some fascinating
statistical studies on crime reduction and methadone maintenance in
Washington,
Our final witness today is Dr. Jerome H. Jaffe, director of the Illi-
nois Drug Abuse Program. This multimodality treatment program is
the largest in the Midwest. Currently Dr. Jaffe and his able staff are
treating 1,590 addicts. Dr. Jaffe will explain his approach to metha-
done maintenance and the multimodality treatment method. He will
also share with us his thinking about the possibilities of developing
longer lasting and effective antagonist drugs. Finally, Dr. Jaffe will
advise us how we can best accelerate and coordinate scientific research
into the multiple problems of opiate addiction.
Our first witnesses this morning are three gentlemen who represent
what America's advanced technology can contribute to the fight against
social ills. David Jaffe, William E. Holden, and Dr. Walter F. Yon-
dorf are employees of the MITRE Corp., a research and development
think-tank with heavy experience in space and defense.
These gentlemen are now applying their technology to the possibil-
ity of detecting the illegal cultivation of opium.
Mr. Jaffe is a memlier of the department staff of MITRE, and is
primarily concerned with the application of technology to criminal
justice systems.
Before joining MITRE last September, he was deputy head of the
public safety department of the Research Analysis Corlp., where he de-
veloped program concepts for research in law enforcement and the
administration of justice. Studies he directed included the relationship
between the physical environment and the crime rate, logistic support
to police and fire departments in combating civil disorders, and the role
of police in a ghetto community.
Mr. Jaffe holds a master of science degree in physics and mathemat-
ics from the University of Connecticut.
Mr. Holden, a MITRE department head, is an electrical engineer
with a bachelor of science degree from the Massachusetts Institute of
Technology, and a former naval aviator. During the last 15 years at
Lincoln Laiboratory, MIT, and with MITRE, Mr. Holden has been
responsible for many mission analyses and other planning activities
in the fields of air defense, command and control at senior military
levels, foreign satellite identification, airborne command posts, air-
borne launch facilities, missile test ranges, and Air Force test centers.
He served as a foreign service officer assigned to the NATO interna-
tional staff for 2 years to assist in planning NATO-wide air defenses.
Dr. Yondorf is associate technical director of MITRE Corp's na-
tional command and control division in McLean, Va. The division
provides systems engineering and other scientific and technical assist-
ance to defense agencies, primarily in the areas of communications,
data processing, and sensor development. Sponsors include the De-
fense Communications Agency, the Defense Special Projects Group,
Safeguard Systems Command, Air Force Systems Command and the
Advance Research Project Agency. Dr. Yondorf's earlier MITRE as-
signments have included the development and implementation of a
5-year project to improve and automate JCS strategic mobility plan-
80
ning capabilities, responsibility for requirements analysis of the Na-
tional Military Command System, the study of attack assessment sys-
tems, and research in crisis management.
Before joining MITRE in 1962, Dr. Yondorf was a senior staff mem-
ber at the Laboratories for Applied Sciences, University of Chicago,
where he was engaged in strategic studies and the political and eco-
nomic analysis of limited conflict. Earlier, he was an instructor at
the University of Chicago teaching courses in the committee on com-
munication.
As a fellow of the Social Science Research Council, 1959-60, Dr.
Yondorf undertook a study of the dynamics of political and economic
integration in the European Common Market.
Dr. Yondorf was educated in Germany, Switzerland, and the United
States, and holds M.A. and Ph. D. degrees in political science from the
University of Chicago.
Gentlemen, we are pleased to have you with us today.
Mr. Perito, our chief counsel, will you please inquire of the witness.
Mr. Perito. Mr. Jaffe, I understand that you have a prepared
statement ?
STATEMENT OF DAVID JAFFE, DEPARTMENT STAFF, MITRE CORP. ;
ACCOMPANIED BY : WILLIAM HOLDEN, DEPARTMENT HEAD; AND
DR. WALTER YONDORF, ASSOCIATE TECHNICAL DIRECTOR,
NATIONAL COMMAND AND CONTROL DIVISION
Mr. Jaffe. Yes ; I do.
Mr. Perito. Would you care to read that statement for the
committee ?
Mr. Jaffe. Yes.
Mr. Perito. Thank you, please proceed.
Mr. Jaffe. Thank you very much. I am pleased to contribute to
the work of this committee at your kind invitation, and am grateful
for the opportunity to discuss with you the role that the technical
community should be playing in the control of narcotic and dangerous
drugs. I will suggest how the application of technology could make
some significant contribution to the solution of the pressing and criti-
cal problems of drug abuse and to the control thereof : I will describe
some typical benefits that may be derived from the adaptation of ad-
vanced techniques; and I will suggest a program for realizing such
benefits.
A little less than a year ago this committee heard a presentation by
Dr. William F. Ulrich of Beckman Instruments in which he outlined
the ways in which scientific and engineering capabilities could con-
tribute to drug control. He touched on the subjects of technology
transfer and systems analysis, and I would like to expand on those
topics to show how some specific programs might assist those conduct-
ing the fight against illicit drug production and distribution.
Suggestions on how to solve the drug problem differ as to approach.
There are those who argue for an attack on the sources: Foreign
growers of opium and local manufacturers of psychotropic substances.
$1
There are others who would have us concentrate on interrupting the
distribution channels. Still others believe the attack should be focused
on rehabilitating the users. I submit that we need a coordinated effort
in all these directions.
To say that the problem is complex is not to argue that solutions are
impossible, or slow to be realized. My thesis is rather that, if we are
to achieve effective controls in reasonable time, we must begin by
accepting the complexity, understanding it fully, and devising rea-
soned rather than intuitive or emotional responses.
Techniques which were developed for analysis of highly complex
systems, if properly understood and managed, can be powerful weap-
ons in revealing subtle relationships and vulnerabilities. The methods
of systems analysis and systems engineering are not cure-alls. As
with any highly structured method, the results cannot be more precise
than the information used.
BACKGROUND
What then are the particular problems which should be addressed
by the scientific and engineering community ?
Source Detection
The sources of opium, the fields of the Middle East, Southern Asia,
and of Southeast Asia, present an interesting challenge because of the
combination of difficulties encountered. To begin with there is the
problem of detecting the presence of small, out-of-the-way, illicit
crops, primarily an operational and technological problem. Then there
is the consideration that opium is often the principal or only cash
crop for the local farmer, an economic problem. In Southeast Asia,
some tribes have built a nomadic lifestyle based on opium poppy culti-
vation, a sociological problem. And we hear frequently about the polit-
ical barriers to opium control.
The necessity to solve each kind of problem, and all of them on an
integrated basis, is apparent. The detection of illicit crops is a key
factor in the entire process because it should provide the detailed
facts on which can be based the economic, social, and political solu-
tions. Other parts of an integrated program rely, to some degree, on
being able to specify the location and extent of illicit opium cultiva-
tion with precision and confidence.
Laboratory Detection
A second major problem area which may be amenable to techno-
logical attack is the location of the laboratories where the opium and
morphine bases are transformed into heroin.
In the past, these laboratories have escaped detection from the air.
They remain prime targets partly because of their strategic function
in the heroin supply process, and partly because much raw material
and important personnel can be captured at these places.
Tracers
It would be helpful to law enforcement officers if they could reliably
trace the movement and chemical transformation of narcotic ma-
82
terials. If they could introduce an identifiable tag at the poppyfield
and intercept some of that material at several points in the distribu-
tion network, a much clearer description of that network would result.
The operational possibilities for such tracer materials are numerous.
The problem is in finding suitable tags which are, among other things,
reliable and safe.
Sensors
Another problem susceptible to technological solution is the detec-
tion of concealed drugs at short distances. It would be of immeasur-
able value to be able to reveal the presence of drugs hidden in suit-
cases, automobiles, packages, on the person, and in many other places.
Devices are needed which can detect extremely small amounts of opi-
ates w^ith response times of seconds and reliability in the upper 90
percentile. The requirements of sensitivity, speed, and reliability tend
to be mutually exclusive and difficult to achieve. Development of such
devices requires extensive research and design and some amount of
tradeoffs in design.
Data Bank
The complexity of the international drug enterprise is reflected in
the great amount of information needed to describe the production,
distribution, and consumption of the products. The effectiveness of
drug control is dependent on access to that information. And the ef-
fectiveness will also be a function of how timely the retrieval is and of
how complete is the data produced.
It follows that a comprehensive data bank is required as a reposi-
tory of worldwide information on all aspects of the drug problem.
Narcotics agents at all levels should be able to request rapid retrieval
of information. The high mobility of dealers in drugs and the world-
wide nature of their operations suggest the need for a similarly ex-
tensive data bank.
O'perations Analysis
Referring again to the intricate nature of the illicit drug business,
it is often difficult to predict the ultimate consequences of any control
activity. Squeezing the balloon at one place may simply cause it to
expand some place else. A comprehensive, systematic, analytic method
is needed which can help to identify how other parts of the system
will be affected if one part is changed.
A corollary problem is the allocation of drug control resources.
Like managers in all other situations, drug control administrators
must decide how to assign their personnel, equipment, dollars, and
management attention so as to realize the most beneficial results. It
would help these people to have a technique for anticipating the
effects of their allocation decisions. No such technique will replace a
good manager, but it can provide him with information he would
otherwise not have.
BENEFITS
Some of the benefits which should be derived from such efforts
by the scientific and engineering community are :
Worldwide location of opium crops ;
Information on potential yield of opium crops ;
83
Determination of harvesting time ;
Selective destruction of crops ;
Tracing of distribution networks ;
Sensing of concealed material at ports of entry ;
Detection of clandestine laboratories ;
Kapid retrieval of pertinent data ;
Identification of network sensitivities and vulnerabilities ;
Assessment of alternative control measures :
Mechanism for training exercises ; and
Good resource management.
I must urge you to keep in mind that these benefits, as I have been
calling them, are not going to solve the full range of narcotic and
drug problems. In fact, we cannot be entirely certain that all of these
benefits, and others which could be added to the list, can be achieved
in a reasonable time or at acceptable costs. And the changing opera-
tional requirements may make some of them obsolete before long.
But for the present, we should not overlook any tool which answers
a real need, and these benefits can be vital elements to the integrated,
coordinated attack which, in my opinion, is the only reasonable route
to effective control.
PROPOSED PROGRAM
Before identifying how the scientific and engineering community
might participate in the control of drugs, I wish to acknowledge that
there are already in progress some efforts along the lines to be de-
scribed. The Bureau of Narcotics and Dangerous Drugs and the Bu-
reau of Customs have active research and development programs which
address many of the points contained in this statement. In addition
to their own projects, these Bureaus are being assisted by other Fed-
eral agencies which have specialized capabilities. I have met with a
number of people involved in these efforts and can attest to their
competence and dedication. But the scope of the ongoing efforts, and
the adequacy of available resources, remain as appropriate questions
before this committee. I will return to this issue presently.
Having established some of the benefits which research and develop-
ment should pi'oduce, let us examine how such a program might be
structured. We can conveniently view the woi'k that needs to be done
as a five-part program.
Surveillance of Opiy/m Poppy Crops
The remote sensing — that is, from aircraft and satellites — of agri-
cultural crops dates from the early 1930's when aerial photographs
were used to locate and measure fields. Since then, observational and
interpretive techniques have progressed a great deal, although much
experimentation and development remains to be accomplished. I have
several photographs to illustrate what can be accomplished with ad-
vanced techniques.
Mr. Perito. Mr. Chairman, may the record reflect the lights are noAv
being turned out and the photographs about to be shown will be made
available for the committee to incorporate in its record.
Chairman Pepper. So ordered.
Mr. Jafte. The first figure is a well-known photo made from Apollo
9 at 131 nautical miles over Imperial Valley, Calif. It was taken with
84
Figure 1
infrared Ektachrome film with a spectral response between 0.510 and
0.890 microns. The dark dotted patches are crops. Across the bottom is
seen a section in which the amount of dotted area, and consequently the
vigor of the vegetation, is markedly lower. That sharp line of demarka-
tion is close to the Mexican border. A single color photograph like this
one contains limited useful information.
The next figure (fig. 2) shows the same scene in three photos made at
the same time. The one on the upi^er left was taken with Pan X film
with a green filter; the upjx^r right on Pan X with a red filter; and the
lower photo on black and white film "sensitive to infrared radiation. It
is apparent that each photo produces different relative contrasts and
enhances the images of some features over others.
The next photos (fig. 3) demonstrate the different resi^nses that
similar crops will provide in relatively narrow spectral bands. The left
photo, made with a blue filter, shows little difference between oats and
85
Figure 2
wheat. But the ones made with red and infrared filters show the dis-
tinction quite clearly. So, in a simple case at least, we see that it is
ix)ssible to isolate crops in this way.
In fact, it is possible to do a lot better than that. The next photos
(fig. 4) show how two varieties of corn which can hardly be differenti-
ated at visible wavelengths (on the left) look quite different at infrared
wavelengths.
Mr. Perito. May the record reflect the lights being turned back on
and we are continuing with Mr. Jaffe's statement.
Chairman Peppek. Without objection, so ordered.
You may proceed.
Mr. Jaffe. What I have illustrated here are the mere fundamentals
of remote sensing of agriculture. These techniques have been advanced
86
Figure 3. — Tones of wheat (W) and oats (O) differ when recorded by an airborne
multilens camera filtered to three spectral regions (0.38 to 0.44 micron, at left ;
0.62 to 0.68, center; and 0.58 to 0.89, at right).
[Data Collected by Purdue University Agronomy Farm.]
to include simultaneous observation in many spectral bands and com-
puter analysis of the data.
I am not aware of opium poppies having been observed by these
methods, but it is reasonable to expect that they would be readily dis-
cernible; perhaps even by single band, rather than multispectral, sens-
ing. "VVliat is needed is a set of experiments to establish which ap-
proach produces the desired information with reference to opium
poppy cultivation. It should be possible to use either an established
poppyfield or a specially prepared one and to overfly it with equip-
ment designed for spectral analysis. The signatures of poppies could
thus be obtained and examined for uniqueness. Once unique, charac-
teristic images are obtained from the test bed, the appropriate appa-
ratus would be used in an operational test to determine what, if any,
real-life difficulties might be encountered. Further refinement of the
technique would follow.
Remote sensing from aircraft is very likely to be successful in locat-
ing opium fields. Similar observations from satellites, particularly
from NASA's Earth Resources Technology Satellite (ERTS), are
somewhat less certain to produce useful results. The multispectral
sensing devices on the initial ERTS spacecraft will provide resolution
of objects down to about 300 or 400 feet. The smallest opium fields
are said to be about i/^ acre or typically about 150 feet in linear di-
mension. It is possible, but not at all certain, that a distinctive signa-
ture of that size will be discernible by an instrument with the resolu-
tion available on ERTS. Needed is experimental determination of the
poppy signatures and some experience with the real capabilities of the
ERTS instruments. We must also consider future instruments that
may provide finer resolution and other favorable characteristics.
Trace?' Technology
Tracers, or tag identifiers, can be used to identify captured samples
as coming from the same sources. It may be possible to introduce trac-
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ers at the poppyfields or at any point thereafter. For manufactured
drugs, methods of tracing are not nearly as difficult because of distinc-
tive characteristics of tablets and capsules.
Four primary handicaps exist in the use of trace materials ; insert-
ing the tracers into the drugs and the tagged drugs into the illicit
traffic ; the tracer must be safe for use internally or intravenously ; the
tracer must be highly reliable ; and a tracer, to remain a unique identi-
fier, cannot be reused until the tagged material has been cleared from
the marketplace — a condition which can require several years.
The advantages to be derived from being able to correlate the origin
of captured samples, and therefore being able to correlate the network
links and nodes, should compensate for the difficulties involved in over-
coming the handicaps. Captured shipments can be tagged and rein-
serted in the network ; radioactive tracers may not be totally safe, but
chemically idenifiable tag materials are possible; the reliability of
unique identification can be very high; and large numbers of trace
materials can be found in time. To introduce tracer materials into the
poppy plant, and consequently into the opium, requires trace materials
that can survive the processing that transform the opium into heroin.
Analysis of the morphine alkaloid, the heroin, and the impurities that
remain after processing could suggest ways of altering the chemical
composition. Alterations would presumably be distinguishable and
hence would serve to identify a particular batch of material.
Trace materials can also be inserted into the distribution network
at points other than the source. For this purpose, it is necessary to
have tag materials which replace those used at later stages in the proc-
ess. For example, it could be possible to use traceable acetic anhydride
in converting morphine base into heroin (diacetylmorphine).
It should also be feasible to introduce trace materials still later in
the network ; as for example, during the cutting phases. Either chem-
ically distinguishable but similar substances could be used, or inert
and distinctive things, perhaps plastics, could be added. But all of this
will take intensive investigation and development before operational
utility is achieved.
Sensor Technology
Sensors for the detection of concealed narcotics and drugs, and for
the detection of effluents at heroin laboratories, will also require dedi-
cated research and development. The first task will be to identify
technioues which can sense very small amounts of drugs or related
materials. The second task will be the adaptation of those techniqu'°s
to operationally useful forms.
More so than for other technological weapons, sensors are highly
susceptable to countermeasures. It should be fairly easy, once the sens-
ing technique is recognized, for the narcotic distributors to devise eva-
sive procedures or devices. The need is therefore for an arsenal of sen-
sors and a variety of ways for utilizing them in order to keep the other
side off balance.
There are a number of analytic technioues which are useful in
identifying narcotic and dangerous drugs. These methods include gas
chromatography, infrared spectroscopy, mass spectroscopy. X-ray
spectroscopy, free radical electron resonance, and a number of chemi-
cal analyses. But the apparatus which is most attractive for the opera-
89
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90
tional situations has handicaps. These devices require preconcentration
of the sample material, are too heavy to be portable, or may react too
slowly for expedient analysis.
However, mass spectrometers have been made with reduced size and
weight, and trade-offs are possible in design requirements. The recent
intensive effort in developing air pollution monitoring equipment has
resulted in promising devices and technology which might be applied
to the near real-time detection of gas or particulate contaminants as-
sociated with the production of controlled drugs. ^lerging the fields
of qualitative instrumental analysis with particulate detection, the
possibility arises of highly special and sensitive mechanical sensors.
Dr. Lou Rabben of the MITRE Corp. suggested a scheme developed
for another purpose. He proposes to use an infrared spectrometer with
a sample chamber constructed in such a manner that the infrared beam
passes through the gas sample many more times than is usually the
case for this type of analysis. Hopefully, this would result in greatly
enhanced sensitivity. I must emphasize that the applicability of this
or other techniques to drug detection is unknown. I merely wish to
suggest examples of how the application of sensor technology might
be pursued in the solution of these problems. Similar developments
may be possible with other techniques. Adaptation of existing tech-
nology would seem to be a sensible approach to the initial acquisition
of suitable equipment.
Data handling
I spoke isarlier of the need for a comprehensive data bank covering
all facets of the drug enterprise. A data bank will serve both the re-
search community in its efforts to analyze the system and find its weak-
nesses, and the enforcement agencies in their operational activities. I
doubt the need to elaborate on this item except to mention that a modest
start has been made in this direction.
Network modeling
The established technique of network modeling could be applied to
describe the entire procedure whereby narcotic and dangerous drugs
proceed from source to user. Such a model would include :
(1) Location of illicit poppy fields; (2) growing seasons of illicit
poppyfields; (3) economic analysis of poppy cultivation ; (4) packag-
ing and transport of raw opium; (5) ports of exit and entry, plus
procedures followed to avoid detection; (6) chemical processing:
(a) plant locations,
( h ) methods of shipment to and from,
(c) possible signatures of processing effluents, and
[d) chemical and supplies used ; where obtained ;
(7) finished product handling and shipping; (8) distribution
systems :
{a) economic analysis,
(6) organizational structure; and
(9) covert intelligence ; its cost versus its value.
At each point of the network, alternative routings, sources or pro-
cedures should be identified to reveal how the network Avould be dis-
rupted by elimination or modification of that point.
The economic as well as physical networks should be simulated and
these models should be operated to determine alternative control meas-
91
ures; to assess likelihoods of success of those control measures; to
evaluate sensitivities of the systems to variations of the elements; and
to identify the links and modes which may be most susceptible to at-
tack. A corollary use of the models should be the training of super-
visory level personnel in the Federal and local enforcement agencies.
APPROACH
A few words on how to proceed with a research and development
program.
The various aspects of applicable technology- — surveillance, trac-
ers, sensors, a data bank, and network modeling — must be structured
into an integrated and focused research and development program.
In a systems approach of this kind, the benefits are not only those re-
sulting from each specialized technique or procedure, but also from
the coordinated use of all methods available.
As mentioned earlier, there is some work underway in the areas
cited, so any program should begin by assessing the scope and direc-
tion of those efforts, I have made a limited survey which indicated that
current efforts are minimal.
In addition to a status survey, an intensive feasibility analysis
should be undertaken to reveal what may be technologically, eco-
nomically, and operationally possible both in the short term and the
far term. This feasibility study would, using a complete systems ap-
proach, show just which of the areas I have mentioned are most fruit-
ful to pursue at the present time. The efforts in this area which are
underway at BNDI) and the Bureau of Customs, and through them by
other agencies, need to be enlarged and unified by this coordinated
across-the-board attack on the drug problem. Important consideration
should be the operational needs — the real-life situations faced by en-
forcement agents — and potential countermeasures.
The feasibility analysis should be followed by a detailed research
and development plan providing for the elements of the program sug-
gested above and including cost estimates and multiyear projections.
The plan must be produced from the point of view of an attack on the
entire drug problem ; from the producers to the chemical processors
to the street level distributors and users. The drug problem is not
static; the planning and implementation of its control cannot be static
either. Every plan must be part of a logical long-term effort, but the
plan will change as the problem changes. The plan should include
provision for evaluation of results achieved and for readjustments in
scope and direction.
SUMMARY
I have tried to indicate some of the problems faced by drug con-
trol agencies, to show what benefits could be derived from increased
employment of technology, and to indicate an approach to increased
involvement by the research and development community.
Programs of the kind suggested are not inexpensive and often re-
quire more time than one would like. But in the context of the overall
drug problem and its direct and indirect social and economic drain
on our society, the costs of an intense research and development pro-
gram would be small indeed in view of the potential benefits, such
as —
92
Locating illicit opium crops ;
Detecting illegal material at ports of entry ;
Developing drug network vulnerability data ; and
Improving resource management.
The important aspects are (1) the need for a total systems ap-
proach; (2) the need for an accelerated research and development
effort ; and (3) the need to get started now.
Thank you very much.
Chairman Pepper. Mr. Jaffe, I want to commend you on your mag-
nificent and comprehensive statement, that you have given as to how
this whole problem should be coordinated in an effective and compre-
hensive program.
Mr. Perito, do you have any questions ?
Mr. Perito. Mr. Jaffe, you have had some contact both with the
Federal Bureau of Narcotics and Dangerous Drugs, and U.S. Customs
regarding your presentation ; is that correct ?
Mr. Jafft:. Yes.
Mr. Pertto. Could you estimate what it would cost the Government
at this point to put together the type of research and development
program which you have suggested ?
Mr. Jaffe. It is very difficult to answer that on a short-term basis.
On a longer term basis, and comparing it to the existing budgets as
I have been able to reconstruct them, which is difficult, I would guess
it runs something on the order of $10 million over a 5-year period;
something like that.
Chairman Pepper. Excuse me.
You mean $10 million for 5 years ?
Mr. Jaffe. Distributed over a 5-year period.
Mr. Perito. Mr. Jaffe, do you know how much is now being spent on
such efforts by the Federal Government ?
Mr. Jaffe. No ; I do not know precisely. I have some bits and pieces
of information about what particular subagencies are spending, but
that is all.
Mr. Perito. I assume then, based upon your contacts, vou would
conclude that the Federal Government is spending something mini-
mal, at best ?
Mr. Jaffe. Oh. very minimal.
Mr. Perito. If you were assigned the responsibility of policing an
international narcotics treaty, wherein all the signatories would agree
not to Arrow poppies, do vou believe this technological approach could
be used by the International Narcotics Control Board, for example,
to police throuflfh satellite surveillance the cultivation of poppies?
Mr. Jaffe. The use of satellite surveillance may not be available to
us in the immediate future. But high-flying aircraft, and ultimately
the use of satellites, will provide that kind of capability. It would sig-
nificantlv contribute — in fact, it is difficult to imagine how such a
treaty would be enforceable without such surveillance or something
equivalent.
Mr. Perito. At the present time, do you know of any accelerated re-
search concerning an international data bank?
Mr. Jaffe. I don't have anv specific knowledge about that; no.
Mr. Perito. Do you envision that a data bank could be set up so
that you could have input from several countries and protect the dis-
closure from those people who should not get disclosure ?
93
In other words, can you envision a data bank which would suffi-
ciently service an organization like Interpol, yet at the same time not
be available to the individuals who could wrongfully profit by this
information ?
Mr. Jaffe. The question of security in data banks has received a lot
of attention of late, and I would suspect that the probability is it could
be done as well as it coud be done in any other area. I think that could
be effected.
Chairman Pepper. Just one question before the other Congressmen
inquire.
Mr. Jaffe, would it be possible to develop any sort of technical
method by which you could detect the conversion of morphine base
into heroin as it takes place in the laboratories of southern France by
flying over the area where the laboratories are located?
Mr. Jaffe. Yes ; I think there is at least a sufficiently good chance
of that being done so that it deserves more attention than it seems to
be getting.
Yes; as Dr. Yondorf is saying, that would be susceptible to counter-
measures, and one gets into this problem which the military faces, of
countermeasures and counter-countermeasures. But I don't think that
is a sufficient argument not to take the first step ; that is, for us to take
the initiative in trying to locate those laboratories, especially from the
air.
Chairman Pepper. Mr. Brasco, do you have any questions ?
Mr. Brasco. Yes.
I am sorry I am late, Dr. Jaffe. This is rather interesting.
I didn't get a chance to go through the beginning — that we do have
at this time such devices or are you suggesting the $10 million go into
the research and developinent of such devices ?
Mr. Jaffe. I am saying that there is a very limited effort under
way on the development of such methods.
Mr. Brasco. But we don't have the devices that you are speaking
about ?
Mr. Jaffe. Generally not of the various things I have spoken about.
Generally they are not available in an operational sense. They are not
being used on the street by enforcement agencies.
Mr. Brasco. This $10 million that you were speaking about is the
cost of the entire project? Is that the cost for the entire project, as
you set forth in your summary ; that is, locating, detecting, developing
the dragnet work and improving the resource management?
Mr. Jaffe. Yes; provided that you understand that that does not
mean it includes the operational costs, the cost of using it. That figure
is the cost of a research and development program that should produce
such results.
Mr. Brasco. I understand. Now, what would then be the cost after
it is produced, if you have any idea, of putting it
Mr. Jaffe. That is really a little bit out of my realm, and I don't
know. For example, if we developed a technique for overflying, what
it costs to run an aircraft for an hour I really don't know. But it
would be that sort of thing.
Mr. Brasco. How long, if you had the $10 million, do you think it
might take to develop such a program ?
94
Jaffe. Well, there would be some immediate results or very early
results, and they would be distributed.
Mr. Brasco. I know you said 5 years, but are you saying it is 5 years
before any of the equipment could be used ?
Mr. Jaffe. I use tlie 5 years only as a way of averaging cost.
There is no significance in the 5 years, in terms of when results
would be available. I would expect there to be a stream of results
over a longer period of time, too. Just as a way of averaging the cost
I say I think that the program might run something like $10 million
over a 5-year period. If you like, say an average of $2 million a year
or something like that.
Mr. Brasco. I wasn't inquiring so much about the money. I was con-
cerned about when it might be operational.
I am trying to find out when you would have a system that you are
talking about? I am not trying to pin you down, just trying to get
an idea.
Mr. Jaffe. I think it might be as early as a year before we can spot
poppyfields from the air, or a fraction of a year, within a year.
Some of the other techniques, the establishment of a model for
example, and the operation of that, generally takes longer because
there are long periods .of validation necessary while you test the thing
out and make sure you got the right model.
So there are differences. I think that sensors, for example, might
run 1 to 2 years, something in that period, or even less.
Chairman Pepper. Dr. Yondorf ?
Dr. YoNDORF. Thank you, Mr. Chairman.
I would suggest that sensing from satellites would require much
more development. It is easier with our pjresent technology to identify
poppyfiields with airborne sensing equipment; that is, with minor
adaptations of sensor equipment now existing on aircraft. On the
political problems of flying over foreign territory with aircraft, you
are more expert than I am, but technically this is where one should
start. Sensors aren't sufficiently discriminating now to identify crops
from very great altitudes. Research and development money initially
should be spent to develop more sensitive sensors and test them out.
Mr. Brasco. Thank you.
Chairman Pepper. Mr. Wigsins.
Mr. Wiggins. I have no ouestions, Mr. Chairman.
Chairman Pepper. Mr. Mann.
Mr. Maxn. You imply that the governmental efforts beins: made
now in these areas are minimal. Are they doing anything with refer-
ence to opium crop detection capabilities, sensor devices?
Mr. Jaffe. Yes; they are. In fact, with the exception of the data
bank on which I was not able to uncover anything, something is being
done in each of the other areas. There is something being done on the
question of surveillance from the air, and some of the others — the
sensors and tracers, too. There is some very limited modeling going on.
Mr. Mann. Dr. Yondorf, you sujrgested that aircraft surveillance
to develon the techniques is a preliminary step to developing a satel-
lite capability.
Do you think a satellite capability is possible ?
Dr. Yondorf. We do think it is possible. It is just a matter of refin-
ing existing techniques. Of course, one can ai-gue Ihon from which
d5
altitude the satellites should operate. We have satellites that go up
to 22,000 miles— synchronic altitude— and it probably is extremely
difficult to see poppies from that altitude.
But low altitude satellites might well attain the discrimination one
would need for this purpose.
Mr. Mann. Mr. Jaffe, are you aware of any aerial surveillance, aerial
efforts made by the United States of poppyfields?
Mr. Jafte. No ; and those who are in a lot better position to have
heard of any such things tell me that they are 99 percent sure that
there is no such thing in existence. To date, no aerial surveillance has
been made of poppyfields.
Mr. Mann. Well, is my information correct that there are poppy-
fields in areas of this world. Southeast Asia, for example, where we
have a lot of aircraft operating ?
Mr. Jaffe. That is true.
Mr. Mann. No further questions.
Chairman Pepper. Mr. Steiger.
Mr. Steiger. Thank you, Mr. Chairman.
Just a couple of questions, Mr. Jaffe.
Incidentally, I for one find your presentation very interesting as
opposed to my colleagues' rather casual interest. I wonder if you have
heard of the work of Joe Zabitzi — and I can't tell you how to spell it,
He works for the USGS and has developed infrared photography pri-
marily in the search of water resources and has developed
Mr. Jaffe. I have heard of the work they are doing, but the name is
not familiar.
Mr. Steiger. I think it might be of interest for you gentlemen to
coordinate with him because he has done some very dramatic things
I have seen, and obviously, it coincides completely with the type of
thing you are doing here. I know you are aware of this, but I think
the record should reflect your awareness, since your statement does not.
In all your research and development I would assume you would
suggest the need for security, even in the research and development
phase, so as to at least minimize the opportunity for the countermeas-
ures you referred to ?
Mr. Jaffe. Absolutely ; yes. I certainly agree with that.
Mr. Steiger. I say this because, interestingly enough, Mr. Zabitzi
recited to me a proposal by a gentleman from the private sector, I
believe would be a friendly way of saying it, who asked him if he
could find poppyfields for him. He was on a United Nations mission
in North Africa, and he was asked if his technique would show up
poppyfields.
This fellow, who said he was a horticulturist, which I thought was
interesting, indicated that he would be willing to pay for the informa-
tion as to the location of the poppyfield.
So there is an awareness among the group.
Mr. Wiggins. Horticulturists ?
Mr. Steiger. Among the horticulturists.
That is all, Mr. Chairman.
Chairman Pepper. Mr. Rangel.
Mr. Rangel. Mr. Jaffe, in the course of your studies, upon what do
you base the assumption that the United States does not know where
these opium crops are located or where the laboratories are ?
96
Mr. Jaffe. Primarily on the fact that there seems to be more than
casual interest among the enforcement agencies in techniques of this
sort when we do talk to them about these things. From the fact that
they have some ongoing programs in these areas, one would assume
that they don't know precisely where the fields are or where the labora-
tories are. And it is just information of which I don't have firsthand
knowledge, but I think pretty good secondhand knowledge.
Mr. Rangel. Well, in view of the fact that we have — at least I think
we can admit we have — U-2 surveillance aircraft, we have been, able
to detect missiles in Cuba, we have been able to determine areas of
vegetation in Vietnam and Korea before this, and in view of the fact
rhat we have a very close economic relationship with the countries that
we are mentioning that are considered to be friendly to us, and so
therefore there is an assumption that Government is cooperating with
us, it seems to me that all of the information would lead us to believe
that we know exactly where the crops are located and where the labora-
tories are.
Mr. Jaffe. I think there is a difference between knowing generally
where they are and knowing specifically where they are. It strikes
me that that really is the difference that we would be getting at with
technology.
Mr. Rangel. Well, have you studied any of the reports of the sophis-
tication of our U-2 aircraft ?
Mr. Jaffe. Well, I know generally about what they can do, about
their operational capabilities.
Mr. Rangel. And the information has been rather specific ?
Mr. Jaffe. Yes.
Mr. Rangel. And if we can send these aircraft over unfriendly na-
tions, I just presume we can send them over friendly nations.
Mr. Jaffe. I would agree.
Mr. Rangel. And if we can do all of this I presume that we have
the knowledge that we want already.
Mr. Jaffe. I can't disagree with your presumption. The informa-
tion I have is that the locations are not precisely known over a period
of time. Obviously if they detect one, if they find it, they know where
that one is, but
Mr. Rangel. If my presumptions are correct, we don't need any more
research and development?
Mr. Jaffe. The location of a laboratory, for example, from the air,
does require additional research and development. There is no suitable
way at the moment of overflying or finding a laboratory.
Mr. Rangel. We can find missile bases but we can't find laboratories ?
Mr. Jaffe. Correct; because the laboratory, from the air, looks like
nothing more or less than an ordinary house, somebody's private home.
Mr. Rangel. Even with information given to us by so-called
friendly nations ?
Mr. Jaffe. Well, I don't know about that part of it.
Mr. Rangel. Well, let me ask you one last question, Mr. Jaffe. As-
suming that we did get the refined sophisticated type of research and
development that you are suggesting; after we got it, what would you
suggest we do with it ?
Mr. Jaffe. AVell, all through my remarks I stressed the need to have
the research and development program aimed at the operational needs
97
of the enforcement agencies. So presumably, the output would be some-
thing which is immediately operationally useful to an enforcement
officer.
The next step, then, would be to turn it over to him and let
him use it.
Mr. Rangel. Have any of the law enforcement agencies in the United
States ever requested this type of support that you know of ?
Mr. Jaffe. Yes. They have ongoing programs, and I have discussed
with them the magnitude of those programs. I think I can say that
there is a need and they would agree to a need — not everyone, you
know, of course. If you talk to the guy about his little laboratory he
says this is fine, this is my kingdom.
Mr. Rangel. Is there any agency that has a mandate to eradicate the
international trafficking of drugs, that has gone on record in asking
for more Federal assistance in the area you have testified to ?
Mr. Jaffe. I don't know. I really don't know.
Mr. Rangel. Thank you.
Chairman Pepper. Excuse me just 1 minute.
Mr. Jaffe, as I understood the import of your testimony, you were
assuming that if we had an international treaty or agreement that
would ban the growing of the opium poppy then if somebody were
to plant a field of opium poppies it could be detected by surveillance
methods so that the policing could be effective ?
Mr. Jaffe. That is exactly right.
Chairman Pepper. Is your information the same as mine, that these
laboratories in southern France are moved around from place to place,
from time to time, so there is no fixed location?
Mr. Jaffe. That is true. They do move quite a bit. Some of them are
easily knocked down and set up again somewhere else.
Mr. Mann. To that may I make a statement ?
Chairman Pepper. Go right ahead.
Mr. Mann. I was in Paris last week where I conferred with the
director of the National Police Force, a representative of the BXDD
in Paris, and I came away persuaded that France is making every
effort in cooperating with us and the law enforcement arena to un-
cover the laboratories, that there is no reluctance on their part or no
economic considerations on their part that are interfering with their
cooperation in attempting to uncover these laboratories.
Chairman Pepper. Mr. Winn.
Mr. Winn. Thank you, Mr. Chairman.
Mr. Jaffe, your statement intrigues me, partly because I am on the
Science and Astronautics Committee and I am aware of the work that
has been done in the satellites and sensors by ERTS. How much work
have you actually done on the feasibility of the total systems
approach ?
In other words, have you taken each of the suggested — like the
laboratory detection tracers, sensors — have you actually tried to co-
ordinate all that and put a package together ?
Mr. Jaffe. No ; we haven't really done that in this particular case.
Our organization and others like it specialize in doing that sort of
thing, but in this particular application we haven't yet done that.
Mr. Winn. Well, I don't mean to be rude about that, but I gather
that from your guess of $10 million, because I don't think you are
98
in the same ball park about what it would cost. But that is ray own
opinion.
I do think you are on the right track, and I wish possibly some-
where m your realm you would try to coordinate more closely these
potentials.
I don't really care whether any law enforcement agencies in this
country or the world have asked you to do it.
I would hope someone with your capabilities would do it, and there
is a tremendous need for it.
Now, on the satellite capabilities, I have no doubt that within a
very short period of time— and I agree with your time schedule that
within a year, we can view from the air, from satellite, the poppy-
fields. Of course, some one might get up on the floor of the House and
say that their poppyfield had been bugged, but I think we are going
to have to use those approaches, and go at it from that direction.
Because here is a program that is already available to us, here is a
program where we have spent millions of dollars trying to use the
science and technology research capabilities of these men. These are
the same men whom we are now putting out of jobs because some of
our programs are being phased out, and we could use their ability to
help solve some of the drug problems in the country.
I think you are on the right track. I commend you for your state-
ment and I hope that possibly you can put some additional informa-
tion in the record as far as coordination is concerned.
Thank you very much.
Chairman Pepper. Mr. Keating ?
Mr. Keating. No questions, Mr. Chairman.
Chairman Pepper. Mr. Brasco, any questions ?
Mr. Brasoo. Yes, I wanted to ask one question and make an
observation.
I heard several times about an agreement being necessary, but it
would appear to me if we are talking about satellite surveillance I
don't know if we need any agreement to use that kind of technique,
and I think it makes it more attractive because of that because you
are apt to get an arrangement where you can perfect the equipment
before you get an agreement. But the one question I would like to
ask in connection with the sensors that you spoke about, which ap-
parently would detect the drug, you mentioned that they were not
of sufficient capability at this time to be possibly used in satellites.
Could you use whatever equipment you have now, and are they
using it, anyone, if you know, at points of entry in the United States
just to detect it, if someone has it, you know, in a bag or on their
person, or somewhere in the vicinity of the airport or the seaport?
Mr. Jaffe. First of all, there are really two different classes of
things that we mean when we talk about surveillance from the air and
sensing at a point of entry. The techniques for detecting opium fields
from the air are generally available. They just haven't been applied in
this direction and haven't been adapted to this application.
Mr. Brasco. How about the latter one that I was talking about ?
Mr. Jaffe. On the latter one. the Bureau of Customs does have a pro-
gram underway in that area. I don't know of anything being used now.
I don't think anything has progressed to the point where it is being
used now.
99
ISIr. Brasco. Is that a possibility, in your opinion, to develop that
kind of thing:?
Mr. Jaffe. Very much so.
Mr. Brasco, That obviously is not included in the program you are
talkinof about now ; or is it ?
Mr. Jaffe. Yes ; it is included in the program suggested.
Mr. Brasco. How far might we be away from getting something like
that effected? I am talking about — let's take away the satellites and
the other kinds of survellances that we could develop something that
customs agents could use for detecting on peojjle, in bags, what have
you, on ships coming into the United States.
Mr. Jaffe. I think with the right kind of program, on the order of a
year.
Mr. Brasoo. Do you have any idea as to what that specific item would
cost, just that item.
Mr. Jaffe. That is so hard to do without sitting down and working
it out for that particular application.
Anybody want to guess ?
Mr. Brasco. Xo idea ?
Mr. Jaffe. It is very easy to say on the order of a half a million
dollars to a million dollars, something like that.
Mr. Brasco. Thank you. Dr. Yondorf , do you have anything to add
to what Mr, Jaffe has said ?
Dr. YoxDORF. I generally agree, but not with his numbers. I, person-
ally, guess — I haven't made a survey — that this research could be very
much more expensive, as Mr. Winn has said. How much more is diffi-
cult to say. The sort of thing one would try to permit detection at entry
gates would be some simple thing first, perhaps several techniques in
the area of spectrum analysis. If it doesn't work one would have to try
many other techniques. I don't think we have done enough research,
certainly not any of us here, to have a very good feeling of what mag-
nitude of effort would be required if at first simple things don't work.
First feasibility tests — this is indeed what we suggest here — can
be undertaken and some results gotten within a year. But before one
can make a solid estimate as to how^ much more work is required one
has to have that feasibility study under one's belt. We haven't done
that.
Mr. Brasco. Notwithstanding disagreement with respect to the num-
bers, but you do agree with Mr. Jalfe's position that it can be done?
Dr. Yondorf. That can be done ; yes.
(For more detailed statement concerning proposed research and de-
velopment program see exhibit Xo. 8(a) page 101.)
Chairman Pepper. Mr. Holden, would you add anything?
Mr. Holden. Perhaps just a statement in regard to Mr. Rangel's
point that the militaiy has been flying IJ-2's all over the world and
satellites surveying, apparently, anything of interest. So why haven't
we done this — located illicit poppyfields? It is a question of where
we, as a government, point our cameras find which budget pays for
what type of surveillance coverage.
It is obvious the military has done a lot of work in this area of
aerial and spatial surveillance. The point here is that this activity
ought to receive its fair share of the budget to apply survellance tech-
niques to the fight on drug abuse.
100
Chairman Pepper. Mr, Waldie, do you have a question?
Mr. Waldie. Well, Mr. Chairman, I am intruding in a conversation
that has already occurred, but it seems to me that to invest any great
sums of money in surveying that area of the globe where opiimi is
being grown is moving to the problem in the wrong way. We know
where opium is being grown. It is being grown in Laos. It is being
grown in Burma. It is being grown in Turkey.
It has not been a problem of identifying where the fields are. It is
getting those who grow the opium to curtail production of it. Their
failure to curtail production has not been a failure on their part to
identify where it is being grown.
It would seem to me that money ought to be spent, first, to get
willingness on the part of the governments that own the land on
which the opium is being grown to embark upon a program of eradica-
tion and then, perhaps, to a system in identifying the areas in which
eradication is necessary.
I don't think there is any problem of identifying Laotian opium.
It is participated in by the Laotian Government. They are profiting
from it. Burma opium crops are not any secret ; neither are the Turkey
opium crops. I just am not quite certain why we would invest any
money in aerial surveillance to determine where the fields are that are
growing opium at this point.
Chairman Pepper. I think, perhaps, you didn't get the assumption.
Mr. Jaffe would you state what the assumption was upon which you
recommend the use of these detection devices for growing poppyfields ?
Mr. Jaffe. First of all, the idea that there is no one route, there is
not lust one thing that needs to be done and that the aerial surveillance
of the opium fits into a total scheme of things which would include
such things as international agreements, which would then have to be
enforced, and violations of that treaty would have to be detected.
From there we get to the aerial surveillance. That is one route, to get
to the aerial surveillance.
But it is within the total scheme of things, we think, that aerial sur-
veillance plays a part. I would agree that in the case of Laos there may
be no, or very little reason to want to know where each field is
precisely.
But I think the reasons in Turkey and other countries that are
closer and friendly, the reasons become somewhat more compelling.
It is one thing to have an agreement from them to limit the growth of
opium. It is another thing to be sure that it is actually happening and
to know where it is and isn't happening.
It is in that context that we propose to use it.
Chairman Pepper. Gentlemen, if I understand it, you surmise, as did
Assistant Secretary of the Treasury Rossides. that the bringing in of
heroin to this country is effectuated largely by an international con-
spiracy of people who are perpetrating that crime in order to make
hundreds of millions, if not billions of dollars, a year. They are ruth-
less, they are well organized, they are ably directed.
In other words, it is a criminal conspiracy of great magnitude.
You are suggesting that if we are to be effective against that kind
of an international conspiracy to bring opium into this country and
distribute it we must employ or we should, to be most effective, employ
the most modwn techniques and the most comprehensive program for
dealing with it ; is that the theme of your statement ?
101
Mr. Jaffe. I think it is a very precise statement of the case.
Chairman Pepper. Thank you very much.
Have you anything for the record, Mr. Perito ?
Mr. Perito. Yes, Mr. Chairman.
May we place in the record the supplemental statement and curric-
ulum vitae of Mr. Jaffe; also, the prepared statement of Mr. William
S. Ulrich, which was unfortunately omitted from our New York hear-
ings, but relates to the statements made by Mr. Jaffe, Dr. Yondorf,
and Mr. Hoi den.
Chairman Pepper. Without objection, they will be received.
(The material referred to follows:)
[Exhibit No. 8(a)]
Supplemental Statement of David Jatfe, Department Staff, MITRE Corp.
The suggested research and development program consists of five major parts.
In what follows, each part is further defined in terms of tasks, products, and
probable cost. The cost estimates are related to performance periods, as
appropriate.
The structure of these efforts is highly variable, and the corresponding per-
formance period and cost will be sensitive functions of the approach selected.
A conservative approach can be taken in which ideas are investigated one at a
time, or a redundant program can involve several simultaneous efforts with the
same objective. The cost estimates given below are for conservative approaches.
They are subject to considerable flexibility and interpretation and should be
taken as gross values appropriate only for initial planning.
(1) Surveillance of Opium Poppy Crops
An initial experiment would establish the basis for assembly of test apparatus.
After evaluation of the test gear, designs would be finalized and prototype equip-
ment, suitable for aircraft-bome operation, would be constructed and tested.
Culminating in delivery of the prototype instrument with operating procedures,
this effort might cost about $2.5 million and take 1 to 2 years. The prototype
instrument would be suitable for use by operational agencies in verifying func-
tional utility and in specifying future procurements.
Satellite observations would at first make use of data from available instru-
ments. Only then could the possible need for special hardware be determined.
Depending on the results of initial experimentation, this project could cost
between $500,000 and $2 million. The lower figure presumes ability to use avail-
able data ; the higher one would be the cost of a special instrument package
suitable for flight on a satellite.
(2) Tracer Technology
This effort would consist of identifying tracer materials which could be used
in a variety of operational situations. Contracts would be let to chemical research
firms to develop specific tracers which would be subjected to tests for suscepti-
bility to detection and countermeasures. The product of this effort would be
recommendations to the enforcement agencies for use of a variety of tracers.
Costs are estimated at $1.5 million over a 2- to 3-year period.
(3) Sensor Technology
Techniques known to be capable of identifying heroin would be rated as to
their potential for meeting the constraints of the operational situations. Con-
tracts would be let for redesign of the two best possibilities and for tests of
techniques which might prove to be applicable. Prototypes of the most promising
designs would be constructed, tested, and made available to enforcement agencies.
A continuing effort would be devoted to finding additional useful concepts and
designs. In a 5-year period, it is expected that three or four prototypes would
be completed at a total cost of about $4 million.
(4) Data Handling
A computerized data bank would be designed using information on all facets
of illicit drug production, distribution, use, and control. Information to be in-
cluded would be determined by the operational requirements of the enforcement
102
agencies and input data would be supplied by those agencies. The agency charged
with maintaining the data bank would be provided with a complete system
design, including performance specifications for hardware and software. They
would also receive technical assistance during the implementation and testing
phases. Total cost of this effort is estimated at about $1 million.
(5) Netivork Modeling
Drug production and distribution networks, and their economic systems, will
be simulated by mathematical relationships and other representations. The
models will be operated to reveal sensitivities and vulnerabilities of the illicit
trade. This project is viewed as a joint effort by the model developers and a
user agency for 5 years, after which the model will be run entirely by the agency.
The 5-year cost above the normal agency costs will total about $1 million.
[Exhibit Xo. 8(b)]
Curriculum Vitab of David Jaffe, Department Staff, MITRE Corp.
EDUCATION
Brooklyn College, B.S., 1951, physics and math.
University of Connecticut, M.S., 1952, physics and math.
Additional graduate courses in solid state physics, mathematical statistics, and
magnetic resonance.
EXPERIENCE
The MITRE Corp., September 1970 to present :
Department staff. Concerned with the application of technology to criminal
justice systems. Communications, information systems, sensors and alarms, and
specialized technology are the subjects of these efforts. Methods of approach
include operations analysis and systems engineering.
Research Analysis Corp., October 1965 to September 1970 :
Deputy head, public safety department. Developed program concepts for
research in law enforcement and the administration of justice. Directed studies
including the relationship between the physical environment and crime rates,
logistic support to police and fire departments in combating civil disorders, the
development of specifications for techniques and devices in the prevention of
burglary, the role of the police in a ghetto community, and others.
As deputy department head of RAC's unconventional warfare department,
conducted studies of dissident and insurgent grouns. their modes of operation,
and their vulnerabilities. Assessed national threats from internal and external
population segments. Investigated the feasibility of techniques designed to
measure magnitudes of insurgent activities.
American Machine d Foundry Co., Alexandria Division, 1959 to 1965:
Assistant manager, space instrumentations department. Directed the re-
research and development activities of about 30 men. This group, consisting of
physicists, electronic engineers, and mechanical designers as well as support per-
sonnel, specialized in the conception, design, development, fabrication, and test-
ing of scientific instrumentation, primarily for use on satellites and rockets.
Areas of primary competence include X-ray. optical, and microwave instrumen-
tion and measurements. A major nroject was the design and constrnrtion of soft
X-ray solar spectrometers for flight on Aerobee rockets and the OSO series of
satellites.
As head of physics section, directed experimental and development programs
in general phvsics. iuf'luding classical and quantum disciplines. Tvnimi pro-
grams were the investigation of gaseous microwave spectroscopy involving ex-
tremely sensitive receivers ; visible signals in space, their sources, and their
interactions: develonment of specialized ontical and electro-ontiral sy--tenis and
instrumentation: ion and atomic beams for space communication: parametric
amplifiers: the generation of submillimeter waves: standardization measure-
ments on microwave components: microwave attenuation in dielectric materials.
Diamond Ordnance Fuze Lahnrntoric^. iri"> to 1959.
Conducted theoretical and experimental studies of the behavior of ferromag-
netic materials at microwave frequencies. Investigated ferromagnetic resonance
in ferrite and garnet materials to develop a microwave detector. Measured the
103
magnetostrictive behavior of ferrites. Made infrared measurements of ferrite
materials.
Ballistic Research laboratories, 1953 to 1955 :
Employed high resolution radioactive tracer techniques in the investigation of
internal ballistic effects. Designed and constructed scintillation and photomulti-
plier systems for detection and location of radioactive sources.
Naval Ordnance Laboratory, 1952 to 1935 :
Designed tests and associated equipment for the evaluation of electronic and
magnetic underwater ordnance components. Included were opertaional, life, and
environmental tests. Designed an automatic and fast-operating open-circuit tester
for a complex cable harness.
HOXORS
Sigma Pi Sigma (physics) .
PUBLICATIONS
D. Jaffe, J. C. Cacheris, and N. Karayianis, "Ferrite Microwave Detector,"
Proc. IRE, 46 (3) : 594-601, March 1958.
D. Jaffe, Cacheris, and Karayianis, "Detection of High-Power Microwaves by
Ferrites and Garnets," Diamond Ordnance Fuze Laboratories, TR-867, Wash-
ington, D.C.
D. Jaffe et al., "Some Aspects of Indicator Analysis," Research Analysis Corp.,
RAC-S-1900, McLean, Va., 1966.
Other reports classified or proprietary.
[Exhibit No. 9]
Prepared Statement of William F. Ulrich, Ph. D., Manager, Applications
Research, Scientific Instruments Division, Beckman Instruments, Inc.,
Dated June 27, 1970
Scientific methods have numerous applications in law enforcement programs
including the detection and determination of narcotics and dangerous drugs. Yet,
utilization of modern technology still falls short of its potential in this field. I
appreciate the opportunity to comment on this point and to discuss areas in which
positive action might be taken.
To a large extent my remarks are based upon discussions with individuals
from various law enforcement agencies throughout the country. Almost without
exception, these people have been cordial and most helpful in describing the
needs and practices in their diverse operations. From their comments it is obvious
that narcotics and dangerous drugs, which only a few years ago were encoun-
tered rather infrequently, now represent a major factor in their daily workloads.
Furthermore, the problem is not restricted to major population centers but can
be found in virtually all sections of the country. To combat this, mre effective
methods are needed for handling the large number of samples processed each
day. Even more desirable is the development of new technology which will pro-
vide an effective means for halting production and preventing distribution of
illicit materials.
In evaluating technology in this regard, several distinct areas merit consider-
ation. The first and perhaps simplest of these is to improve the utilization of
techniques and methods which have already been developed within this field.
In an age when communications permit instant transmittal of information and
computers can be used for storage and retrieval, much of the technical informa-
tion within the law enforcement field still follows a relatively slow and haphaz-
ard path. Several publications are devoted to this purpose but even with these
information is often delayed. Even worse is the fact that much of the infor-
mation either is not published at all or is published in journals or internal publi-
cations which are not readily available to other workers. Certainly this is not
an insurmountable problem but it does require an organized program which
w^ould encompass all efforts in this field.
A related area to be considered is the utilization of technology developed in
other disciplines. Many of the techniques and metbod^ applied for the life
sciences, space research, environmental control, and other areas can serve
equally well in the law enforcement field. In fact, this has been the basis for
much of the technology now in use. However, for this to be truly effective,
greater contact with these disciplines must be fostered.
In both of these areas, there should be greater opportunity for law enforce-
ment scientists to devote time to development efforts. With present workloads.
104
most facilities are barely able to handle daily problems let alone give thought
and attention to new and improved methodology. Only a relatively few lab-
oratories are able to do this type of work and even in these much of the effort
is performed on an ott-huurs basis. Until this situation is improved, technical
advancements will be slow and inefficient.
In assessing opium products, more specific objectives can be considered. Es-
sentially, this market can be described on the basis of classical supply and de-
mand principles. Greater control can be achieved either by restricting the
supply or by decreasing the demand. The latter involves a host of social, en-
vironmental, medical, and other factors. Technology participates in these but is
not a dominant factor.
On the other hand, scientific methods can and do play an active role in com-
bating the production and distribution of illicit narcotics. Current technology
provides simple and reliable procedures for identifying and quantitatively
determining these substances even when they are heavily diluted with excip-
ients or present in minute quantities. Unfortunately these methods are applicable
mainly to seized materials and are relatively ineffective for interception pur-
poses. Thus, they are more useful for prosecution than for prevention whereas
ideally the latter would be preferred. Therefore, more consideration should be
given to the development of remote sensing and tracer techniques.
In terms of opium products, at least six discrete points can be identified where
technology can be applied :
(1) The point of origin; namely, the naturally occurring or cultivated crop.
This represents an ideal point at which specific tracers could be added.
(2) The facilities where the raw material is refined and processed to yield
high-grade morphine and heroin. Surveillance here might be facilitated by de-
tection of the chemical reagents utilized or emitted during processing.
(3) The port of entry where the illicit material is brought into the United
States.
(4) The secondary processing facility where bulk samples are diluted and
repackaged.
(5) Transportation to the ultimate user.
(6) The user, his dwelling or property.
Each of these represents a unique set of circumstances and levels of difficulty.
For example, chemical detection of material in sealed containers is far more
difficult than when it is being processed or otherwise exposed to the atmosphere.
In the first case, it may be necessary to open the container for detection whereas
in the latter even remote sensing is conceivable. In terms of need, interception
near the source is more desirable than at the ultimate user because of the
quantities involved. The point to be made is that interception is not a simple,
single concept but rather a set of individual opportunities each of which
should be examined on its own merit. Therefore, an approach similar to that
used by systems-oriented technologists can be visualized. A simplified outline
of such a program might involve the following steps :
(1) Clearly define primary and secondary goals.
(2) Research and evaluate existing state-of-the-art or level of knowledge
of the known and presumed technology which may be involved.
(3) Outline all approaches conceivable for achieving the specified goals.
(4) Evaluate current feasibility of each approach, the manner in which these
interrelate, and the potential for their practical application.
(5) Select the approach or approaches which should be pursued as based on
social and economic factors and the probability of technical achievement.
(6) Design, develop, and test the new technology, systems, and procedures
and apply to the problem.
(7) Continually evaluate the effectiveness of each approach to insure it con-
tinues to move toward the specified goals and to detect new approaches which
might evolve from the advancing technology. , , i ,
Depending upon manpower and other resources, parallel efforts should be
considered as a means of providing answers in the shortest period. At the out-
set a program should be undertaken to evaluate current capabilities and knowl-
edge which exist within the various agencies of the Federal establishment, inter-
national organizations, academic institutions, and private iiulustry It may well
be that technology already exists for this purpose and only needs to be directed
to the proper aL^encies for exploitation. At the very least, such information would
be of considerable value to law enforcement programs at all levels and even to
external groups such as those engaged in medical research.
105
I would do this committee a serious injustice to suggest that a simple, fool-
proof detection device is just around tlie corner. Ratlier, it seems likely that
progress will be made in orderly steps which ultimately will provide effective
deterrents to the illicit traffic. I urge this committee to provide support and en-
couragement to such a program.
Chairman Pepper. Will Dr. Frances Gearing please come forward?
The committee is pleased to welcome now Dr. Frances Gearing. In
addition to her medical degree. Dr. Gearing holds a master of pnblic
health degree from the Columbia University School of Pnblic Health
and Administrative Medicine.
Since 1957, Dr. Gearing has been associated with the Columbia Uni-
versit}' School of Pnblic Health and Administrative Medicine, where
she now holds the rank of associate professor of epidemiology.
Since 1967, Dr. Gearing has served on the Xew York State Narcotics
Commission's advisory committee on criteria for funding narcotics
treatment pi-ograms. This year, she was appointed a member of the
professional advisory committee on heroin addiction of the District of
Columbia Department of Human Resources.
Since 1965, Dr. Gearing has been director of the evaluation unit
for methadone maintenance treatment program for heroin addic-
tion, in which position she has supervised a comprehensive study of the
efficacy of methadone maintenance and its relationship to crime control.
Dr. Gearing, we w^elcome your testimony on this matter of critical
importance.
Mr. Perito, will you inquire ?
Mr. Perito. Dr. Gearing, we understand that you have conducted
several studies on the relationship between the use of the methadone
modality treatment approach and the decrease in crime by addicts
under such treatment ; is that correct ?
STATEMENT OE DR. FRANCES R. GEARING, ASSOCIATE PROFESSOR,
DIVISION OF EPIDEMIOLOGY, COLUMBIA UNIVERSITY SCHOOL
OF PUBLIC HEALTH AND ADMINISTRATIVE MEDICINE
Dr. Gearing. Yes.
Mr. Perito. I wonder if you could review for the committee the
approach that you took and the type of studies that have been final-
ized by you or under your direction.
Dr. Gearing. Well, for the record, it is all one study. It is a con-
tinuing ongoing evaluation.
We have looked at it in several ways. First of all, we did before-
and-after pictures of what has happened to the patients who have been
admitted to the program, looking at their previous criminal records
and comparing this with what has happened to them since they have
been in the program.
Our latest review would say that you could almost look at metha-
done as some kind of a vaccine against crime and look at it in a vaccine
efficacy-type model and in that light we would say that methadone
maintenance patients have a decrease in their criminality in the first
year of 81.5 percent ; in the second it is about 92 percent; in the third
year, 96 percent ; and for those who stay in the fourth year, it comes
close to 99 percent. That is using the same patients' previous crim-
inality records as a basis for comparison.
60-296 0—71 — pt. 1 S
106
We have also studied a ^roup of addicts who have been admitted to
the detoxification unit at Morris Burns Institute in New York City.
This is a short-term drym^ out process where they remain in the facil-
ity for approximately 2 weeks, .qfettintr decreasing: doses of methadone.
We matched these people with patients in the studv populaHon and
looked at their criminal records pr'or to time of admission in detoxifi-
cation and what has happened to them subsequentlv.
The contrast is rather strikinsj. The detoxification does not prevent
crime. Their records, since under our observation, are no different than
thev were prior to admission for detoxification.
Mr. Pertto. Dr. Gearina:. how large a samplinq; did vou use? Did
you use the entire group when you did this profile analysis that you
gave us from 81.5 to 99 percent?
Dr. Gearing. The figures I gave you of the 4 years would be the first
1,000 patients admitted to the pro.qrram. I have another figure for the
first 600 patients who were admitted on an ambulatory basis. The
figures are roughly similar.
Mr. Pertto. The first 1,000 patients, I take it, those were not all
ambulatory patients ?
Dr. Gearing. None of them were.
Mr. Perito. How long were the addicts confined for treatment ?
Dr. Gearing. Six weeks.
Mr. Perito. Then released and come back on a periodic basis ?
Dr. Gearing. No ; they are released, then, to an ambulatory or out-
patient clinic unit where they come in initially every day for their
medication and gradually twice a week.
Mr. Perito. Did you personally secure the raw data or was it pre-
sented to you by people working in the program ?
Dr. Gearing. No, sir ; the majoritv of the data we secure ourselves.
Our prime source is from the New York City narcotics register, as re-
ported from the police.
However, the data that we get from the program would tend to show
that it is very useful, too, because the patients do report to the program
when they are arrested because legal counsel is available to them.
Mr. Perito. Did you take a sampling or did you do some personal
interviews with each of these addicts to make a determination as to
their rate, for example, of illegal activity which did not result in some
type of criminal charges being lodged against them ?
Dr. Gearing. No, sir.
Mr. Perito. Do you know of any study such as this in the United
States where the addicts were interviewed as to their criminal activity
as opposed to a pure evaluation of the process ?
Dr. Gearing. No, sir. I think there is a group at Harvard that may
be undertaking such a study in a patient population in New York.
Our charge was to obtain objective criteria for evaluation, and we
tried to make it as obiective as possible and find things that we could
measure, and the things we could measure were arrests and incar-
cerations.
Mr. Perito. And your study of the New York program is ongoing ;
is that correct?
Dr. Gearing. Yes, sir.
Mr. Perito. I understand that you are also about to do an analysis
and efficacy study of the Narcotics Treatment Administration in Wash-
ington ; is that correct ?
107
Dr. Gearixg. I have been asked to consult with them and assist them
and to set up some kind of ongoing evahiation for their program.
Mr. Perito. Now, going back to your New York program, the
statistics, the 81.5 to 99 percent, did those statistics only include the
1,000, or did the amount of patients in that study increase ?
Dr. Gearixg. No; they decreased because I started with 1,000
patients, the first 1,000 patients admitted. Not all of them have been
in the program for 4 years because of the way the patients were
admitted.
Mr. Perito. What was, to the best of your knowledge, the dropout
rate of the first 1,000 patients ?
Dr. Gearixg. The dropout rate is approximately 15 percent during
the first year, about 5 percent in the second year, and about 2 percent
a year for the ensuing years.
Mr. Perito. Did your analysis also include an evaluation of their
return to work or to school ?
Dr. Gearix^g. Yes, sir.
Mr. Perito. Could you tell us what those statistics show ?
Dr. Gearixg. The average employment percentage for patients en-
tering the program during the early phases was approximately 25
percent.
Those who stayed in the program for 6 months, approximately 45
percent of them were employed.
Those who stayed in the program over a year, the percentage goes
up to 55, and for those who have been in the program 5 years or longer,
it is approximately 90 percent.
Of those who were admitted initially on an ambulatory basis be-
cause of the selective process by which they tested the ambulatory
procedure, a higher percentage of them were employed or in school
at the time of admission.
So that their rate of increase of employment is not as great.
However, it levels off to approximately the same figure at 18 months.
Mr. Perito. Dr. Gearing, did you ever have occasion to do a com-
parative study of the drug- free approach in New York ?
Dr. Gearixg. Did I ever have occasion to ?
Mr. Perito. Yes.
Dr. Gearixg. I offered my services. They were not accepted.
Mr. Perito. Do you know of any studies done similar to the studies
which you did on the methadone programs in New York of drug-free
programs anywhere in the United States ?
Dr. Gearixg. I wish I did.
Mr. Perito. To the best of your knowledge, those studies do not
exist ?
Dr. Gearixg. That is correct.
Mr. Perito. Dr. Gearing, you have presented us, kindly, with a paper
which you presented to the Third National Conference on Methadone
Treatment on Saturday, November 14, 1970 ?
Dr. Gearixg. Yes, sir.
Mr. Perito. And also a paper which you gave at Pontiac, Mich.,
on December 2, 1970, and these relate to your studies of the evaluation
of the methadone maintenance approach ; is that correct ?
Dr. Gearix'g. Correct,
Mr. Perito. Are these the two latest studies which you have done ?
108
Dr. Gearing. Yes, sir; I would not consider the position paper a
study. That was a lawyer's confrontation for which I wrote a position
paper.
Mr. Perito. Mr. Chairman, I would at this point ask that these two
papers be incorporated in the record.
Chairman Pepper. Without objection, they will be admitted for the
record.
(The documents referred to above appear at the end of Dr. Gearing's
testimony.)
Chairman Pepper. Just one question before we proceed.
Is it your conclusion, therefore. Dr. Gearing, from the studies that
you have made over a period of time that methadone is the best treat-
ment now known and now available for heroin addiction?
Dr. Geartxg. I wouldn't make quite that strong a statement, ISIr.
Pepper. I would say that for those patients who volunteered for the
methadone maintenance treatment program who have a history of
long-term heroin addiction, this is the best treatment we have at the
moment ; yes.
Chairman Pepper. And you did find a striking diminution in the
amount of crime committed by the people who took methadone who
previously had a heroin addiction ?
Dr. Gearing. Yes, sir. These were patients who by definition, to get
into the program, have had to be known as "criminal addicts." They
had to have had previous infractions of the law.
Chairman Pepper. Have you had long enough experience with these
people who took methadone to determine Avhether it became addictive
with them.
Dr. Gearing. I am not sure the patients who have been on the pro-
gram a long time consider themselves addicted. They consider them-
selves dependent, and happily dependent because it has freed them
from the problems they had when they were chasing heroin.
Chairman Pepper. Did you find the people who took methadone over
a period of time have suffered any apparent trouble or physical injury ?
Dr. Gearing. As far as we can determine, from serial medication
examinations, and the patients in the program 5 years or longer have
been monitored carefully, there seems to be no physical or physiologi-
cal problems.
Chairman Pepper. Yesterday, we had some distinguished witnesses
here who said that they did not think that private physicians should be
authorized to prescribe methadone.
What is your recommendation on that ?
Dr. Gearing. If you will look at the recommendations that the ad-
visory committee and I put together at the end of that last rei)ort, we
make the same recommendation, that it is not for use of the ])hysician
in his private office, because methadone, in and of itself, is only really
a brid.o-e which allows the patients time to get involved in their own
rehabilitation.
The big need, for manv of them, is to gain extra skills, to find a job,
and many other social services.
Chairman Pepper. Mr. Blommer, do you have any questions?
Mr. Blommer. Yes.
109
Doctor, on page 3 of the paper that you have kindly given us, you
show the reasons for discharge from the program as being alcohol
abuse and abuse of other drugs. Now, these figures are relatively
small.
What standards are applied to the people in the program that
could lead to their being discharged ?
Dr. Gearing. Every effort is made in the program to help them
with their problems. It is continual abuse, and inability to handle
their other problems, that may lead to discharge.
But there are supportive services. In fact, particularly in the Har-
lem area, working on the alcohol problem they have one full-time
person. And many of the patients do very well.
Mr. Blommer. Doctor, would it be a fair statement to say that
merely because someone is abusing the program, and by that I mean
not just taking methadone, but also taking alcohol, taking ampheta-
mines, that this abuse would not be grounds enough to drop them from
your program?
Dr. Gearing. That is correct. I think initially they were dropped
from the program for two reasons :
One was the program was not equipped to handle these problems;
and second, there was such a long list of patients waiting to get into
the program; the waiting time had become so long that the decision
on the part of the program people was, "How to do the best job for
the greatest number," and if some patients Averen't making it then it
was better to substitute somebody else. I think that was the philosophv
as I understood it,
Mr. Blommer. In any case. Doctor, if someone has a job, would you
say they Avould most likely be retained in the program, that job being
an indication they were adjusting?
Dr. Gearing. Someone has a job, even though he may be abusing
drugs or alcohol ; definitely.
Mr. Blommer. So that your statistics of people having a job bene-
fits your program?
Dr. Gearing. It is not my program, sir.
Mr. Blommer. Excuse me. The program that you evaluate. The
chart seems to go up, showing that more and more people have jobs,
and the sampling goes down.
Dr. Gearing. It is not the sampling. Remember, patients are being-
admitted all the time. So that at any point in time you have so many
patients in the program only 2 weeks or 3 months. For instance, when
I started evaluating the program there were 66 patients in the pro-
gram. Forty-five of those patients are still in the program, but those
are the only ones on whom I can say I have a 5-year followup, because
that is all the patients who had been admitted at that time.
Mr. Blomer. In other words, there are fewer and fewer patients
that meet the criteria ; is that correct?
Dr. Gearing. No ; the program started 5 years ago with 66 patients.
That is all the 5-year followup patients I could possiblv have, ever:
right?
Mr. Blommer. I see.
Dr. Gearing. Now, in the 4-year followup we have a smaller num-
ber and right now, if I were doing a 3-month followup, I would have
110
somethino: in the nei<rhborhood of 6,000 patients. That is the rate at
■which admissions are being taken on now.
Mr. Blommer. Let me switch topics. Doctor.
Is anyone in the Dole-Nyswander program receiving methadone
maintenance but no therapeutic services?
Dr. Gearing. There is a small group that was started last July.
Mr. Blommer. Have you any statistics on whether they are able to
stay out of trouble and keep jobs?
Dr. Gearing. I have a very short followup on them.
Mr. Bi,0MMER. Is there any trend emerging?
Dr. Gearing. Yes; the dropout rate is somewhat higher. Their ar-
rest record is about the same, and their rate of obtaining new employ-
ment is slightly lower.
Mr. Blommer. The same as the ones who are receiving therapy ?
Dr. Gearing. That is on the first 100 patients.
Mr. Blommer. Would it be a fair statement to say that the trend,
then, is away from therapy as opposed to more therapy ?
Dr. Gearing. No; I would say the trend is an attempt to select out
of a group of patients who need the additional supportive services and
concentrate the supportive services on those who need them the most,
or start with supportive services for patients who seem to need it and
gradually put them into a less-structured program.
Mr. Blommer. I have no further questions, Mr. Chairman.
Chairman Pepper. Mr. Waldie ?
Mr. Waldie. No questions.
Chairman Pepper. Mr. Wiggins ?
Mr. Wiggins. Yes, Mr. Chairman.
Doctor, what is the proper name for this program to which we have
referred in general terms ?
Dr. Gearing. It was ori.qinollv known as the Dole-Nvswander pro-
gram ; later on known as the Beth Israel procrram ; now the Methadone
Treatment Program in New York City and Westchester County, be-
cause it now encompasses, in addition to those units I have mentioned,
another unit in the Bronx and the New York City program which
started the first of November.
Mr. Wiggins. Who is the dire<"tor of the program ?
Dr. Gearing. Dr. Harvey Gollance would be the director of those
portions that come under what is now called the Beth Israel program.
Mr. Wiggins. How do you spell his name ?
Dr. Gearing. G-o-l-l-a-n-c-e, and Dr. Robert Newman is the direc-
tor of the New York City program and Dr. Edward Gordon is the
director of the Westchester program.
Mr. Wiggins. Is this a private program or a Government program ?
Dr. Gearing. Beg pardon ?
Mr. Wiggins. Is this a private program or a Government program ?
Dr. Gearing. It is a projrram, with one small minor exception,
supported by the State of New York Narcotics Addiction Control
Commission.
Mr. Wiggins. So far as you know, are there any direct Federal
grants involved in the program ?
Dr. Gearing. As far as I know, except for perhaps some laboratory
research at Rockefeller University, there is no Federal money in this
program.
11(1
Mr. "VViGGixs. How does a patient qualify for the program, Doctor?
Dr. Gearing. Well, that is a little bit out of my field, but a patient
applies for admission. He is screened and he has to meet certain
criteria.
Mr. Wiggins. Would it be accurate to say that all of the patients
are voluntary?
Dr. Gearing. Absolutely. In fact, they have to sign a voluntary
commitment to take the medication.
Mr. Wiggins. Is there a method, so far as you know, of course in
the State of New York, whereby courts may compel attendance to
methadone programs as a condition to probation, for example?
Dr. Gearing. Compel ?
Mr. Wiggins. Yes, ma'am.
Dr. Gearing. No; I think they can give the patient the option of
taking methadone or going into one of the other nonmedication pro-
grams.
Mr. Wiggins. Have you had any experience in evaluating other pro-
grams in which you might give us some guidance concerning the
wisdom of compulsory methadone programs.
Dr. Gearing. No ; I sort of shudder at the thought of compulsory
treatment programs. I would think that voluntary treatment programs
in prisons might be useful.
I think to legislate medication goes against my physician's blood.
Mr. Wiggins. Yes, ma'am.
You describe in your prepared statement certain security techniques
that are employed to insure that your patients are not using the pro-
gram to satisfy their own drug needs. How is this information au-
thenticated ?
More specifically, let us suppose that a patient qualified, how do you
know that he is not also continuing to feed his heroin addiction on the
street ?
Dr. Gearing. Well, he is periodically tested with urine samples.
Initially, he has a urine sample taken every time he comes in. While
the patients are being built up to their tolerance dose, many of them
do shoot heroin, there is no question about it.
Mr. Wiggins. Will a urine sample detect the presence of heroin ?
Dr. Gearing. No : it will detect the breakdown products, morphine,
and also since we in New York still cut it with quinine, it also detects
quinine.
Mr. Wiggins. In that event you can still tell whether a patient is
continuing to feed his heroin addiction by shooting heroin from th"
street ?
Dr. Gearing. Yes.
Mr. Wiggins. How about the other drugs ?
Dr. Gearing. This is really a program-type question. I happen to
know something about it, but this is not really my field.
The other drugs, amphetamines, barbiturates, methadone, and co-
caine, can be detected in urine. Marihuana and alcohol ; no.
Mr. Wiggins. Let's suppose a patient signs up for and qualifies for
a program in New York City and he also tries to sign up and qualify
for another program to get a double dosage. How is that prevented 2
Dr. Gearing. We are attempting to prevent this in that we have
what is known as a data bank where each patient that applies for a
112
program is put into the machinery and matched by his first name,
last name, and his mother's maiden name, which seems to be more
useful than the birth date, to prevent this kind of duplication.
So far, I think two have been picked up.
Mr. Wiggins. If a person just simply used a different name, would
he be detected ?
Dr. Gearing. No. What purpose would be served by a patient going
to more than one program 'i
Mr. Wiggins. Well, 1 don't know, Doctor. Maybe you can help me.
Dr. Gearing. Because he takes his medication daily. He takes his
medication at the clinic. He is giving no medication to take home.
Mr. Wiggins. I understand that. Would a person who is dependent
upon methadone and had a prior history of heroin addiction, get a
greater euphoric effect, or whatever the impact may be, from a second
dose of methadone than he would from just one ?
Dr. Gearing. You will have to ask the patients. I don't know.
I know the experience with the majority of the patients who have
been in the program for some months, many of them ask to have their
dosages cut down. They do not develop a tolerance like with heroin
where they have to get increasing dosage. At the stabilizing dose, some-
where between 80 and 120 milligrams a day, they don't appear to crave
more.
Mr. Wiggins. Is that conclusion generally held in the medical com-
munity ; namely, that a stabilizing tolerance is achieved with metha-
done programs, unlike other analgesic substances ?
Dr. Gearing. I don't think there is anything about the drug addiction
field that is universally held in the medical profession.
Mr. Wiggins. Do you have any comment about that? Have your col-
leagues, so far as you know, come to a contrary conclusion?
Dr. Gearing. None who work for the program; no.
Mr. Wiggins. Doctor, I gather that there is some diversion in
methadone and that it can be obtained occasionally on the street. What
do you believe is the source of that diversion?
Dr. Gearing. In New York City the source of that diversion is al-
most exclusively the private-practice physician who, in being kind to
his patient, gives him not one dose but several doses, such as a pre-
scription for several doses or a week's supply.
Mr. Wiggins. Do you have any recommendations to this committee
on how that problem might be curtailed ?
Dr. Gearing. I think my recommendation is that I wish that physi-
cians were not giving it in their private offices, but apparently that is
being done.
Mr. Wiggins. Will it be your recommendation that the private dis-
pensing of methadone outside of a control clinic be banned entirely ?
Dr. Gearing. No; the recommendation is that those physicians wlio
are interested in working with drug addicts in methadone maintenance
affiliate themselves wnth some kind of an ongoing progi-am and that as
the patients become stabilized and no longer need the supportive serv-
ices of a total program that the private sector could then take on the
patient.
Mr. Wiggins. Doctor, so far the witnesses agree that methadone is a
dangerous addicting narcotic, and 1 am sure you agice with that
statement.
Dr. Gearing. Yes.
113
Mr. WiGGixs. Is it more difficult to withdraAv a patient addicted to
methadone than it is a patient addicted to heroin ?
Dr. Gearing. No; I think it takes a little bit longer, because the
methadone that they are getting when they are on methadone mainte-
nance is pr-etty good stuff. The heroin that they are getting on the street
is not such good stuff.
Mr. Wiggins. I am going to use a term that may not be appropriate.
I am going to use the term "euphoria." That may not be truly descrip-
tive of the effect on the human body, but you use the appropriate tenn.
What is the difference in the euphoric effect between the use of heroin
and the use of methadone ?
Dr. Gearing. The difference is primarily in the mode in which it is
given. If methadone is injected euphoria is obtained. Methadone given
by mouth, the euphoria, as I understand, it does not occur.
Heroin given by mouth doesn't do anything.
Mr. Wiggins. Methadone is an antagonistic drug; isn't it?
Dr. Gearing. No ; it is known as a block.
Mr. Wiggins. Yes ; but it is not antagonistic.
TVhat satisfies the psychic craving for the euphoric effect if they
don't get it on the methodone maintenance program ?
Dr. Gearing. My judgment Avould be that the heroin addict has two
phases. He has a euphoric phase. He also has a fear of withdrawal
phase. I think that this stabilization seems to block that craving. I can't
answer that any further because I don't know.
Mr. AViGGiNS. Have you observed that there is abuse by shooting
methadone on the streets of New York, for example ?
Dr. Gearing. Very little.
Mr. Wiggins. Is it more dangerous if applied intravenously?
Dr. Gearing. The methadone that is used in the methadone main-
tenance program is theoretically noninjective.
Mr. Wiggins. That i=i all I have, Mr. Chairman.
Chairman Pepper. Mr. Waldie ?
Mr. Waldie. No questions.
Chairman Pepper. Mr. Brasco ?
Mr. Brasco. Yes.
Dr. Gearing, I understood you to say before — correct me if I am
wrong — that the methadone detoxification program as measured in
relationship to criminality was not as successful
Dr. Gearing. I didn't talk about the methadone detoxification pro-
gram. I talked to about 100 patients that we selected out of the detoxifi-
cation program by virtue of the fact that they matched by age and by
ethnic group and time of admission to detoxification unit the patients
in the methadone maintenance program, and we followed this.
Mr. Brasco. May I ask you this. Doctor? In connection with the
methadone maintenance program ; is there anything within the con-
fines of the program itself that leads toward the eventual withdrawal
of all drugs ?
Dr. Gearing. There is no plan in the program for a time when a
patient shall be withdrawn from methadone ; is that what you mean ?
Mr. Brasco. Yes.
Dr. Gearing. Many of the patients ask to be withdrawn with the
notion that they think they can make it on their own, and they are
withdrawn and then they are given the privilege of returning. I think
114
you have some data there that shows that a goodly portion of them do
return.
Mr. Brasco. They do return ?
Dr. Gearing. Although a small proportion of them go into absti-
nence programs.
Mr. Brasco. In connection with dispensing of methadone, I under-
stood you to say that initially the patients took their dosage at the insti-
tution where they entered the program and later on they come twice a
week.
Dr. Gearing. Some of them come twice a week. Some of them never
get beyond the every day. This depends upon a good many things, in-
cluding their own rehabilitation.
Mr. Brasco. I take it those who come twice a week
Dr. Gearing. Yes ; in a locked box.
Mr. Brasco. No ; I wasn't trying to be — I personally agree with your
first statement. Maybe I should have said that first, that this is proba-
bly the best we have to offer.
Dr. Gearing. At the present time.
Mr. Brasco. What 1 was trying to do was to get some answers from
you. The program has been from time to time, as you know, criticized.
One of the things is the incidence of death. I heard some statistics — I
am not saying it is true, I am just saying
Dr. Gearing. That is from what, bv whom ?
Mr. Brasco. Where did we get the statistic, Paul, with respect to
the deaths ?
Mr. Steiger. In children.
Dr. Gearing. Death in children, three.
Mr. Steiger. Six.
Dr. Gearing. Is it six now ? In New York City ?
Mr. Steiger. Here, in Washington, D.C.
Mr. Brasco. In any event, is there any reason why we couldn't have
all of the people in the program report every day for their dose?
Dr. Gearing. It impairs the rehabilitation of the patient. In trying
to be fair to a patient you would like to give him some freedom as he
stabilizes and becomes a productive citizen.
Therefore, this is actually the one punitive measure that is used in
a program, and that is if a patient begins getting into trouble or act-
ing up or abusing other drugs they are put back to having to come in
every day.
At the moment, they are all given weekend medication to take
home.
Mr. Brasco. Just one last question in connection with Mr. Wiggins
line of questioning concerning the fact that some of the methadone
was getting into the streets of New York. That must be measured with
the severe limitations that there are in connection with the program.
I had a young man come to my office several weeks ago, and it took
me a day and a half, calling all oVer the place, trying to find a spot
for him. ,
In any event, I kind of suspect that if the program was developed
i n large cities in the way that you described
Dr. Gearing. The program is expanding astronomically.
Mr. Brasco (continuing). There would never been any need tor it
being dispensed by anyone else.
115
Dr. Gearing. The New York City program, which started on No-
vember 1, was wondering where they were going to get their patients.
They now have a waiting list of over 1,000 patients. They have 3,000
who may be accepted, and money for 2,000, and the other 1,000 will
be waiting.
Mr. Brasco. The question really is : In New York there are mone-
tary limitations?
Dr. Gearing. It is monetary limitations and staffing.
Mr. Brasco. And staffing ?
Dr. Gearing. Yes; and also finding locations which will accept a
narcotic treatment program in the area. Not every area of New York
City, as you may know, enjoys the idea of having a methadone main-
tenance treatment program on their block.
Mr. Brasco. Unfortunately, I do know something about that.
Might we integrate that with a hospital service? Might that help
cut down on that problem ? In other words, use a portion of a hospital ?
Dr. Gearing. This has been done at Delafield and the Washington
Heights Center. There are two units in the Washington Heights
Health Center and one in the Delafield Hospital.
Mr. Brasco. Thank you.
Chairman Pepper. Mr. Steiger.
Mr. Steiger. Thank you. I was very interested, Doctor, in Mr. Wig-
gins' approach on the possibility of the patient continuing his heroin
habit undetected. The urine analysis is the only method that this
program uses to detect the heroin ?
Dr. Gearing. It is the only method there is, as far as I know, and
it only detects heroin taken within the last 24 hours.
Mr. Steiger. I assume they use interviews also; I mean, they ask
them?
Dr. Gearing. The patients squeal on each other.
Mr. Steiger. ^Yhat is the incentive to squeal ?
Dr. Gearing. Pride in the program.
Mr. Steiger. Is there any method you know of, of beating the test,
beating the urine analysis ?
Dr. Gearing. Oh, I am sure there is. The urine analysis is not used
in the punitive sense. It is used primarily for counseling. They don't
shake their finger and say "You have been a bad boy."
Mr. Steiger. An addict who was continuing a heroin habit and had
the desire, he could conceivabl}^ continue it and stay in the program
undetected ?
Dr. Gearing. I wouldn't say undetected; no. There have been, I
think, something like 1 percent of the patients who have been dropped
from the program for continual shooting of heroin after they were
reaching — supposedly — a stabilizinsr dose. The theory here is that in
these patients this treatment doesn't work, obviously.
Mr. Steiger. The ingenuity of the addict is fairly well known. He
will do a great many things to achieve — to acquire — the drug and
use it. It occurs to me that maybe we, as an interested coneressional
committee, might want to explore possibly a more efficacious test.
This would be my only concern, because we have had reports of urine
analysis, the methods of beating urine analysis itself, some very in-
genious methods. It occurs to me it might be worth while to explore a
better test.
116
Dr. Gearing. It depends on what you are concentrating on. Are you
concerned about the urine or the patient ? I really don't know what
difference the urine makes if he has become a productive citizen and
is able to function and is staying out of jail, because I suspect that in
certain groups of the population, we could test for a variety of drugs
and find habitual users, even among such illustrious people as among
our Congress.
Mr. Wiggins. Users of what ?
Dr. Gearing. Drugs, amphetamines, barbiturates, tranquilizers, pep-
up pills, et cetera.
Mr. Wiggins. I just didn't want you to be misunderstood as accusing
Members of Congress shooting heroin.
Dr. Gearing. No. I think in a rehabilitation program of this kind
one can get overly hung up on urine testing, which is a very expen-
sive and time-consuming part of the operation. I think it is very good
from a counseling standpoint to let the patient know that big brother
is watching him, but as far as handling the patient and his problem,
it is not his urine you are concerned about.
Mr. Steiger. The whole problem, it seems to me, the basic objec-
tion to the problem in terms of laymen is we are substituting one
dependence for another, and in this instance we may not even be doing
that. We may simply be mitigating the original dependence.
I would like to ask one question : On urine analysis, have you been
able to get a statistically representative group of people who have been
through the program for a given period, whatever that may be, and
now no longer take methadone and are no longer addictive and are
productive ? Are' there any fisrures like that ?
Dr. Gearing. We are in the process of trying to find those people.
They can find those who haven't made it. That is the easiest thing,
because we can find them through our other reporter services.
We have a group of some 20 percent of the patients who have left
the program that we haven't been able to find through these sources.
We are now in the process of trying to find out what proportion of
these people are, in fact, drug free.
Mr. Steiger. My question is: In your opinion is it possible for
somebody, through the methadone maintenance program, to achieve
independence from methadone and anything else, or do we have to an-
ticipate that he will be a methadone addict for the rest of his life '?
Dr. Gearing. From the information I have at the present time I
would equate methadone maintenance with insulin for diabetics, as
probably a lifelong commitment for many of the patients.
Chairman Pepper. Mr. Mann.
Mr. Mann. Doctor, in your evaluation, what employment problems
or patterns do you find these people having and is the community prej-
udiced or reluctant to employ these neonle ?
Dr. Gearing. The answer to the last question is yes. in some areas.
The experience that has come about in the pro.Qfram is that it is like
getting the first olive out of the bottle. Gettin.q; the first man on meth-
adone maintenance employed in a particular industry or jxroiin is the
tough one. Once they have accepted the first one and thev find out
that he is a useful citizen, then getting other people into that is a
simnler iob. That is one point.
The main point, I think, is that many of them have to be given
117
some kind of skill training in order to be employable above the wel-
fare level, and this has taken some doing and is an active part of
the program.
Does that answer your question ?
Mr. Mann. Yes ; thank you.
Can a person be on methadone and take a periodic heroin shot
for the euphoric effect and incur no increased physical danger be-
cause of the combination of the two ?
Dr. Gearing. I can't answer the question on physical danger. The
answer from the standpoint of the patient is that many of them in
the first few months that they are on methadone maintenance do
shoot heroin and come back very angry because they spent their money
on nothing, because they get no euphoria. That is supposedly the block
of methadone, is that it blocks the effects of heroin.
Chairman Pepper. We will take a short recess at this point.
(A brief recess was taken.)
Chairman Pepper. The meeting will come to order, please.
Dr. Gearing, if I may interrupt before the other members return,
I Avould iust like to ask you three things :
One : We have had reports that about six people have died fn the
District of Columbia in the last few months from taking methadone.
Have you any comment to make on that ?
Dr. Gearing. I would defer that to Dr. DuPont in his testimony,
because he has the knowledge. I have only read it in the newspapers.
Chairman Pepper. Have you experienced deals from methadone in
New York?
Dr. Gearing. Yes.
Chairman Pepper. Roughly how many ? ^
Dr. Gearing. Aside from the ones in children, which were acci-
dentally taken thinking it was orange juice, I think that there may be
two or three in the young teenagers.
Chairman Pepper. In your experience, are the deaths generally in
cases where they were not previously addicted to heroin and they just
started right off taking methadone ?
Dr. Gearing. They were not tolerant to the dose of methadone they
were taking. Whether they were on other drugs or not, I don't know.
Chairman Pepper. Does the taking of heroin give you a tolerance for
methadone ?
Dr. Gearing. I don't know.
Chairman Pepper. Well, the deaths, you would say, are people who
have not developed tolerance for methadone ?
Dr. Gearing. That is correct.
Chairman Pepper. Who are beginning to take it for the first time ?
Dr. Gearing. Who just took it accidentally or just for kicks, just like
many of the heroin deaths we have in New York City are not in
addicted kids. They are. in kids that are shooting for the first or second
time and get either an allergic or some other kind of reaction, or a real
overdose.
Chairman Pepper. Do you agree with the testimony before this
committee of Dr. Halpern of the city of New York, that any given
dose of heroin, even to an addict, may be a fatal one ?
Dr. Gearing. I certainly wouldn't contradict Dr. Halpern in a field
in which he is an expert and I am not.
118
Chairman Pepper. Would you have any comment to make about the
District of Columbia methadone maintenance program ?
Dr. Gearing. Very few comments at the present time, because I
have just recently started working with them. I think my first com-
ment is on how rapidly it has ^rown and how well they were handling
the problem of large numbers in any single unit.
On my first visit to D.C. Hospital I was overwhelmed with the size
of their population, that they were handling with the staff that they
had and their unit at that point was, I think, something in he neighbor-
hood of 600 patients. In T^ew York City, most of the outpatient units
handle between 125 and 150 patients each.
Chairman Pepper. Do you have enough money and personnel and
facilities for the treatment of all of the heroin addicts in the city of
New York?
Dr. Gearing. Do I, sir ?
Chairman Pepper. Yes. Are there available enough facilities and
personnel ?
Dr. Gearing. I am sure the answer to that is an unqualified no. I
don't know if there is enough money in the world.
Chairman Pepper. Same situation all over the country ?
Dr. Gearing. Yes.
Chairman Pepper. One other thing. Would you state what are the
goals of the methadone maintenance program ?
Dr. Gearing. Freedom from "heroin hunger," decrease in antisocial
behavior, increase in social productivity, and recognition and willing-
ness to accept help for other problems, such as alcohol abuse, other
drugs, psychiatric and medical problems.
Chairman Pepper. Mr. Winn.
Mr. Winn. Thank you, Mr. Chairman.
Dr. Gearing, just a quick question. We heard yesterday in the testi-
mony the difference between psychotic craving and physiological crav-
ing. What is the methadone reaction to these two cravings ?
Dr. Gearing. The two psychiatrists who will follow me will probably
be able to answer that question much better than I.
It would appear from the patients who are admitted to the metha-
done maintenance program in New York City that gross psychiatric
problems are not a major portion of their problems. They have be-
havioral problems very similar to the behavior problems that some of
the rest of us have, and need sometimes more help with those and
psychiatric help is available both on an individual basis and group
psychotherapy.
But it is not universally required.
Mr. Winn. The testimony yesterday was that they could go through
all of these treatments, cold turkey and all of that, and still have a
psychiatric craving, that even though they were supposedly cured, the
psychiatric craving would drive them back to hef oin.
Dr. Gearing. I am sorry, but I don't know what a psychiatric crav-
ing is, so I can't answer your question.
Mr. Winn. But you have heard the term ?
Dr. Gearing. Yes.
Mr. Winn. Thank you very much.
Chairman Pepper. Sorry, Mr. Mann, had you finished your ques-
tioning?
119
Mr. Manx. I have one or two more, and I think perhaps I am in the
psychiatric field, too, but not in the evaluation field.
Would a nonaddict enjoy the methadone program ?
Dr. Gearing. Would a nonaddict ? I wouldn't think so.
Mr. Mann. Well, it offers a lot of other benefits, other than mere
Dr. Gearing. Not really; you have to take an awful lot of medica-
tion every day.
Mr. Mann. Could a nonaddict get into the program ?
Dr. Gearing. It would be difficult.
Mr. Mann. This again is a question I perhaps shouldn't ask.
Does the existence of a methadone program perhaps lessen the stigma
or lessen the resistance to one becoming involved in heroin in the
first place ?
Dr. Gearing. I have no idea but I would think not ; no.
Mr. Mann. You would hope not ?
Dr. Gearing. Yes.
Mr. Mann. You obviously have great faith in this program, and I
am curious as to your major reaction, based on your evaluation as to the
disadvantages, not in detail, but your major reaction to the disad-
vantages.
Dr. Gearing. The disadvantages have been well stated by many
people. The first one is that it is an addictive drug that you are sub-
stituting for another one. This is not my major objection.
The second is it is a drug that has to be taken every day. It is our
hope that at some point there will be developed a longer acting metha-
done kind of treatment.
I think the major objection to the program in New York City is
the waiting time it takes to get into it, once the patient makes the de-
cision that he wants to try it.
Mr. Mann. Thank you.
Thank you, Mr. Chairman.
Chairman Pepper. Mr. Keating?
Mr. Keating. No questions.
Chairman Pepper. Mr. Rangel ?
Mr. Rangel. Yes ; Mr. Chairman.
Doctor, a lot of support is received by the methadone proponents
because of the drastic decrease in crime. You presented, this morning,
some rather dramatic statistics, and if I understand them correctly,
you took a sampling of drug addicts and compared their records after
having gone through the methadone treatment.
Dr. Gearing. Yes; using the same sources of information we use
on patients in the program.
Mr. Rangel. And using their past criminal records as an indication
of how drastic the criminal activities were reduced.
Now, as a part of your program, I understand that you offer medical-
psychiatric-social services, educational, job training, and all of this as
a part of the methadone training program or methadone treatment
program ; is that correct ?
Dr. Gearing. Those services are all available to the patient ; yes, sir.
Mr. Rangel. Assuming that all crimes are not comitted by addicts,
that you had a group of people in central Harlem that have the same
type of criminal record, and they were offered the same type of sup-
portive services, of course, without the assistance of methadone, would
120
it not be so that we could project a drastic decrease in their criminal
activity, especially in view of the fact that many of these addicts are
former addicts employed by the programs on which they are treated?
Dr. Gearing. I would hope that that were true, and I would like
some data to show that it is true. The problem that we have had, is we
have no comparative data, that is the reason we have to force a com-
parison group. We have no data from any group that has such a
facility.
The only data we do have is in the detoxification unit. They do
have a group where they have offered the services and they have not
been terribly successful.
Mr. Rangel. Notwithstanding all of this dramatic data and de-
crease in crime, you could not really determine whether or not the
decrease was due to job training, consultant services, opportunities
for employment, or methadone?
Dr. Gearing. That is correct. What we are saying is that this pro-
gram offering this package in this way is doing this. That is all we
can say.
Mr. Rangel. Right.
Now, in answer to a previous question you were saying that it is pos-
sible for one to get a high, say, from methadone if not given orally.
Dr. Gearing. It is my understanding that methadone intravenously
gives a very nice high.
Mr. Rangel. Well, the drug which is presently being adminis-
tered in New York, could that be reduced to liquid so that it could be
given intravenously ?
Dr. Gearing. As I understand it, it is very difficult. I was goin^ to
say it can't be done, but I was told today that it can, and knowing
addicts who can shoot milk and a few things that some of the rest of
us wouldn't dream of, they probably could shoot it ; yes.
Mr. Rangel. Well, being raised in that community and still li\dng
there, there is some thought we have now developed a type of metha-
done addict, and my real question was in view of the earlier question
of dual registration or using different names, if you now believe, as I
believe, that it is possible to be produced as to what is dispensed to a
drug that can be injected into the body intravenously, then what is to
prevent a community from becoming addicted to methadone as a first
experience in view of the fact that the patient could give any name
and give a different name and receive free drugs?
Dr. Gearing. I think this goes back to my suggestion that the dis-
pensing of the drug is the key issue in this whole problem.
Mr. Rangel. My question was one of registration. As I understood
earlier
Dr. Gearing. The patients do not get a week's supply of medication
to sell on the street. The patient gets one dose that he takes on the
premises.
Mr. Rangel. What about the patients that you were saying come
in twice a week?
Dr. Gearing. Well, those patients are not the source of the drugs
on the street. Those are the patients who have been in the program for
a good long time. They are not selling it.
Mr. Rangel. What I am asking is : Is it possible for this patient to
121
go to two or three different clinics and use two or three different names
and receive two or three weekly dosages ?
Dr. Gearing. If he went to a different place he would have to start
all over again, because he would have to register as a new patient.
Mr. Brasco. Would you yield for one moment?
Mr. Rangel. Yes.
Mr. Brasco. Dr. Gearing, I have heard, as Congressman Rangel has
been trying to point out, that there is some traffic in the street with
methadone, but what would be the value ? This is something that es-
capes me. Why take the methadone if you don't get the euphoric effect
that you want ? Is there some other valiie ?
Dr. Gearing. These are questions that I cannot answer. This is not
my field. I know that there is methadone on the street, and I think I
told you where we believe the major source of it comes from. In fact, it
was highlighted in the Xew York Times the other day. I do not think
that the majority of methadone on the street comes from the patients
who are on methadone maintenance. This is a very valuable piece of
equipment to the patients.
Mr. Brasco. But you don't know, then, I take it, the answer to my
question. "Whether or not the use of methadone is the initial attraction
as the use of heroin would be to an individual ?
Dr. Gearing. I wish you would save those questions for Dr. Jaffe.
Mr. Brasco. Thank you.
Mr. Rangel. My last question is do you know of any reason why the
Food and Drug Administration has not certified this drug?
Dr. Gearing. I think they are overly cautious, to put it mildly.
Chairman Pepper. Any other questions ?
Thank you very much, Dr. Gearing. We appreciate your valuable
testimony this morning.
(The following material, previously referred to, was received for
the record:)
[Exhibit No. 10(a)]
Successes and Failures in Methadone Maintenance Treatment of Heroin
Addiction in New York City
(By Frances Rowe Gearing, M.D., M.P.H. (Supported under Contract No. C-
35806 from New York State Narcotic Addiction Control Commission), Associ-
ate Professor, Division of Epidemiology Columbia University School for Public
Health and Administrative Medicine, and Director, Methadone Maintenance
Evaluation Unit)
For Presentation at Third National Conference on Methadone Treatment, Satur-
day, November 14, 1970, Park Sheraton Hotel, New York, N.Y.
introduction
October 1 marks the fifth anniversary of the establishment of the methadone
maintenance evaluation unit and the first meeting of the evaluation committee.
When our unit began operations there were 66 men and eight women in the pro-
gram and there were facilities available to admit approximately seven new
patients each month. As time has marched on, the progress reports from our
Evaluation Unit have attempted to monitor the progress of the program with
cautious optimism, with the result that we have been quoted and misquoted by
legislators at all levels of government and by all the mass media.
Our recommendation for continued expansion of the program has resulted in
a veritable population explosion in the past year. As of October 31, 1969, the
methadone maintenance treatment programs under our surveillance included
six inpatient induction units, and ambulatory induction was just beginning. The
60-296 O— 71— pt. 1 9
122
admission rate was approximately 50 patients each month, equally divided be-
tween ambulatory and inpatient induction with rather cautious selection of those
admitted for ambulatory induction.
This year has seen an almost complete reversal in this procedure. The vast
majority of patients are currently being stabilized on an ambulatory basis, and
inpatient services are used only for those patients who present unusual problems.
As of October 31, 1970, we have under surveillance 13 inpatient induction units
and 46 active outpatient and ambulatory units. These units cover the four largest
New York City boroughs and lower Westchester County. How many patients
are involved? Table 1 shows the October 31, 1970, census. There have been 4,376
admissions to date, and 3,485 patients are under treatment. This is contrasted
with the census as of October 31, 1969, when there were 2,325 admissions and
1,886 patients in treatment. This highlights the rapid expansion from approxi-
mately 50 patients per month to a level of 50 new patients each week. The loca-
tions of the inpatient and outpatient units are listed in appendixes A and B for
those who are interested. The rapid induction group is a relatively new unit,
opened in late July 1970, to which a group of approximately 100 patients from
the waiting list have been offered ambulatory induction to methadone main-
tenance with medication only and little or no supportive services at the outset.
The success rate in this group is being followed with great interest because Its
initial objective is to delineate that portion of the accepted patients which can
be maintained with only minimal supportive services.
DESCRIPTION OF SAMPLE
The age distribution of patients in the methadone maintenance treatment pro-
gram has not changed substantially over the past 5 years despite the change in
age criteria for admission. This appears to be the result of two balancing forces.
These are (1) the inclusion of a few 18-year-old patients, and (2) the admission
of a small number of oriental patients who are in their late 50's. Therefore, the
median age of all patients remains at about 33.3 years with the average age of
the black patients somewhat older (35.6) .
The ethnic distribution remains approximately 40 percent white, 40 percent
black, 19 percent Spanish and 1 percent oriental.
We will discuss the "failures" first.
RATE OF DISCHARGE
The rate of discharge by month of observation has demained amazingly stable
despite the changes in admission criteria and the change of emphasis from in-
patient induction to ambulatory induction. This is illustrated in figure 1 where
the rates of discharge for the two groups are contrasted. The two curves are
identical. The Van Etten group, which active tuberculosis as an additional prob-
lem to heroin addiction, demonstrate a somewhat accelerated discharge rate as
might be expected.
In figure 2 we contrast three cohorts of 500 patients by date of admission, and
once again we find no difference in rates of discharge among these three cohorts
representing the first 1,500 patients admitted to the program.
Figure 3 contrasts the discharge rate for men and women. The slight difference
shown is not significant due to the much smaller number of women. The rate of
discharge for men by age at time of admission is shown in figure 4 and once
again shows no difference between younger and older patients. A small difference
appears in figure 5 between the rate of discharge in the third year between
black and white patients. This difference is not statistically significant at this
point but bears monitoring in the future.
SEASONS FOR DISCHARGE
As shown in figure 6 problems with alcohol abuse as a reason for discharge
increases with age at time of admission for both men and women, drug abuse
(primarily amphetamines and barbiturates) as a reason for discharge decreases
with age and is more common among the women than among the men. Voluntary
withdrawal from the program increases with age particularly among the men.
Discharge for behavior or psychiatric reasons is more common among the
younger patients of both sexes. Deaths follow the pattern in the general
population.
123
When we look at reasons for discharge by ethnic group as shown in figure 7,
we note that alcohol problems are more common among the black patients and
drug abuse is more commonly a factor among the white and Spanish patients.
Voluntary withdrawals and discharge for behavioral reasons account for the
majority of dropouts in the first year. Chronic problems with alcohol abuse, and
continued drug abuse were the major causes of discharge in the second and third
year.
FOLLOWUP OF DISCHARGED PATIENTS
With the assistance of two medical students, (Michael Lane, Downstate Medi-
cal School, and Mary Hartshorn, Medical College of Pennsylvania) during this
past summer, we completed an intensive foUowup on a sample of patients who
had left the program. We selected all patients who were discharged alive by
December 31, 1969, and who had been in the program 3 months or longer at the
time of discharge. This gave us a pool of 562 persons. We divided this group into
two segments: (1) those who had left the program voluntarily, and (2) those
who had been discharged from the program for cause.
Our primary source of followup was the New City Narcotics Register which
receives reports from the police and correction agencies, hospitals, and treat-
ment programs, and from private practitioners. Another very useful source was
a series of interviews with patients who left the program and have subsequently
been readmitted. This was a major contribution by the medical students.
For the sample of 281 patients on whom we could obtain 6 months of follow-
up the results are shown in table 2.
Those patients who left the program voluntarily had a lower arrest and de-
toxification record, than the rest. They also had a larger proportion admitted
to other treatment programs an one-third had been readmitted to the program,
contrasted with only 6 percent of those discharged for cause. If one considers
that no record found is roughly equivalent to remaining "clean," one-third of
this group were still "clean" 6 months after leaving the program.
The same sampling procedure was followed for the 396 patients on whom we
could obtain 12 months to followup. These results are shown in table 3. In this
group only 21 percent would be considered still "clean." The readmission rate
was somewhat lower (13 percent). Except for arrests and deaths those who left
the program voluntarily are very similar to the other group.
Table 4 shows the results of the followup on our sample of 181 patients on
which we had a followup of 1 year or more. Here the readmission rate is 22
percent and the proportion who appear to have remained "clean" is only 18
percent and the death rate reaches 5 percent.
These data would tend to indicate that, among those patients who withdraw
from methadone maintenance treatment, only a small portion have been able to
"make it" on their own.
Because of the tremendous current interest in "criminality" associated with
addicition, we looked into the previous arrest records of those patients who
have remained in the program, contrasted with those who left the program
voluntarily, and those who were discharged for cause. We contrasted this, in a
"before and after" picture, as shown in figure 3. It is interesting to note that
the past history of those who were discharged for cause with reference to arrests
is worse than either of the other two groups — and that their behavior following
discharge is as poor or worse than before admission. Those who left voluntarily,
demonstrate a short preiod of improvement but also tend to return to their
previous arrest pattern. Those who remained in the program show a constant
and accelei'ated decline in criminal behavior as measured by arrests.
Enough of failures. Now let's discuss successes.
CRITERIA FOR SUCCESS
The criteria established by our evaluation unit with the approval of the evalua-
tion committee for measuring success of the program has resolved around four
basic measures :
(1) Freedom from heroin "hunger" as measured by repeated, periodic "clean"
urine specimens.
(2) Decrease in antisocial behavior as measured by arrest and/or incarcera-
tion (jail).
(3) Increase in social productivity as measured by employment and/or school-
ing or vocational training.
(4) Recognition of, and willingness to accept help for excessive use of alcohol,
other drugs, or for psychiatric problems.
124
BESULTS
(1) Although many of the patients test the methadone "blockade" of heroin
one or more times in the first few months, less than 1 percent have returned
to regular heroin usage while under methadone maintenance treatment.
(2) Antisocial behavior as measured by arrests and incarcerations (jail) have
been looked at in several ways. First, the percentage of arrests among patients
in the program during the 3 years prior to admission was compared with the per-
centage of arrests of these same persons following admission. This "before and
after" picture is also contrasted with the proportion of arrests in a contrast group
of 100 men selected from the detoxification unit at Morris Bernstein Institute
matched by age and ethnic group and followed in the same manner. The results
are illustrated in figure 9. The arrest records of these two groups are quite simi-
lar for each year of observation prior to admission. Following admission to the
program, the contrast is striking for each period of observation with the metha-
done maintenance patients showing a marked decrease in the percentage of
patients arrested, and the contrast group showing a pattern very similar to the
earlier period of observation.
We have also calculated the arrests per 100 patient-years of observation for the
3 years prior to admission in contrast to the arrests per 100 patient-years of
observation after admission. We have compared these data using the same com-
putations for the contrast group. The results are shown in table 5. These results
would appear to indicate that remaining in the methadone maintenance program
does indeed decrease antisocial behavior as measured by arrests or incarcerations.
(3) Increased social productivity can best be illustrated by the employment
profiles shown in figures 10 and 11. There is a steady and rather marked increase
ii the employment rate with a corresponding decrease in the percentage of
patients on welfare as time in the program increases. This is true both for the
men and the women. These data include both ambulatory and inpatient induc-
tion groups. This accounts for the increased percentage of men employed at time
of admission since this was one of the early criteria for admission to an ambula-
tory unit.
(4) Figure 12^ is an attempt to illustrate stability of employment among
patients remaining in the program as contrasted with their previous employment
experience. The shaded area might be considered as a measure of their increased
social productivity since admission to the program.
(5) Although chronic alcohol abuse continues to be a problem for approxi-
mately 8 percent of the patients (both men and women), and for some becomes
the principal reason for discharge, a majority of these patients show continued
improvement in their ability to handle their alcohol problem with the support
and assistance of members of the program staff who recognize the problem, and,
are willing and able to cope with it.
(6) Problems with chronic abuse of drugs such as barbiturates, amphetamines,
and more recently cocaine are evident in approximately 10 percent of the patients.
There again, for some, it has resulted in discharge from the program. For many
othets, the patients are able to function satisfactorily, with the assistance and
support of members of the program staff.
CONCLUSIONS
On balance, the successes in the methadone maintenance treatment program
far outweigh the failures. The rapid expansion of the program during the past
year, and the change in emphasis to include primarily ambulatory induction
under the expanded admission criteria does not appear to have made any notice-
able change in the effectiveness of this treatment for those heroin addicts who
have been accepted into the program. A majority of the patients have completed
their schooling or increased their skills and have become self-supporting. Their
pattern of arrests has decreased substantially. This is in sharp contrast to their
own previous experience, as well as their current experience when compared with
a matched group from the Detoxification unit, or when compared with those
patients who have left the program. Less than 1 percent of the patients who
have remained in the program have reverted to regular heroin use.
A small proportion of the patients (10 percent) persent continued evidence of
drug abuse involving use of amphetamines, barbituarates, and cocaine, and
another 8 percent demonstrate continued problems from chronic alcohol abuse.
These two problems account for the majority of failures in rehabilitatin after the
first 6 months.
125
Methadone maintenance as a treatment modality was never conceived as a
"magic bullet" that would resolve all the problems of patients addicted to heroin.
For this reason, we believe that any treatment program using methadone mainte-
nance must be prepared to provide a broad variety of supportive services to
deal with problems including mixed drug abuse, chronic alcoholism, psychiatric
or behavioral problems, and a variety of social and medical problems.
Many questions continue to remain unanswered with reference to the role of
methadone maintenance in the attack on the total problem of heroin addiction ;
nevertheless the data presented on the group of patients who have been ad-
mitted to this methadone maintenance treatment program continues to demon-
strate that this program has been successful in the vast majority of its patients.
After a careful review of the data related to successes and failures over the
past 5 years, the methadone maintenance evaluation conmiittee has submitted
the following recommendations as of Friday, November 6, 1970 :
KECOMMENDATIONS
As a result of the continued encouraging results in the methadone maintenance
treatment program through October 31, 1970, the methadone maintenance evalu-
ation committee recommends :
(1) That there be continued financial support for the methadone mainten-
ance treatment program to allow continued intake of new patients using ad-
mission criteria including a minimum age of 18 years and a history of a mini-
mum of 2 years of addiction with care in selection of patients to prevent the
possibility of addicting an individual to methadone who is not physiologically
addicted to heroin.
(2) That there be continued evaluation of the long-term effectiveness of the
methadone maintenance treatment program for the group stabilized on art in-
patient basis, the group being stabilized on an ambulatory basis, and the group
undergoing rapid induction.
(3) That new programs which plan to use methadone maintenance should in-
clude all eleemnts of the program including :
(c) Availability of adequate facilities for the collection of urine and labor-
atory facilities for frequent and accurate urine testing.
(&) Medical and phychiatric supervision.
(c) Backup hospitalization facilities.
id) Adequate staff including vocational, social, and educational support
and counseling.
(e) Rigid control of methods of dispensing methadone and number and
size of aoses given for self -administration in order to prevent diversion to
illicit sale or possible intravenous use.
(/) Staff members of potential new programs planning to use methadone
maintenance be trained in this technique in a medical center which has
been shown to use methadone maintenance effectively.
4. That continued research is essential particularly with reference to :
(c) The role of methadone maintenance in the treatment of young heroin
addicts ( under 18 ) .
(&) Developing programs using methadone maintenance in combination
with other approaches to the treatment of heroin addiction.
Projects in these areas should be supported and encouraged, but must be con-
sidered new research studies, and should be subjected to the same surveillance,
and independent evaluation as the current programs.
(5) That methadone maintenance not be considered at this time as a method
of treatment suitable for use by the private medical practitioner in his office
practice, because of the requirements for other program components including
social rehabilitation and vocational guidance.
(6) That a pilot or demonstration project be developed involving the use of
properly trained practicing phy.sicians as an extension of an organized methadone
maintenance treatment program to treat those patients whose needs for ancillary
services are minimal. These patients should be continued under the supervision
of the methadone maintenance treatment program for periodic evaluation and
urine testing.
ACKNOWLEDGMENTS
1. The members of the methadone maintenance evaluation committee, both past
and present with particular reference to Dr. Henry Brill, who has so aptly
chaired that committee since its inception.
126
2. All the members of the methadone maintenance treatment program staff for
their devotion to their job and for their cooperation whenever needed.
3. The staff of the Rockefeller Data Bank especially Dr. Alan Warner and
Mrs. Ellen Smith for their willingness to make available to us, whenever re-
quested, data which has been a crucial starting point of our evaluation.
4. Those medical students who have made substantial contributions to our
efforts over the past 4 years.
5. The directors of the New York City Narcotics Register who have allowed
us to use their data for validation and for followup. These listed in chronological
order over the past 5 years are : Dr. Florence Kavaler, Mrs. Zili Amsel, Miss Joy
Fishman, Mr. Sherman Patrick.
6. The diligence and devotion of my staff including : Mrs. Dina D'Amico, Mrs.
Angela del Campo. Mrs. Frieda Karen, Miss Elaine Keane, Mrs. Dorothy Mad-
den, Mrs. Ingel Mayer.
7. And last but not least to the New York State Narcotic Addiction Control
Commission for funding our efforts.
127
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1.0 -
30-
20-
10-
11/10/70
128
HETHADOHE MAINTENANCE TREATMENT PROGRAM
Rate of Discharge by Month for Patients Inducted on an Ambulatory Basis
Versus In-Patient Induction and Van Etten
as of June 50, 1170
n= 1921
n= 130'i o-
n= 11)7 X-
— - In-Patlent Induction
-O = Ambulatory
-X» Van Etten
—r
12
— r
15
21
2k
— r
27
30
— r
33
36
Months
— r
39
U2
Figure 2
Methadone Maintenance Treatment Program
Rate of Discharge by Month for Three Successive Cohorts of 500 Patients
By Dote of Admission
kO
Cohort #1 = • '
Cohort #2 -
Cohort #3 = X X
2e
10
n/K/70
—r
-r~
"T"
12 15 18
21 2k 27 30 33 36 39 1(2 1*5
Months
kS
129
Figure 3
METHADONE MAINTENANCE TREATHEIIT PROGRAM
Rate of Discharge by Month for Men versus Vtonen
as of June 30, 1970
100-
90 i
SO
70
60
50-
llO-
30-
20-
16
n/ic/70
~~o~r
~o^r-
^=r-
--o^^r^
-o—
-o~-
12
— r-
15
— 1-
18
2i 21' 27 30 33 36
Months
O o-
Men n= 2835
Women n= 537
Figure ^i
60-1
so-
li 0-
30-
20-
10-
Methadone Maintenance Treatment Program
Rate of Discharge by Hcnth for 2835 Men by Ag? at Time of Admission
as of June 30, 1970
— r-
12
. .= -^30Yrs. n= 709
•= 30-39 Yrs.n= 1802
> v= I10+ Yrs. n= 32'i
— I 1 1
15 18 21
Months
zif 27
— r-
30
33
— I
36
11/18/70
Figure 5
100-
SO-
SO-
70-
60-
50 •
o
C
o
i-
«
a.
20
130
Methadone Halnten?nce Treatment Program
Rate of Discharge by Month for ?306 Men by Ethnic Group
as of June JO, 1970
10
11/' 0/70
. ■= White n=l IJO
X v= Spanish n= SS^
= Black n=I122
0 3 6 9
"1 1 1 1 1 1 1 1 1 1
12 15 18 21 2i) 27 30 33 36
Months
Figure 6 METHADOflE MAIMTEMANCE TREATMENT PROGRAM .
Percentage Distribution of Principal Reason for Discharge of 718 Patients by Age at Time of Admission
<lO
c 20
-Ti
f
i
Alcohol
40
20 -
I
i
i
A) Women n=l 19
I
^
■
Arrests Drugs Voluntary ''ehavior
I
i
Death
[;f: :JAge 20-29
B) Men n=599 |_l*9e 30-39
K/ylAge 110+
JZZZL
E^m
Alcohol Arrests
Drugs Voluntary Tehavior
Death
11/10/70
131
Figure 7 METHADONE HAINTEHAHCE TREATMENT PROGRAM
Percentacje Distribution of Principal "eason for discharge of 710 Patients by Ethnic Group
"lO-
c 20-
i
r-^
A) Women n= 1 19
i
m
Alcohol Arrests Drugs Voluntary "ehavior Death
Jia
20-
1
i
B) Men n= 599
D
Black
V/hite
Spanish
n^
Alcohol Arrests Drugs Voluntary Behavior
Death
11/10/70
132
TABLE 2.-METHAD0NE MAINTENANCE TREATMENT PROGRAM
IFollowup of 281 patients 6 months following discharge from M.M.T.P.; in percent]
Left
volun-
tarily
Dis-
charged
for cause
Total
dis-
charge
Left
volun-
tarily
Dis-
charged
for cause
Total
dis-
charge
Arrest or jail
Dead
Detoxification
Other Rx program
Medical or psychiatric
facility .
10
2
13
11
2
26
2
20
4
3
2
23
2
19
7
2
2
Moved
Readmitted
No reports found
Total sample
Total N..
7
33
22
1
6
36
1
11
33
. 45/100
. 90
236/100
472
281/100
562
Private medical doctor. .
TABLE 3.— METHADONE MAINTENANCE TREATMENT PROGRAM
IFollowup of 198 patients up to 1 year after discharge from M.M.T.P.; in percent]
Left
volun-
tarily
Dis-
charged
for cause
Total
dis-
charge
Left
volun-
tarily
Dis-
charged
for cause
Total
dis-
charge
Arrester jail
Dead
Detoxification
Other Rx program
Medical or psychiatric
facility
Private M D
13
34"
6
3
3
28
2
23
6
4
1
25
2
25
6
4
2
Moved
Readmitted
No reports found
Total sample
Total N
25
2
13
21
2
13
21
. 32/100
. 64
166/100
232
198/100
396
TABLE 4.-METHAD0NE MAINTENANCE TREATMENT PROGRAM
[Followup of 181 patients 1 year or more after discharge from M.M.T.P.; in percent]
Arrest or jail.
Dead
Detoxification
Other Rx program
Medical or psychiatric
facility..
Private M.D..
Left Dis-
volun- charged
tarily for cause
18
37
11
6
6
30
5
27
11
7
3
Total
dis-
charge
28
5
28
22
7
3
Left Dis-
volun- charged
tarily for cause
No reports found.
Readmitted'
21
129
17
121
Total sample 28/100 153/100
Total N 56 306
Total
dis-
charge
18
122
181/100
362
> Readmitted patients each had 1 or more reports of arrest or detoxification.
Figure 8
133
HETHAOOIIE MArMTCMArXE JREMIW.'T PROGRAM
Comparison of Arrest Records Amonn Persons
Continuing and Oischarcerl from Methadone Maintenance Treatment Program
Prior to Admission
a - Since Admission
■^ b £ c - Since Discharge*
years
' years ^
n ".MP , (2560) (2560)
n Vol.Dis. CtS) CtS)
n lnvol.Dis.(23f>) (23&)
(2560) (2560) OSA'.) (788) iiBt*)
('•5) (AS) (32) (20
(236) (236) (166) (153)
*AI1 discharges had participated in HMTP for at least 90 days prior to discharge.
10/26/70
Figure 9
134
Methadone tlaintenance Treatment Progran
Percentage Distribution of Arrests for 2G'»1 Men In Methadone Maintenance Program
Three Months or Longer as of Harch 31, K-?") and Contrast Group
5y Months of Observation
DEFORE <-
START
^ AFTER
Percentage
30-1
20-
10-
Year Prior to Admission
to Program
Year After Admission
to Program
n MMP (28'il)
(23'il)
(28'»J)
(281)1)
(15'*'.)
(788)
OSM
n Contrast (100)
(100)
(100)
(100)
(98)
(95)
(92)
11/10/7^
135
TABLE 5.— METHADONE MAINTENANCE TREATMENT PROGRAM
iThe Number of Arrests and Incarcerations per 100 Person-Years for Methadone Maintenance Patients Before and After
Admission Contrasted With Patients From Detoxiflcation Unit]
Methadone Detoxification
group group
Before admission:
Arrestsper 100 person-years 115 131
Jail per 100 person-years... 49 52
N=person-years 17,500 600
Following admission:
Arrestsper 100 person-years 4.3 135
Jail per 100 person-years 1.0 63
N=person-years 10,800 1,040
136
Figure 10
Methadone Ka'ntanance Treatmf:nt Program
EfTipIoyment Status and School Attendance for Men in Metiadone Maintenance
Three Months or Longer as of March 3'. '970
(In-Patient and Ambulatory Induction
00- ^
^
^
^
:^
^
^
^
-_
1
— 1
— 1
— 1
80-
/
^32
'
=
—
^ —
—
/ y
[ '
60 - /
• y/^
//
/ /
/ /
"tO -11
20 _
0 -
•
School
Welfare
Supported by
Others
Employed
6 Months 12 Months 18 Months Ih Months 30 Months 36 Months 'i2 Months A8 Months
Months Following Admission to Program
n- (I97lt) (1807) (1330) (891) (650) (468) (330) (203) (R1)
11/9/70
Figure II
Methadone Haintensnce Treatmant Program
Employment Status and School Attendance for '(66 Women in Methadone Maintenance
Three Months or Longer as of 'l.-.rch ?1, WT^
(In-Patlent and Ambulatory Induction)
100
11/10/70
n= (1)66)
VsM School
Welfare
Homemsker
Employed
6 Months 12 Months 18 Months 2't Months 30 Months 36 Months
Months Following Admission to Program
(JitS) (2i.5) (161) (109) (71) (A5)
137
Figure 12 Methadone Maintenance Treatment Program
Percent of Pcrson-fonths of Observation During Which Mon in Program l/ere Employed
Defore and After Admission by Duration of Employment
as of July 31, '963
Increase of Observed
Over Expected
* F 1 A Person-Months of Employment
* Einployed = Person-Months of Observation
Sli Months
'/] 51 Months
% Employed
Prior to Admission
% Employed
Following Admission
ADMISSION TO PROGRAM
11/10/70
60-296 O - 71 - pt. 1 - 10
138
Appendix A^ — Methadone Maintenance Treatment Program
Inpatient Induction Units by County as of October 31, 1970
Manhattan :
Grade Square Hospital (men and women).
Harlem Hospital (men).
Morris J. Bernstein Institute (men ad women).
Riker's Island (men).
Rockefeller University Hospital (men and women).
Roosevelt Hospital (men and women).
St. Luke's Hospital (men and women).
Bronx :
Albert Einstein Medical Center ( men and women ) .
Bronx State Hospital (men and women) .
Brooklyn : Brookdale Hospital (men and women).
Westchester County :
St. Joseph's Hospital (men and women).
White Plains Hospital (men and women).
Yonker General Hospital (men and women).
Appendix B — Methadone Maintenance Treatment Program
Outpatient and ambulatory induction units by county as of October 31, 1970
Number
of units
Manhattan :
City Probation 2
Gracie Square Hospital 1
Greenwich House 1
Harlem Hospital 5
Jewish Memorial Hospital 1
Morris J. Bernstein Institute 1
Lower East Side 10
Lower West Side 2
Rapid Induction 1
Mount Sinai Hospital 1
Rockefeller University
Hospital 2
Roosevelt Hospital 1
St. Luke's Hospital-
St. Vincent's Hospital.
Bronx :
Bronx State HospitaL.
Lincoln Hospital
Van Etten Hospital—
1
1
1
1
1
Number
of units
Brooklyn :
Brookdale Medical Center 1
Coney Island Hospital 2
Cumberland Hospital 2
Lutheran Hospital 1
Methodist Hospital 1
Queens :
Long Beach Memorial
Hospital
Triboro Hospital
Westchester :
St. Joseph's Hospital 1
White Plains Hospital
Yonkers General Hospital
Yonkers Public Health Build-
ing (WCCMHB)
1
2
1
1
[Exhibit No. 10(b)]
Position Papek : Methadone: — A Valid Treatment Technique
(By Frances Rowe Gearing, M.D., M.P.H. (Supported under Contract No. C-35806
from New York State Narcotic Addiction Control Commission), Associate
Professor, Division of Epidemiology, Columbia University School of Public
Health and Administrative Medicine, and Director, Methadone Maintenance
Evaluation Unit)
For Presentation at State Conference on "Drugs — The Issues on Trial,"
Pontiac, Mich., December 2, 1970
Position Paper — Methadone Maintenance : a Valid Treatment for
Heroin Addiction?
My answer to this question is yes when properly administered in an organized
methadone maintenance treatment program.
There are at least five basic reasons for my positive response which I list:
139
1. DRUG PKOPEKTIES
Methadone has several properties which make it useful as a treatment for
heroin addicts. These properties includes the following :
(a) It is a longer acting drug than heroin. Patients on methadone mainten-
ance, after a relatively short induction period, require only one dose a day. This
contrasts with four to six fixes a day for the patient "hooked" on heroin.
(&) Methadone is given by mouth in noninjectable form. This alone makes it
most attractive from a medical standpoint, because it is well-known that many
of the medical problems of heroin addicts are related to intravenous injection
without proper sterilization techniques. These problems include, hepatitis, endo-
carditis, tetanus, and a plethora of other medical problems.
(o) Patients on methadone can be gradually built up to a stabilizing dose of
between 80-120 mgs. daily, and can be maintained at this level over periods of
time up to 5 years without having to alter the dosage level. This is in sharp
contrast to the addict's experience with heroin. Patients on heroin rapidly de-
velop a tolerance to the ordinary street "bag" to the point where they have
eitlier to increase the number of bags for each "fix" and increase their hustling
in order to get more "bags" more often to support their needs, or to apply at a
detoxification unit for a drying-out period which will bring them back on the
street within 2 weeks with a less-expensive habit.
(d) Methadone maintenance when used at high dosage levels produces a
"blockade" against the effect of heroin which might be referred to as heroin
"euphoria." Under carefully controlled circumstances, patients stabilized on
methadone maintenance given by mouth have demonstrated that this blockage
is effective even with high doses of pure heroin.
(e) The long-term medical effects of methadone maintenance are minimal.
This statement is based on a careful medical followup of a series of 80 patients
who have been on 80-120 mgs. of methadone daily for a period of over 5 years.
These properties make methadone a very useful tool in the treatment and
rehabilitation of patients addicted to heroin for the basic reason that it gives
former heroin users a chance to use their time in a more productive way. Under
methadone maintenance they are relieved of the problem of spending most of
their waking hours in hustling for means to get their next "fix." This difference
might be equated with the difference between the old insulin treatment for di-
abetes patients which involved three to four injections per day based on urnie
samples. The new look in diabetes treatment is more apt to be one injection a day
of long acting insulin or control by medication which can be administered orally.
2. REHABILITATION — EMPLOYMENT AND SCHOOLING
Patients on methadone maintenance can remain in their local community with
their family or peer groups throughout their treatment. They are encouraged
and offered considerable assistance by members of the program staff to complete
their basic education at least through high school, to acquire a skill through
additional vocational training, to becoming a wage earner and hopefully become
self-supporting.
These objectives have been achieved in a majority of the patients in the metha-
done maintenance treatment program in New York City as illustrated by the
employment profiles by men and women in figures 1 and 2. There is a steady and
rather marked increase in the employment rate with a corresponding decrease
in the percentage of patients on welfare as time in the program increases. This
is true both for the men and the women.
3. CRIMINALITY
Patients on methadone maintenance have demonstrated a rather striking
change in their antisocial behavior as measured by arrests as shown in figure 3,
where the percentage of arrests among patients in the methadone maintenance
treatment program is contrasted with their arrest experience for the 3 years
prior to adminission and this "before and after" picture is contrasted with the
proportion of arrests in a contrast group of men selected from the detoxification
unit at Morris Bernstein Institute matched by age and ethnic group and followed
over the same period. The arrest records of the two groups are quite similar for
each year of observation prior to admission. FoUwing admission to the program
the contrast is vivid for each period of observation with the methadone mainte-
140
nance treatment patients showing a constant and accelerated decline in criminal
behavior and the contrast group showing a pattern very similar to the earlier
period of observation.
4. SUPPORTIVE SERVICES
Patients on methadone maintenance have available to them on demand one
or more members of the program staff who are ready, willing, and able to re-
spond to their needs whether these needs be medical, psychiatric, vocational,
social, or legal.
5. PROGRAM PHILOSOPHY
Treatment programs for heroin addiction using methadone maintenance have
accepted the fact that the "hard-core" addicts have a chronic disease, and, there-
fore, need medication and support over a long period of time, if not for life.
This philosophy has resulted in a more permissive attitude toward patients
who show evidence of recurrent abuse of other drugs such as barbiturates and
amphetamines or continued chronic alcohol abuse, and every effort is made to
assist the patients in handling these problems. Only when this support fails are
patients dropped from the program.
CONCLUSION
Methadone maintenance is a valid treatment for those hard-core addicts who
are 18 years or older with a history of at least 2 years of addiction and who
have had difficulties in adjusting to the stringencies of abstinence programs.
Among patients selected in this manner methadone maintenance has proved
successful in 80 percent of more than 4,000 patients in the New York City metha-
done maintenance treatment program. A majority of the patients have com-
pleted their schooling or increased their skills and have become self-supporting.
Their pattern of arrests has decreased substantially. This is in sharp contrast
to their own previous experience, as well as their current experience when com-
pared with a matched group from the detoxification unit, or when compared with
those patients who have left the program. Less than 1 percent of the patients
who have remained in the program have reverted to regular heroin use. No other
treatment program can demonstrate a better rate of success.
Methadone maintenance as a treatment modality was never conceived as a
"magic bullet" that would resolve all the problems involved in heroin addic-
tion. For this reason, we believe that any treatment program using methadone
maintenance must be prepared to provide a variety of supportive services to deal
with such problems as mixed drug abuse, chronic alcoholism, as well as psychia-
tric or behavioral problems and a variety of other social and medical problems.
Therefore, methadone maintenance should not be considered as a method of
treatment suitable for use by the private medical practitioner in his office prac-
tice, because of the requirements for other program components including social
rehabilitation and vocational guidance.
141
Figure I
Methadone Maintenance Treatment Program
Employnent Status and School Attendance for 15-:6 i-ien in Methadone Maintenance
Three Months or Lcnqer as of March 31. 1*^70
(In-Patient Induction)
100—
80-
fo-
w_
20-
0-
v\-
, ^
s^^
>^:;l ^
ii^
;nV
\v
^
/
Welfare
Employed
n= (13i6)
C .or.ths 12 Monfis 18 Months i'4 Mcr.ths 30 Months 35 Months hi Months U% Months
Month: Fcllowing Adrnission to Program
.-23) (•.;7J) (77M (606) (IjSA) (330) (203) (31)
\'in(>na
Figure 2
Methadone Maintenance Treatment Program
Employment Status and School Attendance for ^S6 Vtomen in Methadone Maintenance
Three Months or Longer as of ''arch '1, l-'?"
(In-Patient and Ambulatory Induction)
100—
11/10/70
(':!i£)
'vTsi School
V/el fare
Homemaker
Employed
6 Months 12 Months 18 Month; Ik Months 30 Months 36 Months
Months Following Admission to Program
(3^5) (2^5) (161) (10?) (71) Ct?)
142
Figure 3
•lethadone Kaintenance Treatment Program
Percentage Distribution of Arrests for 2u'»I '';en in Methadone f'aintenance Program
Three Months or Longer as of 'jrch 31, ''7"^ arid Contrast Group
^y Mor.ths of Observation
CEFORE <-
START
-^ AFTER
Percentage
3r-i
20-
10-
Year Prior to Admission
to Program
Year After Admission
to Program
n (IMP (ZSkl)
(2341)
(2841)
(2841)
(1544)
(780)
(384)
n Contrast (100)
(100)
(100)
(100)
(98)
(95)
(92)
11/10/70
143
Chairman Pepper. Our next witness is Dr. Robert L. DuPont, Di-
rector of the District of Columbia Narcotics Treatment Administra-
tion since its creation in February 1970.
Dr. DuPont, a young man with impressive credentials in medicine
and phychiatry, has been changed with implementing Mayor Wash-
ington's pledge to have treatment available to every heroin addict in
the District of Columbia within 3 years.
Prior to assuming his present position, Dr. DuPont was Associate
Director for Community Services in the D.C. Department of
Corrections.
In that capacity, Dr. DuPont participated in the preparation of a
report that revealed that some 45 percent of all men brought to the
District of Columbia jail in August 1969, were heroin addicts.
Since then. Dr. DuPont has used the word "epidemic" to describe
heroin addiction in the District.
Dr. DuPont is a graduate of Emory College in Atlanta and the
Harvard University Medical School. He served his medical internship
at the Cleveland Metropolitan General Hospital and his residency in
psychiatry at the Massachusetts Mental Health Center, Harvard
University.
For 2 years, Dr. DuPont served in research and clinical psychiatry
at the National Institute of Mental Health.
Dr. DuPont, we are glad to have you again before this committee.
STATEMENT OF DR. ROBERT L. DUPONT, DIRECTOR, DISTRICT OF
COLUMBIA NARCOTICS TREATMENT ADMINISTRATION
Dr. DuPont. Thank you, Mr. Chairman.
Chairman Pepper. Mr. Perito, would you inquire?
Mr. Perito. Dr. DuPont, as you know, this committee is particularly
interested in an evaluation of methadone and related drug abuse pro-
grams. One of the matters of particular interest to the committee is
the question of the efficacy of methadone maintenance and its relation-
ship to the decrease in crime rate or illegal activity of those addicts
under such treatment. Have you any statistical studies which reflect
findings similar to those which Dr. Gearing presented to the commit-
tee this morning ?
Dr. DuPoNT. Yes, Mr. Perito. First of all, the District's program
is not simply a methadone program. It is a multimodality program in
which some people are taking methadone and some are not. Some
patients receive methadone maintenance ; others are taking it for de-
toxification.
I will answer your question, but I want to begin with that qualifica-
tion because it relates to some of the statistics that I want to bring up.
Mr. Perito. Can you tell us how many addicts are presently being
treated in your program ?
Dr. DuPoNT. The current number is 3,106 as of last Friday, and of
that number 1,760 are on methadone maintenance, 633 methadone de-
toxification, 631 are in abstinence programs. An additional 82 are re-
ceiving methadone on what we call "methadone hold" which means
emerqfency treatment prior to complete evaluation.
Chairman Pepper. How many on methadone ?
144
Dr. DuPoNT. 1,760 on methadone maintenance, 633 on methadone
detoxification, 82 on methadone hold, which is an emergency short-
term treatment, and 631 are in abstinence programs, that is, receiving
no methadone.
Mr. Perito. Do you have a waiting list, Doctor ?
Dr. DuPoNT. We don't have a waiting list right now. We have in
the past, and we are moving in the direction of having a waiting list
again. We found that a waiting list discourages many people from
coming into the program. Only about 30 percent of the people who
sign up on a waiting list actually show up, at least in our experience.
Whenever procedures are set up as hurdles for people to get over
before treatment, act to discourage the use of the treatment, and ac-
cordingly limits the kind of people who will go over these hurdles
to get in. It is a grave step to take to build up barriers of any kind to
get into narcotics treatment.
Narcotics treatment of a continuing nature, regardless of whether
it is methadone or abstinence, is efficacious in reducing not onlv heroin
use but arrest rates. The critical question that needs to be addressed is
the issue of retention in program. Some programs exaggerate their
fiarures by counting patients who come into the program but who. for
all practical purposes, dropped out and have no continuing relation-
ship. Those patients that do have a continuing relationship and are
participating actively, whether methadone or not, do quite well. I
don't think one needs to feel he has to use methadone.
On the other hand, our experience is that for most criminal heroin
addicts the treatment of their choice and the one that seems to make
the most sense from their point of view does involve methadone. I
think heroin addicts need to have choices for themselves about what
kinds of treatment they are going to get. Our program at NT A offers
considerable choice.
Mr. Perito. Is it fair to say that your programs jjoals are similar to
the goals articulated by Dr. Gearing for the New York urograms?
Dr. DuPoNT. Absolutely. Manv of the best features of our program
have been taken from New York, including our basic goals.
Mr. Perito. Directing your attention now back to my first question,
you have compiled some recent statistics pursuant to the committee's
request.
Dr. DtjPont. Riffht. Last May 1^ we drew a sample. NTA then had
1,060 patients in treatment. We did a random sample of 450 of those
patients. Six months later, 56 percent of them were retained in the
program.
At 11 months, the figure retained had fallen to 40 percent. So that
40 percent of the people in the program last May 15 were still in the
program at the end of last week.
Now, the retention rate in the program is highly related to the use
of methadone. I don't have the followup data to 11 months on the
basis of treatment modality, but at 6 months the results were quite
striking. We found that patients who were on 60 milligrams or more
of methadone had an 86-percent retention rate at 6 months. Of the
patients who elected abstinence, only 15 percent remained in the pro-
gram for 6 months.
There is a very high dropout rate associated with abstinence pro-
145
grams, at least in our experience. Those who did stay in the abstinence
program did well. That needs to be emphasized.
Now, about the arrest rate : Of the 450 in the program on May 15,
1970, 22.5 percent were arrested in the course of the following 11
months.
Of the 186 who stayed in the program the entire 11 months, or until
arrested, a total of 25, or 13 percent were arrested.
Of the 264 who dropped out of the program, 75, or 28 percent were
arrested.
Now, further to clarify this and to attempt to get at some of the
harder data on this, Ave found that not all of the 450 people in the study
had identifiable records of detention in District of Columbia jail.
That is, we couldn't identify District of Columbia Department of
Corrections numbers on all the patients.
Mr. Perito. You had access to the criminal reference reports and
rap sheets, I assume ?
Dr. DuPoxT. We had access to the rap sheets in the Department of
Corrections so that if a person is detained in a correctional institution
we have that information.
However, if he is arrested and released before going on to incarcer-
ation we do not have the data. This has happened in minor offenses,
such as traffic cases and first offenses, but it is not common with addicts.
However, when it happens, we don't have the information.
There is a law in the District of Columbia that prohibits the police
department from releasing information to non-law-enforcement agen-
cies on arrests. We are looking into this and are seeing if we can't get
that information. It won't change any of the results, because we use
the same criteria to apply to those who are in the program and those
who drop out, and also to comparison groups.
So although the total number would change, the relative percentages
would stay the same, at least that is our assumption.
But we asked this question another way : Of those people who have
identifiable rap sheets, how many were arrested over 11 months.
We found that 19 percent of those who had identifiable rap sheets
and who stayed in the program were arrested, whereas, 99 percent of
the 145 who dropped out and w^ho had rap sheets were arrested. The
relative relationships were the same ; that is, the people who dropped
out of the ])rogram had an arrest rate over the period of 11 months
of about 214 times the arrest rate of those who stayed in the program.
Another way to look at this data is to ask, for example, about the
arrest rate for a comparison group or similar group. The most simi-
lar group we have found was the Department of Corrections narcotics-
involved releases prior to the existence of the Narcotics Treatment
Administration, and of that group 36 percent were arrested in 6
months.
We don't have the figure for 11 months, but it would be over 50
percent.
Thus for those who stay in the program there is a considerable
reduction in the arrest rate and methadone treatment is associated
with higher retention rates.
On the other hand, I am not here to say that a simple matter of
giving a person methadone is a panacea. It is not a magic method,
as some have thought, to absolutely eliminate criminal activity. But
146
there are dramatic reductions in arrest. There are some other studies
of a more impressionistic nature and certainly those of us who have
clinical experience could corroborate this, that show that heroin ad-
dicts who are in the treatment programs do in a dramatic way reduce
their heroin use and that much of their criminal behavior was driven
by their need to get heroin.
On the other hand, let's be clear that we are talking about a very
disadvantaged segment of the population, by and large, a group for
which there are often few employment opportunities, a group with
very inadequate education and a group which has developed rather
considerable skills in hustling and illegal activities.
It is therefore, hardly surprising to find that this simple matter of
putting a person in a treatment program does not in itself eliminate
criminal activity, although it clearly reduces it.
Mr. Perito. I asked Dr. Gearing about her knowledge of efficacy
studies of drug-free programs, the value of detached analytical studies,
and similar questions about the crime reduction. Do you know of any
such studies in the drug-free programs across the Nation so that this
committee can compare those results with the results of methadone
and related drug programs?
Dr. DuPoNT. I think drug-free programs have tended to get in-
volved unnecessarily in rhetoric and politics.
They tend to get more involved in this and have a hard time deal-
ing with failures. So they are quite resistant in general to doing the
kind of studies that Dr. Gearing has done and the kind of study that
T reported here which, after all, reports something less than complete
success.
Abstinence programs have a hard time dealing with their very high
dropout rates.
I don't know of any published evidence of the efficacy of any drug-
free programs that is comparable in any way with the kind of data
that Dr. Gearing has presented.
On the other hand, it is my impression from visiting drug-free
programs that they have considerable merit. The problem is that they
are not acceptable to many heroin addicts. And many people who do
start there, do drop out. So I think that any city which is thinking
about programing for heroin addiction treatment, needs to include
abstinence or drug-free programs, but it needs some perspective in
terms of their efficaciousness and their acceptability to the heroin
addicts.
I guess I could have answered that question by simply saying "No."
Mr. Perito. Doctor, at the present time, what is vour appropriation?
Dr. DuPoNT. The current appropriation for the Narcotics Treat-
ment Administration is $2.2 million with an additional $2.9 million
available to us through Federal grants.
Mr. Perito. In addition to NTA's treatment programs, are you pres-
ently carrying on any independent research in the opiate area ?
Dr. DuPoNT. Well, our research is primarily related to two ques-
tions, really :
One is trying to do some monitoring of the epidemic of addiction in
the District of Columbia, and the other is evaluating the performance
of our programs. We don't do any basic research into chemical alter-
natives to methadone, for example, or many other kinds of research.
147
Mr. Perito. Doctor, under the IND concept, as I understand it,
your program is not specifically designated as a methadone mainte-
nance program ^
Dr. DuPoNT. Well, the IND procedure does not specify what main-
tenance is, and this has been a very serious handicap in the District
of Columbia in terms of trying to come to grips with the private phy-
sicians and others who are using methadone in ways that many of us
feel are not responsible. There are regulations associated with the
Food and Drug Administration that deal with methadone mainte-
nance, but since they don't define "maintenance," it is quite possible
for people to talk about long-term or even endless detoxification pro-
grams.
They talk about 20-year detoxification programs. In other words,
there is no point at which detoxification becomes a maintenance. It
is a matter of anyone's semantics.
NTA does have an application with the Food and Drug Adminis-
tration and we have the distinction of being one of the few programs
to be audited by the Bureau of Narcotics and Dangerous Drugs. Five
agents went over our procedures about 2 weeks ago, and this was
very helpful.
But in general the Food and Drug Administration and the Bureau
of Narcotics and Dangerous Drugs make no attempt in assessing com-
pliance, either with their regulations or IND protocol that was filed
with them.
Mr. Perito. Doctor, we have heard testimony from several wit-
nesses that it was their considered judgment that a private physician
could not properly dispense methadone within an ordinary office be-
cause such physician is not able to offer the proper and necessary an-
cillary and supportive services. Do you maintain a similar opinion?
Dr. DuPoNT. Well, I asrain find myself really following in the
footsteps, to some extent, of the work that has been done in New York
City and what Dr. Gearing said today.
lit is obvious in dealing with a widespread epidemic that has clear
medical dimensions and where medical skills are valuable, that it
doesn't make sense to entirely write off the private health care sector
and trv to create an entirelv Government-run clinic system to deal
with all the problems of all the people who are currently heroin
addicts.
So I think the challensre is to find ways to make use of the private
sector in a constructive way.
I think probably a good way to start is to have private phvsicians
associate themselves with ongoing structured programs and then to
pick up stabilized to successfully adjusted maintenance patients to
follow privately.
Therefore, after a person has been in a methadone program and
demonstrated his stabilitv for 6 months or a vear, then he would be
transferred to a private physician who would handle no more than
10 or 20 heroin addict patients as part of his regular practice.
In this way we get away from part of the financial gain of private
phvsicians merelv selling prescriptions.
We don't build Government clinics to treat all diabetics. Most dia-
betics get private care. Stabilized heroin addicts can also move to the
private sector.
148
Health insurance coverage for methadone maintenance is important
once the person is stabilized. The private doctor then has the option,
if that person breaks down, of returnino; him to the public clinic from
which he came for more extensive work.
The private physician doesn't have the capability of control of
methadone that is needed in the induction phases of methadone treat-
ment. This involves more than just ancillary services. Private doctors
have made their greatest errors by p:iving unstabilized patients 1 or 2
weeks' supply of methadone right at the beginnino; so that a patient
takes out a bottle or prescription of methadone which he takes in an
unsupervised way.
I think the dangers to the public from such practices are very great
and ought to be avoided.
Mr. Pertto. Chairman Peoper mentioned tlie situation relating to
recent deaths. Do you anticipate, with tlie expansion of methadone
programs, that death is a natural incident, that there will be three or
four deaths as a result of the inevitable distribution process of your
program, either because of misuse or wrongful distribution or a situa-
tion where a nontolerant person accidentally ingests methadone in-
tended for an NT A addift ?
Dr. DuPoNT. "Well, I think that there will be deaths, and there have
been.
On the other hand, I would certainly not take a fatalistic view that
these are unpreventable and we just pass them off and go to the next
patient.
I think we need to take these methadone-related deaths very seri-
ously and to do everything in our power to try to reduce the likelihood
of that kind of event occurring. For this reason NTA issues take-home
methadone in locked boxes and child-proof bottles. We have rather
elaborate forms that the patient signs.
On the other hand, I think it is a very serious public relations prob-
lem. All of the methadone deaths that are occurring are being charged
either explicitly or implicitly to the NTA programs, and this is far
from being true.
In the last 9 months in the District we have been able to uncover
23 deaths that involved methadone, either alone or with other drugs.
In only five of those deaths was there any relationship to the NTA
program. Thus, 18 of them had nothing to do with the program.
But there were five deaths related to NTA and we do everything
we can to prevent the likelihood of that occurring again. But in a
situation where only about 20 percent of the deaths are associated with
the NTA program, we suffer the criticism for all.
Chairman Pepper. Dr. DuPont, we have had a quorum call on the
floor of the House. If you will please suspend and await our return,
we will go over and answer the quorum and be right back.
We will take a temporary recess until we can get back, to answer
the call on the floor.
(A brief recess was taken.)
Chairman Pepper. The commitee will resume session, please.
Dr. DuPont is on the stand.
Mr. Perito was inquiring of Dr. DuPont.
Mr. Perito. Dr. DuPont, have had occasion to administer cycla-
zocine or naloxone to any of the addicts in your program ?
149
Dr. DuPoNT. No ; we haven't. The only drug we have used is metha-
done.
Mr. Perito. You are probably aware of certain testimony that has
been given previously to congressional committees by Dr. Yolles who
has stated that cyclazocine and naloxone and antagonistic drugs are
one of the most promising areas of narcotic research. Do you have an
opinion, based on your experience, with antagonistic drugs?
Dr. DuPoNT. I think you are going to hear from Dr. Jaffe, who
is one of the foremost experts on the subject.
As a clinician and an administrator, there are problems with the
antagonistic drugs. Put simply, they are not acceptable to patients.
Nowhere in the country, to my knowledge, has there been any large
scale use of these drugs. The real issue — at least one of the initial prob-
lems— is that the heroin addicts don't find the antagonists helpful to
them. Most patients don't, although there are a few who do.
The other problem is that the antagonists are presented to the pub-
lic as if they were somehow more benign than methadone, for example,
or were somehow to be treated more casually.
I think this is a mistake, and I think that the antagonists that we
know of so far are like methadone in that they are only useful so long
as they are taken regularly and remain in the body ; that is, they don't
immunize the person against anything, patients have to go right on
taking cyclazocine or naloxone and we know far less about the long-
term effects of these drugs than we know about methadone.
Mr. Petiro. Two final questions, Dr. DuPont.
When you testified before our committee in October 1970 you stated
that to the best of your knowledge the addict population in AVashing-
ton was 10,400. Subsequently you reevaluated your estimate and you
have stated, to the best of my knowledge, that the addict population
is, in fact, 18,000. Would that be your estimate today, 18,000 ?
Dr. DuPoNT. Well, our current best estimate is 16,800. 1 am not pre-
pared to change that estimate yet, although it may be that the addict
population is not growing any more, as it was in previous years. We
don't have good enough measures, really, of changes in the addict
population.
But the death rate has not been going up in the District over the
course of the last 9 months. If anything, it has fallen slightly during
this period of time.
So I use 16,800 as a ballpark estimate. The only fact that is really
relevant is that there are still very many untreated heroin addicts in
the Washington community who are suitable for and interested in
treatment.
We had occasion 5 weeks ago to open up a new clinic. It was the
first new clinic NTA had opened in many months. This clinic was
swamped with patients, going from zero to 200 patients in the course
of 6 weeks.
Even though we are providing treatment for 3,000 patients we can
recruit 200 new addicts by opening a clinic for just 6 weeks. This is a
very startling demonstration that when clinics are opened they attract
patients. I think the only relevant fact is that there are thousands of
untreated heroin addicts in the District of Columbia today.
Mr. Perito. How many addicts are presently being treated in the
District either under the auspices of NTA or some other program op-
erating and funded within the District?
150
Dr. DtjPont. Well, there are no other proarrams that have anything;
like comparable numbers. I would pav that usingr our definition there
are no more than 500 other heroin addicts who are beinff treated in all
the Drop-rams in the citv. inclndina: the abstinence programs.
Including the detoxification programs and the private physicians,
it mav be that there are as manv as a thousand more patients in all.
I can't imaarine the total beino- hisfher.
Chairman Pepper. Dr. DnPont, you told u« that approximatelv half
of the peonle who were in jail here in the District were found to be
heroin addicts.
Have those figures been carried forward by the police department at
the present time?
Dr. DuPoNT. Yes: we repeated this study in January 1971, and
have not finished analvzinof it. I don't have the full breakdown yet.
But it was very sicrnificant that there wasn't an obvious reduction in
the percent. The figure is still about 50 percent.
One thing: that was quite dramatic, however, was that the percent
of druff arrests had increased dramatically. Whereas when the initial
study was done in August 1969, 10 percent of the total of all people
coming into the jail were on druq- charges. By January 1971, the
figure had risen to 22 percent of all jail intake.
This reflected the fact that far more purely drug charges were being
made by the police.
Chairman Pepper. Has there been any studv made of heroin addic-
tion among people arrested for burglary, offenses against property,
and muggings on the streets?
Dr. DuPoNT. Yes. We found that the addicts were slightly less
likely to commit crimes aarainst people than the nonaddicts coming
into the jail, but that the differences were not statistically significant.
For instance, more than half of the criminal homicides were com-
mitted by addicts.
Chairman Pepper. More than half of the homicides were committed
by heroin addicts?
Dr. DuPoNT. Right. So anybody who is reassured by thinking that
heroin-addiction-related crime is confined to shoplifting, prostitution,
and drug sales is sadly mistaken.
Chairman Pepper. I am glad to get that clarified. I thought it was
generallv assumed that heroin addicts were not very dangerous. They
were satisfied, had a sensation of feeling good, but you said half of
the criminal homicides are committed by addicts ?
Dr. DuPoNT. That is right. But this must be put in perspective.
Most serious crimes, the FBI index crimes, are property crimes. The
last time I looked at the list, 86 percent of all the serious crimes in
America were so-called nonperson or property crimes. So that addicts
are like other criminals, other criminal behavior of other people in
that the primary crimes addicts commit are property crimes.
On the other hand, if you turn the question around and you ask of
the person crimes, of the robberies, of the muggings, of the homicides,
itself, what percentage of those crimes are committed by addicts sup-
porting their habits, the answer is about one-half. This is a very
serious and very important finding.
Chairman Pepper. Half of the crimes against property and against
person ?
151
Dr. DuPoNT. It is about equal. In other words, addicts commit
about one-half of the person crimes and about one-half of the property
crimes.
Chairman Pepper. So that the heroin addiction, then, has a very
direct relationship to crime ?
Dr. DuPoNT. Absolutely, including crimes against people.
Now, again this is not a drug effect. The heroin addict who is high
is not a person inclined to commit crimes because the drug tranquilizes
the person. But he commits crimes to secure money to buy heroin, and
this need leads to desperation on the part of many addicts and they
act in ways that are extremely dangerous to themselves and others.
Chairman Pepper. Well, now, you gave us evidence, as I recall, last
year, when you appeared before our committee, that in your opinion
the average addict in the street, in the District of Columbia stole — or
had to get illegal possession by offenses against the person or other-
Avise — about $50,000 worth of property a year in order to sustain his
heroin addiction. Is that still your general opinion ?
Dr. DuPoNT. Yes. That kind of evidence comes from asking addicts
about the size of their habits and then making some assumptions
about the ways they get their money. For example, if a person says he
needs $40 a day to buy his heroin, you would figure, if he is involved in
stealing property, that he has to steal it at some discount so the total
value of the property stolen is some figure in excess of the $40.
On the other hand, there have been some studies, since I testified
before you last, that would suggest that the total amount of property
crimes in the District of Columbia, at least as reported and estimated,
is not large enough to support that assumption. So that this technique
may overstate the actual criminal activity related to heroin addiction.
On the other hand, we don't really know how much unreported
crime there is. We are also in a swampy area when we estimate how
many addicts there are. The only thing we need to know however is
that there is a tremendous amount of criminal activity associated with
drug addicts. In the District of Columbia alone, $200 million a year
is probably a low estimate.
Chairman Pepper. What do you estimate to be the average cost of
heroin addiction a day ?
Dr. DuPoNT. Well, $40 is the figure found.
Chairman Pepper. In other words, he has to get enough property
in one way or another to net $40 a day ?
Dr. DuPoxT. $40 a day. But the addict will put into his arm as
much as he can get. The limit is not the physiology having to do with
the drug, but his ability to get the money. Some days he is not as able
as others so his habit fluctuates.
Chairman Pepper. Mr. Blommer.
Mr. Blommer. Thank you, Mr. Chairman.
Doctor, we are going to have Mr. Horan, the commonwealth attor-
ney from Fairfax County, testify here tomorrow, and he believes there
is a methadone epidemic.
Dr. DuPoNT. I believe there is a serious problem with methadone
in illegal channels in this city.
Mr. Blommer. Do you accept methadone addicts in your program ?
Dr. DuPoNT. You mean people who come to us and say they have a
methadone habit from somewhere else and say they want to come into
the program ; sure.
152
Mr. Blommer. You would agree there is a black market in meth-
adone ?
Mr. DuPoNT. Yes.
Mr. Blommer. And there will come a time — I assume you are al-
ready thinking of it — when you have hard-core methadone addicts
that may have become addicts from unscrupulous doctors, from the
black market, or whatever, but now we have hard-core methadone
addicts.
Dr. DuPoNT. Most of those people are using heroin, also. It will
depend on the availability. I don't think you are going to find people
who are shooting methadone, for example, who are not also shooting
heroin. Usually they will go back and forth, and use whatever is
more available.
Mr. Blommer. Would you believe it would be efficacious to take
those people in your program ?
Dr. DuPoNT. Yes. They are j ust like heroin addicts.
Mr. Blommer. Doctor, I know we have a disagreement on statistics
and what they mean. I do have a sheet here that I believe we got
from your office that shows in the last 6 months in 1970, 60 people
that were autopsied by the D.C. coroner had narcotics in their bodies.
As I read it, 10 of the 60 died of gunshot wounds, 13 of the dead
people had only methadone in their body, one had cocaine, and one
had Talwin. Therefore, 15 of the 50 remaining after we take away
the gunshot deaths had no heroin in their bodies. That leaves us
with 35 heroin-related deaths. Could you, using whatever analysis
or formula you want, make a judgment on how many heroin addicts
there are in the District of Columbia ^
Dr. DuPoNT. I am having a little trouble following your assump-
tions. You are making the assumption that the methadone addict is
different from the heroin addict when he is pursuing addiction on
the street. In other words, methadone will compete with heroin and
produce the same effects when injected.
Injected methadone produces a high like herom. It strikes me as
sortof a question of semantics.
You could call them opiate addicts and lump them together and
talk about the frequency. . i j i -i j
For example, if it were more available, morphnie would be the drug
of choice. Today heroin is the main drug in the black market, but
other opiates would work just fine. ,
Mr. Blommer. Doctor, what I am suggesting is that it and wtien
we clear up the heroin problem that we might then be dealing with
a methadone problem. . ,
Dr DuPoNT. I don't call that "clear." We now have an opiate
addiction problem that is very serious, and if we switch from one
drug to the other, and have all the same consequences, we have gained
''''Mr!'BL0MMER. But the point is, though, Doctor, no matter who is
giving the drugs out, there will be people who will be methadone
addicts and people who are heroin addicts.
Mv question is: Don't you feel that there is a great danger that
the people becoming metliadone addicts will then ] ust come to vou
instead of to the street pusher that they used to go to for herom?
Dr. DuPoNT. Well, come to me for what ?
Mr. Blommer. For their drugs, for their methadone.
153
Dr. DuPoNT. To do what ?
Mr. Blommee. To satisfy their craving, assuming they are metha-
done addicts, to satisfy their craving for methadone.
Dr. DuPoxT. And then stay in the program and pursue the course
we are interested in in the program. So what is the problem?
Mr. Blommer. The problem is you are aiding them in being addicts.
Dr. DuPoNT. I don't see how we are aiding them in being addicts.
They were addicts before they ever got there.
Mr. Blommer. Doctor, is all the methadone dispensed by your clinic
to the 1,700 people you are maintaining, is all that consumed in front
of you ?
Dr. DuPoNT. No; the patients who are stabilized in the program
have take-home privileges and they take the methadone out with them.
Mr. Blommer. Don't you see a problem ? Couldn't those people sell
to the black market and then take heroin, for instance ?
Dr. DuPoxT. Sure ; but I think you are looking at a little thing and
overlooking a big thing. Where do you think the methadone is coming
from that is causing Mr. Koran's and other people's problems in Fair-
fax County ? It is not coming from our program. He knows that.
He has said as much. Are you saying there should be no take-home
medication? What we need is widespread availability of good treat-
ment programs, whether they are in Virginia or the District. If you
did that you would undercut tremendously the black market in heroin.
You would undercut tremendously the death rates that we are seeing,
and there would be a tremendous social gain associated with that. The
need for good treatment is the big thing. Our take-home procedures
are the little thing. We also need to do something about the uncon-
trolled, unsupervised dispensing of methadone in the metropolitan
area. Do you agree with my statement ?
Mr. Blommer. Well, to some degree; but you seem to premise that
on the fact that the black market now comes from unscrupulous doc-
tors.
Dr. DuPoNT. And perhaps other sources that I don't know about,
but I am quite sure that it is not coming from our NTA program.
Mr. Blommer. Do you have an opinion on how easy it is to manu-
facture methadone ?
Dr. DuPoxT. I talked to Mr. Ingersoll, Director of the Bureau of
Narcotics and Dangerous Drugs, and he said as far as he knew there
was no illegal manufacture of methadone.
Mr. Blommer. My question is : Do you know how easy it is to manu-
facture it illicitly ?
Dr. DuPox'^T. I don't know how easy it is.
Mr. Blommer. Did Mr. Ingersoll tell you about the laboratory?
Mr. DuPoxT. In Tupelo, Miss. They broke that one 2 years ago.
Mr. Blommer. And that man had made 50 kilos of methadone.
Dr. DuPoxT. Yes ; maybe it will be happening again. If your argu-
ment is methadone is not a panacea and needs to be thought of as hav-
ing a serious abuse potential, I agree with you.
Mr. Blommer. My argument is you should have far stricter controls
than apparently you have.
Dr. DuPoxT. There is no evidence of our methadone being a prob-
lem in terms of control. We have questioned the police to find if they
find it in illicit channels. Our methadone is clearly labeled. The police
haven't brought even one bottle that they have found of our metha-
60-296 O— 71— pt. 1—^11
154
done. Where is the evidence ? Nobody in Fairfax County has died be-
cause of our methadone. What is the problem we are addressing?
Mr. Blommer. Mr. Horan, I think, will address himself to that
problem. I don't feel I should speak for him.
That is all the questions I have.
Chairman Pepper. Mr. Mann.
Mr. Mann. Your methadone in the program is administered in a
wav to bring about stabilization, which means they don't get high off
of it?
Dr. DuPoNT. Eight.
Mr. Mann. That w^ould make it different from the street addict of
even methadone ?
Dr. DuPoNT. Right.
Mr. Mann. You mentioned there were a wide variety of choices of
programs under yours. I don't see but two, the methadone maintenance
and abstinence programs. What else is there ?
Dr. DuPoNT. To give you an example of the diversity of the pro-
grams, we have halfway houses in which people can live in where they
can in some cases take methadone and others remain abstinent.
We have 65 beds in a hospital unit for detoxification, primarily for
young people. They have programs entirely abstinent and these are
used a good deal. We have people taking it in decreased dosages, lead-
ing to abstinence and others maintained on it.
For example, in the city we cooperate with Colonel Hassan and the
Black Man's Development Center. In the Black Man's Development
Center patients go through a different experience entirely and are
educated in citizenship training, residential treatment, and decreasing
doses of methadone. That is a very different kind of treatment experi-
ence than goes on in most of the rest of our programs.
Another program, Step-One, run by ex-offenders known as Bona-
bond. Inc., is a halfway house and outpatient clinic that uses no
methadone.
A person can move freely between any of these options.
Another program. Guide, D.C., uses psychologists and social work-
ers, in family and individual therapy of patients, and for those who
find that useful, they can go to the program.
So there is quite a variety of treatment programs, perhaps not com-
plete, but quite a variety.
Mr. Mann. Getting back to the chairman's reaction to your state-
ment of crimes of personal violence. I was interested in your state-
ment that these crimes of personal violence were not motivated by the
drug effect, but were still motivated by the acquisition of property,
of funds to sustain their habits.
Dr. DuPont. Right.
Mr. Mann. Have you made any effort to distinguish those property-
related crimes, even though they result in personal violence, from
crimes of passion resulting in personal violence ?
If you were to take homicides and divide them in half you would
find that half passion and half property ?
Dr. DuPoNT. Right. I haven't looked at that, but that is a good
question. I will look into that and maybe I can supply something for
the record on those crimes committed in our previous study.
Mr. Mann. Very good.
Thank you, Mr. Chairman.
(The information referred to above follows:)
155
100 addicts
125 nonaddicts
Offense with which charged
Profit Passion
Profit
Passion
Larceny
Robbery
Burglary
21
10
6
11 ...
15 ....
8 ...
3 ...
1 ...
Stolen property
3
Housebreaking
Offense/family
1
Assault
5 ....
3 ....
9
Homocide
1
Assault/deadly wea pon
3
A rmed robbery
1
2 ...
1 ....
3 ...
2 ....
Bank robbery
Forgery
Fraud
Manslaughter
2
3
2
2
Private orooertv
4
Total
Total (percent)
48
48
8
8
46
37
20
16
Note.— Table Is a result of study conducted by the Narcotics Treatment Administration at D.C. Jail between Aug. 11 and
Sept. 29, 1969, on an accidental sampling of 225 Inmates.
Chairman Pepper. Mr. Wiggins.
Mr. Wiggins. Dr. DuPont, I am still a little bit confused on the
effect of methadone on the human body. When it is taken by a patient
in your program, what effect does it have on that patient ?
Dr. DuPoNT. Well, the regular effect is that the person comes into
the program and he has an opiate habit which is in almost all cases,
at least as far as I have ever seen any data, a heroin habit.
When he comes he wants some help with that, and he will take an
initial dose of methadone of around 30 to 50 milligrams. Now, when
he takes that he has a suppression of the withdrawal of symptoms
that he usually experiences and he feels relatively normal.
Now, the patient has choices at that point, and he can either go on
decreasing doses leading to abstinence, taking anywhere from a few
days to a few months ; or he can choose a maintenance schedule in which
his dose goes up to about 100 milligrams and he stabilizes at that point
until he feels it makes sense to try detoxification and comes down
again.
Depending on the amount of the drug, and if there is a little bit
more given than is needed just to suppress withdrawal symptoms, the
person might feel a little drowsy, a little euphoria.
He would also, in many cases, experience constipation. Some people
will also experience excessive sweating. Those are the primary effects.
In addition, while the person is on increasing doses or beginning
treatment, some men have a transient impotence, probably associated
with the anesthetic effect of the drug. The mechanism is not clear.
Once he is stabilized, the only effect that most patients experience
is the constipation and excessive sweating. In other words, there is
tolerance to the other effects, except suppression of the opiate drug
craving and the blocking of the euphoric effects of heroin.
Mr. Wiggins. Is there any benefit of feeling good by going out and
getting more methadone if you are on a diet of 100 milligrams ?
Dr. DuPoNT. No. Once on 100 milligrams there is no effect either
orally or injected. Now, many patients do go out and shoot methadone
or heroin to test their blockade. He will not have any euphoric or other
effect.
156
There are several reasons a person might continue occasional use of
heroin. Many persons are fearful about withdrawal symptoms and
feel they must take increasing doses to prevent withdrawal symptoms,
even though they can't feel the drug effects. But they feel very anxious.
We had one patient who, when a private doctor recently stopped his
practice of giving methadone, said, "Oh, I didn't want to tell you this,
but I was getting a second dose of methadone by going to a private
doctor." Since there is no central registry now we didn't know that.
He was taking two doses of methadone each day. "V^Tiat he was doing,
as far as we can understand, was treating his anxiety about not getting
enough.
The treatment was to counsel the patient, to help him see that he
was getting enough methadone, and he stopped taking two doses.
Mr. Wiggins. Dr. DuPont, we are running out of time, and I would
like to get into the record the technique you employed to prevent peo-
ple from abusing your program by obtaining methadone from a sec-
ond source, and the way that you insure that those who take it home
do not misuse it. Would you describe your security procedure?
Dr. DuPoNT. The NTA patient takes his methadone on the premises
for the first 3 months of the program, and then he gets take-home
privileges of gradually increasing duration until the minimum fre-
quency allowed, which is two clinic visits per week. The patient must
be on the program at least 6 months to a year for that to happen.
The patient's urine is tested twice weekly. Urine tests identify all
hard drug use, but, of course, we can't separate a second dose metha-
done. But we know that a person is not going to more than one of our
centers, because all patients come in and have their pictures taken and
get an I.D. card. It is, however, possible to take methadone from an-
other source, either inside the city or out, which is a serious problem.
Mr. WiGGixs. What w^ould be an in-city source ?
Dr. DuPoNT. A private physician. A person could also go to Colo-
nel Hassan's program and register for that program and receive meth-
adone and not be in our central register.
Mr. Steiger. Is he still conducting his program ?
Dr. DuPoxT. Yes ; and only those patients for whom we pay him in
our central registry.
Mr. WiGGixs. What is the solution to that problem ?
Dr. DuPoxT. The solution is a regional registry for everybody who
gets methadone. Everybody who takes a dose of methadone anywhere
in this area ought to be required to be in a central register.
Mr. WiGGGixs. How central ? IMultistate ?
Dr. DuPoxT. We should ultimately involve Baltimore as well as
the suburban counties in Maryland and Virginia.
Mr. Steiger. I wonder if we could have the witness, if he could re-
main? I hate to impose on him, but I think all of us would like to ex-
plore this.
Chairman Pepper. Doctor, could you wait a few minutes more?
Dr. DuPoxT. Sure.
Chairman Pepper. Doctor, let me make this announcement before
we recess. We will come back.
Dr. Jaffe is here, another distinguished witness, and he has kindly
consented to stay over until tomorrow morning. Without objection on
157
the part of the committee, when we do recess today we will recess un-
til 9 :45 tomorrow morning.
AVe will take a temporary recess so we can go over and vote again,
Doctoi'. We are sorry to put you to so much trouble today.
(A brief recess Avas taken.)
Chairman Pepper. The committee will come to order, please.
Dr. DuPont, I understand you have some problems with time to-
day, also.
Dr. DuPoNT. Yes ; I do.
Chairman Pepper. We will try to expedite our examination of you.
Mr. Steiger.
Mr. Stei«er. Thank you, Mr. Chairman.
Doctor, I wanted to get into one thing about half opened up by
your testimony and others, that physicians are a source of the illegal
methadone. I notice that in almost all the drug hearings we have had,
and the committee has held before, even in other areas, there is a great
reluctance to admit the complacency of the medical profession. I say
"complacent" advisedly. I don't mean there is any kind of conspiracy
by the medical profession itself, as a major source of opiates.
I wonder if in your experience, Xo. 1, if you agree that it could
be a problem not only in methadone, but in the dispensing of other
opiates, and if the equation that the reason for many of the people
involved in your program and the New York City program are the
underprivileged as an economic matter that the privileged are able
to buy through pseudolegitimate source the wherewithal to feed their
habits : is this a valid position ?
Dr. DtPoxT. There are so-called medical addicts or people who
have become addicted through medical treatment. This does not neces-
sarily involve any dereliction on the part of the physician, although
oftentimes there is less vigilance than probably was appropriate.
On the other hand, I don't think it Avould be fair to say that opiate
addiction is uniformly distributed throughout the population by so-
cial class and that the lower classes don't have the wherewithal to get
it and the upper classes do. Opiate addiction is concentrated in the
loAver social classes, even adding in people going to private physicians.
On the other hand, those who do go to private physicians are ob-
viously from the upper classes. One thing we have noticed in the Dis-
trict is that whereas about 8 peicent of the overdose deaths in the city
are white, only about 4 percent of our patients are white, which means
that there is an underrepresentation of whites in our patient group.
I am sure that this is accounted for by more white addicts going to
private physicians.
Mr. Steiger. That is a very interesting statistic and I can draw a
lot of conclusions from it, which I don't want to do superficially, but
I am glad to have these statistics.
Now, we have had some specific instances in the Phoenix, Ariz., area
in which physicians were actually dispensing narcotics in a manner
that could hardly be determined medically responsible. I don't think
it serves any purpose to identify it as a racket, but just as irrespon-
sibility.
My question is : In your experience, how widespread — I will phrase
it a different way.
158
It would seem to me a very busy physician who finds it reasonably
profitable and could justify perhaps in his own mind the regular pre-
scription of opiate prescription for persons who didn't require much
attention, and to which he was going to get paid for each prescription.
Dr. DuPoNT. In advance.
Mr. Steiger. In advance. Is that the way it works ?
We have now taken public official notice of the private physician in
regard to dispensing of methadone, and your recommendation there
is that he not be permitted to do this without other qualification,
which I think is very valid, but really we are still skirting the prob-
lem.
Dr. DuPoNT. It is still going on. ,
Mr. Steiger. Well, Ko. 1, of course, there is no way to control it, we
understand that. We all know we are talking theory here. Short of
having the AMA speak to its own, what do you recommend ?
Dr. DuPoNT. Well, the AMA has spoken to its own. They had a
release about a month ago in which they strongly discouraged private
doctors.
I think it is going to take something more than this. I am not an
attorney, but what I understand is that once a drug, any drug, is avail-
able in the pharmacy, any pharmacy, that any doctor can prescribe
it for anything he wants to. There are certain recommendations that
are made by the medical profession and by the Food and Drug Ad-
ministration, but these do not have the force of law and the doctor can
pretty much do what he wants.
Methadone is an established drug available in every pharmacy. I
wonder if it wouldn't require some sort of legislative action to make
methadone an exception and to bring it under control.
You might pursue this with subsequent witnesses who can speak
more authoritatively, because I think it is a very serious problem when
Federal agencies and other groups pretend to have the power to curb
certain kinds of behavior that are considered to be undesirable but
really don't have that power. The question is whether thev do have
the power; if they do have the power, then why has nothing been
done?
I think many people are misled and believe that power exists when
it doesn't.
Mr. Steiger. Good.
Thank you. Doctor, I have no further questions.
Chairman Pepper. Is that all ?
Mr. Steiger. Yes.
Chairman Peppek. Mr. Kangel, have you inquired of Dr. DuPont?
Mr. Rangel. Doctor, in your medical experience, have you ever
found a national health problem such as drug addiction being treated
as you are treating it with — and multimethods of service and com-
munity controls? Is this a usual way to treat a problem of such
enormity ?
Dr. DuPont. I don't think there is anything usual about heroin
addiction. I don't know what the analogy would be. I think it is very
exceptional.
Mr. Rangel. This is a very exceptional method of treatment of any
problem, any medical problem of this sort, isn't it ?
Dr. DuPoxT. I think so. I am not sure where I am being led to, but
I will say, "Yes," and put an asterisk after it.
159
Mr. Rangel. Well, I wasn't goin^ to lead you any further, but I
wonder if we were talking about a different economic class of people,
whether or not those in the medical profession would be more prone
to have this type of community control over dispensation of drugs.
Dr. DuPoxT. That is a good point. If it were a different social class
I don't think the problem would have gone on in Harlem as long as it
did without any treatment at all. It wasn't until the majority of the
country, the more affluent part of the country, in any event, became
very frightened about crime rates in their cities, and until they got
concerned about their own junior and senior high school children using
drugs that we got a national commitment.
But it is coming and I think it is to everybody's benefit.
Mr. Rangel. This national commitment, as far as I can see in the
area of rehabilitation, it has settled down to the question of expand-
ing methadone treatment ; has it not ?
Dr. DuPoxT. No ; I don't think that is true.
Mr. Raxgel. How much time does your institution spend on devel-
oping scientific methods of curing this, other than methadone ?
Dr. DuPoxT. Well, about 25 percent of our patients are not on
methadone, for example.
Mr. Raxgel. But are you looking for other scientific cures ?
Dr. DuPoxT. No; we don't do any basic research. That would be
more properly done elsewhere. We are a city treatment agency.
Mr. Raxgel. But you have no national institution that you can go to
in order to increase your ability to deal with the drug addiction prob-
lem ; do you ?
Dr. DuPoxT. Well, the National Institute of Mental Health is prob-
ably one of the logical sources for this kind of activity. In fairness to
them, some activity is going on there, but very little.
Mr. Raxgel. Have they been of any assistance to you to reach a
program Avhere you could professionally feel that you are doing the
best you can with what is available ? Have they assisted you in devel-
oping your program ?
Dr. DuPoxT. Yes; they have given us $800,000 a year for one major
component of our program.
Mr. Raxgel. I am not making myself clear. I am not talking about
the money. I am talking about you, as a doctor, with your background.
Dr. DuPoxT. I see.
Mr. Raxgel. Have you got a national institution that can give you
scientific data as a result of their research that you can depend on so
that perhaps you could expand and develop other methods of treating
drug addicts, other than methods of Colonel Hassan ?
Dr. DuPoxT. No.
Mr. Raxgel. So that as far as you are concerned, all you have is what
New York City has done as a basis of where you are going ?
Dr. DuPoxT. Well, I think Chicago and Dr. Jaffe added something
very important to the New York experience, and that was the concept
of a multimodality program. So I think there are other additions, and
I think all over the country there are a lot of very resourceful and
energetic people who are involved from a variety of sources.
For instance, in Stanford University, Professor Goldstein, who is a
pharmacologist, made a very important contribution, for example, with
a urine testing technique which promises a lot of advantages over what
160
we had before. I don't think it is quite fair to say there is no where
to turn.
Mr. Kangel. I am talking about on a national level.
Dr. DuPoNT. I think the national agencies have provided very little,
approaching nothing.
Mr. Kangel. You said earlier that there was no difference between
a heroin addict and a methadone addict, and I agree with what you
and I have seen in central Harlem.
On the other hand, other people have testified there is no difference
between a methadone addict and a diabetic. I see a large medical
credibility gap between those two statements.
Dr. DuPoNT. Well, I think Mr. Blommer and I were talking about
the "addict" as different from the "dependent." Dr. Gearing made
this distinctioii. We are going to have to make a distinction between
the person who is taking methadone and is dependent upon it as part
of a structural program and the so-called addict. Both are technically
addicted, although the behavior one observes is quite different.
Mr. Kangel. Let me just use your terminology. Is there any dif-
ference between a person dependent on heroin and a person dependent
on methadone ?
Dr. DuPoNT. Yes; I think there is a dramatic difference. It is as-
sociated with the drug and also with where it comes from.
Mr. Kangel. Didn't you say earlier there was no difference between
a heroin addict and a methadone addict ?
Dr. DuPoNT. When it is out on the street and people are shooting
it and are pursuing an addict life style, there is no difference.
Mr. Kangel. To put it another way, if we were to dispense heroin
or have a heroin maintenance program, then would there be any dif-
ference, taking out the life style of the street and heroin maintenance
program and your methadone maintenance program?
Dr. DuPoNT. Yes ; there would be. I think there are pharmacological
advantages to methadone, which is very important. One is that metha-
done needs to be taken once a day instead of three or four times a day
as with heroin. That is a very important distinction.
Another difference is that methadone can be taken orally rather than
injected. Many of the problems associated with heroin addiction have
to do with its being injected.
Perhaps even more important, methadone allows the person to be
stabilized at a dose and he doesn't continue to crave for increasing
amounts.
The fact is that most people "maintained" on heroin — for exam-
ple, in the British clinics — are dropouts from society. This is not the
typical experience with the methadone-dependent patient in a pro-
gram. He is a person who is able to call on his own inner strength and
pursue a life course that makes sense, including productive prosocial
work.
I think the personal experience of seeing the persons in a methadone
program is dramatic.
I was with the Department of Corrections a little oyer 2 years ago
and had no interest in or special knowledge about this field. I went
through a very personally moving experience when I first visited a
methadone program and talked to the patients. This experience meant
more to me than all of Dr. Gearing's charts. But I was impressed by
161
the sincerity of many of these people as they described the difference
of their lives and their families after methadone treatment. You talk,
for example, to the wives of men who are in the program, and they
are appreciative of the changes that have come about in their
husbands.
Mr. Eangel. You can't attribute all of this to methadone.
Dr. DuPoNT. No, I don't. I think a lot of it has to do with the pro-
gram, but I think the programs could not function without methadone.
If you put a head-to-head kind of test with just the ancillary services
in one and the other you had the ancillary services plus methadone,
you would get 10 percent effect in the one with ancillary services and
90 percent in the other.
I don't think you should underestimate the effect of methadone in
dealing with chronic heroin addiction.
Mr. Rangel. But you don't know if you were able to give all of
these services to youngsters not addicted to anything whether or not
you would still feel great that you were helping youngsters ?
Dr. DuPoNT. I think youngsters need all of the services, regard-
less of whether they are taking heroin, especially employment oppor-
tunities. There are great segments of our society who don't have
enough opportunities now, whether they are on a program or not.
That is another thing that happens to you when you work with these
people, vou learn that.
Mr. Rangel. Would you consider your patients normal? Some-
one said earlier, a witness testified that they believed that the metha-
done patient would always be dependent on drugs. Now, you have
different programs, but you do have one that does not try to diminish
the amount of methadone, and is it fair to say that the person included
in this program will always be dependent on methadone ?
Dr. DuPoNT. No ; it isn't fair to say that, because some will try at
later points to come off and some of those people will make it.
Mr. Rangel. During this period of time, how do you as a doctor
distinguish between them and so-called normal people who are
Dr. DuPoNT. You can't tell any difference. The only way is the
urine test.
Mr. Rangel. But how do they function ?
Dr. DuPoNT. Methadone maintained patients function perfectly
normally. To add to this a little bit, I have never seen this in writing
and I hope it is not denied, but it is, I understand, the case that the
District of Columbia Motor Vehicles Bureau has been very interested
in how our methadone people have been faring in terms of accidents.
Although they have a list of quite a number of our patients asking
for permits about whom we have written saying they are rehabilitated.
So far, these patients haven't had the first accident. The Motor Ve-
hicles Bureau said facetiously, that methadone maintenance may not
only reduce crhne but also reduce auto accidents.
But I think the point is very important. These people do perform
normally.
The same thing goes on with employers. As Dr. Gearing said, em-
ployers are quite skeptical about methadone. Many have learned from
experience that methadone maintenance patients make good employees.
But again I want to emphasize what I think you are saying, which
is that there are vast unmet needs in the community which spawn
162
heroin addiction and support all kinds of destructive behavior. Meth-
adone does nothing about those problems.
Mr. Rangel. Thank you.
Chairman Pepper. Mr. Keating.
Mr. Keating. Doctor, did I understand you earlier to indicate that
there were 26 deaths attributed to the methadone, or did I hear you
incorrectly ?
Dr. DuPoNT. Twenty-three that involved methadone. Not all you
could say could be attributed to methadone, because many of them
also had heroin as well. There were a total of 14 of the 23 that did not
involve heroin also.
Mr. Keating. Breaking that down, did you indicate that five were
associated in some way or another with your group ?
Dr. DuPoNT. Five out of the 23 and three out of the 14.
Mr. Keating. How were you able to determine if these were asso-
ciated with a drug dispensed by your organization ?
Dr. DuPont. Well, two of them were patients who were in our pro-
gram 2 days, one of whom took heroin and alcohol along with the
methadone and died of a multiple overdose.
The second was a young woman who was in the second day of the
program and felt sick in the evening after taking her dose at 8 o'clock.
She went to bed, vomited in her sleep, inhaled the vomit into her
lungs, and died. Those were the only two patients to die of overdoses.
A third death was a person who was put into a cab and who was
about to die of an overdose. The cab raced to the hospital but the
driver noticed that the person who put him in the cab threw some-
thing into the street that was not identifiable. The policeman was told
about this. When he came back and looked in the street he found a
bottle with an NTA label. But we count that as a death that may have
had something to do with our methadone. Two other cases occurred
when people not in the treatment program were given bottles of NTA
methadone and died of overdoses. Both included heroin as well as
methadone ; that is, they participated in an addict drug-taking experi-
ence which involved methadone.
That is the total : Five.
Mr. Keating. Have you had any deaths that were attributed to
people who took the methadone from the clinic to take at home or as
a result of that procedure ? You know, you have some people that only
come in twice a week.
Dr. DuPoNT. No patient who has been on the program longer than
2 days has died from an overdose of anything.
Mr. Keating. I think that helps clear up a number of questions I
had. How do you ascertain the previous experience of the patient in
terms of heroin or methadone or some other drug?
Dr. DuPoNT. We ask them and record the information about when
they say they first begun to use each of the numerous illegal drugs,
including methadone and heroin.
We also take a urine test at the beginning of the treatment. It re-
mains possible for a person who is not an opiate addict to get into our
program and to continue to participate in the program without ever
having been an opiate addict.
For example, if a person would drink a bottle of tonic water, such
as gin and tonic, it would produce quinine in the urine, which is a com-
163
mon finding with people iisino; heroin. We would tabulate that as
heroin "positive." But such an impostor would have to drink the meth-
adone on the NTA premises for 3 consecutive months and give us a
urine sample twice a week. We haven't had any investigators or re-
porters that pursue that course. Whether there are people, children or
otherwise, who have gone through this process and are not bona fide
addicts in the first place, we don't know.
Mr. Keating. How do you know what level to start them ?
Dr. DuPoNT. On the basis of what they tell us. A person who is
young would get a smaller dose and a person without a lot of track
marks would get a smaller dose, and an older person with a lot of track
marks would get a larger dose. In all cases, the dose is from 20 to 50
milligrams to start.
Mr. Keating. Do you have any information of somebody coming in
and getting started in your program ? I think this question was asked
earlier. Is that a constant concern of yours ?
Dr. DuPoNT. I am concerned about it from a theoretical point of
view. I don't have any evidence of that happening. My impression is
it is unlikely because the methadone treatment in my experience is not
a positive one in terms of pleasure. It is certainly disruptive to a per-
son's life to come in every day for 3 months and fill out all the forms,
get an I.D. card, and to give us urine specimens twice a week. This
would deter, I think, a casual fake from coming in.
On the other hand, I am concerned about it and if there was some
evidence to the contrary I would like to know about it. We are really
quite concerned. There isn't any obvious way to find that out, though.
Mr. Keating. You indicated a patient needs a choice of modality.
How many different choices do you provide?
Dr. DuPoNT. There are 15 centers in the city right now, not that
everybody can choose each one of them. For example, some of them are
restricted to geographic areas. So if a patient doesn't live in that geo-
graphic area he can't go there. But every person can choose at least
detoxification on methadone with dex^reasing dosages, or methadone
maintenance, unless he is under 18 years of age or reports a history of
addiction less than 1 year, in which case he cannot choose methadone
maintenance. Each patient can choose an abstinence program and come
in and give a urine sample and participate in counseling programs.
Mr. Keating. Do you check any police records as part of your
procedure, before you put them on your program?
Dr. DuPoNT. No. This is certainly a good thought. We are now con-
sidering trying to identify arrest records earlier, and if we can't, to
make extra efforts to make sure we have the correct identification.
Our initial attempts to make positive identification were not as
strict as they are now. Our current procedure is to find a driver's
license or something else to confirm identification.
In other words, we just don't take the person's word for his name,
the way we did earlier in the program. Everybody who now has his
identification renewed is expected to go through' this same process
of proving who he is.
Mr. Keating. Is there any procedure during the course of your
treatment that would lead to a counseling that would try to persuade
the person to abstain ?
Is there any effort in this direction ?
164
Dr. DuPoNT. I am reluctant to get involved in encouraging that
unless there is some reason to believe it is likely to succeed. It is very
hurtful to people to talk them off methadone when they really need to
be on it. We have had some very bad experiences with people who
have discontinued methadone under some overt or covert staff pres-
sures and then who go back to heroin and leave the program.
Mr. Steiger. Excuse me.
Mr. Keating. Yes.
Mr. Steiger. A person who is addicted or dependent on methadone
in the oral form, and he abstains, are his withdrawal symptoms phys-
ically as stringent as the heroin addict ?
Dr. DtrPoNT. They tend to be, dose-for-dose, less intense and of
longer duration, but, of course, the dose-for-dose qualification is im-
portant because the street heroin addict is likely to have a smaller
total dose. The peo]:)le who are on methadone maintenance have very
painful withdrawal symptoms if they stop abruptly. If they detoxify
over weeks or months the common experience is easy until the patient
is down to about 20 or 30 milligrams a day, at which time he will start
developing hunger for the drug again and he may start shooting heroin
again.
When he takes his last dose of methadone, if he doesn't go back to
heroin, he will have insomnia, aching of his joints and muscles, which
will last for several days to several weeks.
Chairman Pepper. Mr. Brasco ?
Mr. Brasco. Thank you.
There are several observations that have been made, Doctor, and it
is sort of puzzling me. I share the concern of my colleagues about the
problem of methadone traffic in the street. It would appear to me that
if there is no euphoria attached to drinking meliadone, then there
would be no need or no reason for an addict to be taking it in the street,
unless
Dr. DuPoxT. He shoots it, they inject it.
Mr. Brasco. All right. Now, the next thing is if he does that and
based on my own experience in the area, having practiced criminal law
for some 10 years, addicts are not stupid when it comes to their own
needs.
Are the problems that you talk about concerning greater withdrawal
effects in usmg methadone, and obviously if they are obtaining it
illicitly they are paying for it anyway. Wliat would be the advantage
of using methadone when an addict can get heroin in the streets easily.
Dr. DuPoNT. Well, if the methadone is cheaper he would take the
methadone, and I think with the widespread availability of methadone
on the street it is cheaper, dose for dose.
Mr. Brasco. So what you are basically saying is that the people that
are trafficking in the street are using it to shoot it up because of the
availability and the fact that it is cheaper ?
Dr. DuPoxT. Oh, yes.
Mr. Brasco. One other thing.
I agree with my colleague, Mr. Rangel, that the support programs
surrounding the methadone program that Dr. Gearing talked about, if
they were given to underprivileged people without the problem of
addiction they would be very effective in doing a job to lessen crime
rates in deprived areas. But in your program I am wondering whether
165
or not there is great resistance in the job opportunity areas, based on
two reasons :
One, the fact that the individual is an addict in your program ; and
two, this question of the previous record of an individual, which seems
to me probably to be the most destructive force that we have in our
area of rehabilitation. I am wondering if we were able to devise some
kind of system where we could do away with a criminal record follow-
ing you around for the rest of your life, whether or not that would be
helpful in terms of the effectiveness of your program, at least the
followup portion, the job aspects?
Dr. DuPoNT. Well, it might be. It certainly wouldn't hurt. But I
think you have to keep in mind that the average educational level of
the patients in our program is 10th grade. That is, half the people have
dropped out by the time the 10th grade has come around. So we have
some serious handicaps here of an educational nature that are not
going to be dealt with simply by eliminating the arrest record.
I think in some respects I would like to put in a qualification on the
ancillary services and dealing with the patients' problems. I don't
know where the evidence is about job training, for example, or psycho-
logical counseling in terms of reducing unemployment, or many other
things.
I think that the whole manpower question really needs a very hard
look at what is going: on. I am taking the position that it is not just
training that is needed, but opportunities for work. You can have a
lot of training go on and put an awful lot of money into training pro-
grams that don't really go anywhere.
Mr. Brasco. Let nie just rephrase the last question another way:
Getting away from the program that you are talking about and in
the area that you are expert in, do you think that cari-ying a prior
record around for the rest of your life serves any purpose other than
to deprive people of job opportunities ?
Dr. DuPoNT. I think it does deprive people of job opportunities,
but, perhaps, not as many as you may be thinking. It is possible in many
circumstances to establish an identity as a rehabilitated former offender
that is quite positive and constructive.
I don't think it is necessarily a bar forever. There is some evidence
of social change about this. Businesses, I think, now are more con-
cerned about social responsibilities in terms of reducing criminal be-
havior by providing job opportunities, more so than they were 5 years
ago.
Mr. Brasco. Thank you.
Chairman Pepper. Dr. DuPont, I just want to ask you one question :
You estimated there were 16,800 addicts of heroin in the District of
Columbia. You testified you had 3,160 in your treatment program and
most of the rest of them are not being treated.
Now, how much money would it take, according to your best esti-
mate, to provide the best known treatment to all the addicts of the
District of Columbia?
Dr. DuPoNT. Mr. Chairman, our best estimates are that it costs
about $2,000 a patient-year to provide comprehensive multimodality
treatment.
That amount of money in no way meets all the needs of these people,
including health and training, et cetera. But it meets many of them.
166
Using this figure as rule of thumb, it would take about $34 million
to treat 16,800 heroin addicts.
Chairman Pepper. You are now getting a total of about $5,100,000
for the program from the District and Federal Governments ?
Dr. Du Pont. Yes sir.
Chairman Pepper. Well, thank you very much. Doctor. We appreci-
ate your coming.
I am sorry to have kept you so long.
We want publicly to thank Dr. Jaffe again for his willingness to
stay over and let us hear him tomorrow morning.
We will recess until 9 :45 tomorrow morning, in room 2253, and we
win be back in this room at 10 o'clock Thursday.
Without objection, the insertions will be included in the record.
Mr. Perito. For the record, Mr. Chairman, exhibit No. 11(a) is en-
titled "Profile of the Heroin Addiction Epidemic."
Exhibit No. 11(b) is dated January 12, 1971, and entitled "Summary
of 6 Months Follow Up Study."
Exhibit No. 11(c) is in the handwriting of Dr. DuPont and is en-
titled'JDr DuPont's Numbers."
Exhibit No. 11(d) is dated January 1971 and entitled "Administra-
tive Order."
Exhibit No. 11(e) is entitled "A Study of Narcotics Addicted Of-
fenders at the D. C. Jail."
(The exhibits referred to above follow :)
[Exhibit No. 11(a)]
Profile of a Heroin Addiction Epidemic
(By Robert L. DuPont, M.D., D'rector, Narcotics Treatment Administration,
Washington, D.C.)
Abstract
Washington, D.C, is experiencing an alarming epidemic of heroin addiction.
According to current estimates there are now about 17,000 heroin addicts in the
city.
Two-thirds of the addicts are under 26 years of age, 91 percent are black, 74
percent are male, and 52 percent began heroin use within the last 4 years. In one
large part of the central city it is estimated that 20 percent of the boys agei 15
to 19 and 38 percent of the young men 20 to 24 are heroin addicts.
A major treatment program has been implemented in Washington which is now
treating 3,000 heroin addicts of whom about 75 percent receive methadone.
An initial performance study found that 55 percent of all patients remained in
the program after 6 months and that 86 percent of those on methadone main-
tenance were retained in the program during the 6-month study. Among the
patients treated, heroin use decreased, arrest rates fell, and employment rates
rose.
Introduction
Washington, D.C, Is engulfed by an alarming epidemic of heroin addiction.
Increasingly sophisticated research information accumulated over the course of
the last year demonstrates this without a doubt. It is now estimated that there
are 16,800 heroin addicts in the city, or 2.2 percent of the total population of
756,510. The social and personal losses are tremendous. The related crime rate is
appalling.
But the figures do not stop with the tragic consequences of heroin addiction in
the Nation's Capital. Limited data available from metropolitan areas around the
country suggests that these cities are also experiencing the epidemic.
Upon recognizing that heroin addiction was such a disastrous problem in
Washington, D.C, the largest and fastest growing municipal treatment program
167
in the Nation, the Narcotics Treatment Administration, was begun in February
1970. Nevertheless, it is obvious that even this effort is grossly inadequate for
the needs of the Washington community.
What is known of the epidemic in Washington? How many heroin addicts
are there? Where do heroin addicts live in the city? What are the basic char-
acteristics of the addict population? When did the epidemic begin? Is it getting
worse? What is the relationship between the distribution of addiction in the city
and other social factors including crime and poverty? How much does the
epidemic cost the community ? What can be done about it?
This paper attempts to answer these vital questions and should be useful to
the Washington, D.C., community and to other cities and States which know far
less about their problems with heroin addiction.
How many heroin addicts are there?
In the summer of 1969 the only basis for estimating the Washington addict
population was the Bureau of Narcotics and Dangerous Drugs (Justice Depart-
ment) 1968 list of 1,162 addicts in Washington. However, in August 1969 a study
at the District of Columbia jail showed that 45 percent of all new admissions
were heroin addicts. Only 27 percent of the men identified as addicts by inter-
view and urine testing were previously known to the BNDD (1).
On the basis of this new information, the estimate of the total number of
addicts was raised to 3.7 times 1,162 or 4,300 addicts. Next, in cooperation with
the District of Columbia coroner, an analysis was made of the total number of
known opioid overdose deaths in Washington. An opioid overdose death is a sud-
den death, without other cause, of an individual whose urine or other tissues
contain an opioid drug such as heroin, morphine, or methadone (3). In 1967 the
number was 21. Using the Baden formula (2) that one of every 200 heroin addicts
dies of an overdose reaction each year, the total number of District of Columbia
heroin addicts appeared to be 4,200 for 1969. However, there were 13 overdose
deaths in the first 3 months of 1970. This was equivalent to 52 per year and indi-
cated a total addict population of 10,400 using the Baden formula. During the
first 6 months of 1970 a total of 21 people died of overdoses. Thus, in the first 6
months of 1970, the same number died of overdose reactions as died in all of 1969.
In July 1970, again in cooperation with the District of Columbia coroner, a
new more systematic procedure was developed. Complete narcotics drug screens
(using gas liquid chromatography) were performed on all autopsied deaths of
individuals between the ages of 10 and 40 as well as individuals younger or
older who showed evidence of drug use. During the next 6 months, 42 people were
identified as dying of opioid overdose reactions. The annual rate was 84. The
estimate of total heroin addicts was accordingly raised to 16,800.
During the calendar year 1968 a total of 875 narcotic addict information forms
were received by the Biostatistics Division of the District of Columbia Health
Services Administration. In 1969 one of these individuals died of an opioid over-
dose. During 1970 three died of opioid overdose reactions. Thus the rate of death
was one per 438 man-years. This data was not used to compute a '^Washington
formula" because the numbers are small, but it suggests that the multiplier used
by Baden in New York may be low for Washington. If this is true, then the cur-
rent estimate of 16,800 heroin addicts in Washington may also be low.
It should be noted that the increase in the rate of overdose deaths in the last
2 years did not reflect only increased heroin use. In part, the increase was due to
greater awareness of the problem of overdose deaths and to improved and more
frequently used laboratory procedures. For example, during the 18 months prior
to July 1970 drug screens were performed on only 6.3 percent of all autopsied
deaths. During the last 6 months of 1970, the period of the systematic study,
narcotic drug screens were performed on 51 percent of all autopsied deaths. ( See
table 1. )
There was no evidence of increasing death rates over the 6 months of the study.
Twenty-three people died from July through September, and 19 died from October
through December 1970. Thus, although the time span was short, and the numbers
were small, the Washington heroin addiction epidemic may have stabilized during
the last 6 months of 1970. Data collection is continuing and in the next year more
definitive conclusions should be possible.
By January 1971, a private drug treatment program located in the District of
Columbia, the Blackman's Development Center (BDC) which made small doses
of methadone available to addicts as part of a voluntary outpatient withdrawal
program, had registered over 20,000 "drug dependents" — almost all heroin addicts.
Some BDC clients lived in the Washington suburbs, which have almost no treat-
168
ment facilities for heroin addicts. However, it seems unlikely that the suburbs
contributed more than 10 to 20 percent of BDC registrants. Thus, even when the
BDC registration list is discounted for suburban residents, nonheroin users and
multiple registrations for the same person, the 20,000 figure suggests that there
are many more thousands of addicts in Washington than the 1968 list of the
Bureau of Narcotics and Dangerous Drugs indicated.
There are other figures which indicate that the addiction problem is greater
than had previously been estimated. The Washington, D.C., Metropolitan Police
Department reported 4,730 narcotics arrests during 1970. Ninety percent of these
arrests related to heroin use or sale. The numbers of narcotic arrests for each
year from 1967 through 1969 were 818, 1,077 and 1,716 respectively. Thus, there
was a 462 percent increase in narcotics arrests from 1967 to 1970. Undoubtedly,
part of this increase reflects improved and increased police activity. However, it
also reflects the spreading epidemic of heroin addiction.
Evidence for increasing the estimate of the total number of heroin addicts in
Washington comes from several relatively independent sources. These include
the rate of commitment of narcotics offenders to the jail, the rate of opioid over-
dose deaths, and the rate of narcotics arrests. More direct evidence comes from
the universal experience of Washington heroin addiction treatment programs
which report large numbers of registrants.
No one piece of evidence is conclusive. However, taken together, the data form
a pattern which clearly indicates that the number of heroin addicts in Washing-
ton is far higher than earlier estimates. Tlie evidence also suggests that there
has been a major increase in the prevalence of heroin addiction in the last several
years.
What are the characteristics of the addict population?
In February 1970, Washington began a large multimodality treatment program,
the Narcotics Treatment Administration. By January 14, 1971, there were 2,793
heroin addicts in treatment in the NTA programs.
Study of the 77 onioid overdose deaths in 1969 and 1970 revealed demographic
characteristics of the group on the four basic variables of age, sex, race, and
place of residence in the city. This population was then compared to the NTA
patient population using these same four variables. The results are shown in
figures 1 and 2.
There was a close correspondence betAveen these two populations. This sup-
ported the assumption that NTA was reaching typical addicts and, unlike vir-
tually all other drug programs in the country, the treatment population was
generally representative of the total Washington addict population.
Some of the basic characteristics of this population are shown in table 2.
When did the epidemic of heroin addiction tegin?
Assuming that the NTA patient population is representative of the total Dis-
trict of Columbia addict population, it is possible to determine when the heroin
addiction began for Washington addicts. (See fig. 3.)
Fifty^two percent of the Washington addicts began heroin use after 1965 and
65 percent began after 1963. This data indicates that the epidemic began between
1964 and 1966 and became increasingly widespread at least through 1968.
The individual who has become addicted only recently is often less motivated
to seek treatment for his addiction since he is still enjoying the "high" of the
drug and has experienced relatively little of the pain and danger of addiction.
Thus, most treatment programs have an overrepresentation of older, more chronic
addicts. This reluctance of the newer user to seek help probably explains the
sharp drop in the number of addict patients who began use during 1969 and
1970. However, it seems certain that the rise in addiction between 1964 and 1968
reflects a serious epidemic of heroin addiction in Washington. This is corro-
borated by a recent study of the rate of commitment of known addicts to the
District of Columbia jail between 1958 and 1968 which shows a sharp increase
occurred in 1967 (4). (See fig. 4.) This increase also corresponds to a sharp rise
in reported serious crimes in Washington in 1966. ( See fig. 5. )
A recent St. Louis study (5) suggests that the list of the Bureau of Narcotics
and Dangerous Drugs of known heroin addicts, which is derived primarily from
police data, generally offers a good estimate of. total number of addicts in a
community when the total is stable. The data may not be reliable, however, in
a community which is experiencing a sudden epidemic of heroin addiction. The
District of Columbia jail study showed that there is a substantial time lag be-
tween beginning addiction and coming to the jail. For example, the average
169
period of addiction prior to the current incarceration was 7 years (1). Ttiere-
fore, the discrepancy between the St. Louis data and the District of Columbia
data may reflect the acute epidemic in Washington in recent years. This hypo-
thesis gains some support from the fact that the BNDD list for Washington rose
sharply from about 1,100 each year from 1965 through 1968 to 1,743 by December
31, 1970. The earlier BNDD figures for Washington for 1965 through 1969 were:
1,116, 1,164, 1,106, 1,162, and 1,636.
Where do heroin addicts live in the city?
Based on the opioid overdose deaths and NTA patients, and assuming that
there are a total of 16,800 heroin addicts in the city, it is possible to describe a
geographic profile of addiction in the city.
( See table 3 and fig. 6. )
The rates of heroin addiction range from less than 0.1 percent for the rela-
tively affluent northwest section of the city west of Rock Creek Park, to the rate
of 4 percent in the model cities area, area 6. These rates of addiction closely
parallel reported crime rates and other indicators of poverty and social
disorganization.
(See table 4.)
Using this same data it is possible to estimate the number of addicts per
thousand people in various sex and age groups in the Washington, D.C.,
population.
From statistics based on opioid deaths, several conclusions can be drawn.
Addiction is concentrated almost exclusively between the ages of 15 and 45.
Sixty^five percent of the addicts are under 26 and 31 percent are younger than
21 years of age. For the age range 15 through 19, the citywide rate for boys is
10.7 percent and for girls 2.2 percent. The next older age bracket, 20 through 24,
has rates of 19.8 percent and 3.2 percent respectively for boys and girls. From
25 through 29, the rates are 6.2 and 5.0.
( See fig. 7 and table 5. )
Relating this data to the geographic distribution data and using the distribu-
tion of NTA patients indicates that in service area 6 (the model cities area) 20
percent of the boys between the ages of 15 and 19, and an astonishing 38 percent
of the young men between the ages of 20 and 24 are heroin addicts. The District
of Columbia model cities area begins six blocks north of the White House, and
extends east above Massachusetts Avenue to four blocks north of the U-S.
Capitol.
How much does the heroin addiction epidemic cost the community?
The most certain and tragic cost of heroin addition in 1970 was the 63 people
who died of opioid overdoses. In addition, almost all heroin addicts commit
crimes to support their expensive habits. Based on an estimate of 15,0(X) heroin
addicts, and assuming an average habit of $40 per day, a recent study estimated
that the annual value of proijerty and services transferred because of addiction
through robbery, theft, prostitution, drug sales, et cetera, was $328,100,000 (6).
One of the common ways to support a habit is to sell heroin. This spreads the
epidemic. The indirect costs of heroin addiction to the community from urban
disorganization and fear of crime are equally staggering.
What can be done about the epidemic?
Heroin addiction is a treatable disease for most addicts. There is excellent
evidence that methadone maintenance is safe and effective (7). Therapeutic com-
munities (such as Synanon, Day top, and Phoenix House) and community self-
help organizations (such as Blackman's Development Center in Washington)
offer promise of success with many addicts.
A recent study of the narcotics treatment administration program perform-
ance with 475 randomly selected patients for the 6-month period from May 15
through November 15, 1970, showed that 55 percent of all patients in the program
on May 15 were still in the program 6 months later. The retention rate for high
dose methadone maintenance was 86 percent after 6 months. Arrest rates were
down and employment was up for the patient population. Only 7 percent of the
patient population was still regularly using illegal drugs and 55 percent showed
no evidence of illegal drug use during the sixth month of treatment (S).
Seventy -six percent of NTA patients were voluntary, self -referred walk-ins
to one of the 10 NTA centers located throughout the city. Twenty-four percent
were referred by agencies of the criminal justice system, such as probation and
60-296 O— 71— pt. 1 12
170
parole departments. None were civilly committed. About 100 lived in three NTA
halfway houses. Seventy were residents almost always for less than 3 weeks, on
two NTA detoxification wards at District of Columbia General Hospital. The
remainder, about 2,600, were outpatients. Fifty-four percent were receiving
methadone maintenance, 26 percent were in abstinence programs, and 20 percent
were receiving decreasing doses of methadone leading to abstinence.
The unprecedented, sharp dip in the rate of serious crimes in Washington
during 1970 (see fig. 5) was widely attributed to increased police presence and
particularly to the effectiveness of the NTA treatment programs (9) .
How much do treatment progrwms cost?
An economic study of drug addiction demonstrates that if NTA can suc-
cessfully treat only 40 percent of 1,000 patients (a low estimate on the basis of
performance studies) the cost of treatment for 1 year will be $1,400,000. The
benefits in terms of reduced criminal activity will be $5,750,770. This shows a
benefit-cost ratio of 4.1 to 1 (6).
On January 14, 1971, when NTA had 2,793 patients, the total cost »f the pro-
gram was less than $4 million a year.
References
(1) Kozel, N., Brown, B., DuPont, R. : "Narcotics and crime: a study of narcotics
involvement in an offender population." Narcotics Treatment Administra-
tion, 1971.
(2) Glendinning, S. : "District of Columbia coroner's office study." Narcotics
Treatment Administration, 1970.
(3) Johnston, E. H., Goldbaum, R., Welton, R. L. : "Investigation of sudden
deaths in addicts." Medical Annals of the District of Columbia, 38: 375-
380, 1969.
(4) Adams, S., Meadows, D. F., Reynolds, C. W. : "Narcotic-involved inmates in
the Department of Corrections." District of Columbia Department of Cor-
rections Research Report No. 12, 1969.
(5) Robins, L. N., Murphy, G. E. : "Drug use in a normal population of young
Negro men." Am. J. Publ. Hlth., 57 : 1580-1596, 1967.
(6) Holahan, J. : "The economics of drug addiction and control in Washington,
D.C. : a model for estimation and costs and benefits of rehabilitation."
Special Report by the Office of Planning and Research of the District of
Columbia Department of Corrections, 1970.
(7) Gearing, F. R. : "Successes and failures in methadone maintenance treatment
of heroin addition in New York City." Presented at the Third National
Conference on Methadone Treatment, Nov. 14, 1970.
(8) Brown, B. S., DuPont, R. L. : "6-month followup of heroin addicts in a large
multimodality treatment program." Narcotics Treatment Administration,
1971.
(9) DuPont, R. L. : "Urban crime and the rapid development of a large heroin
addition treatment program." Presented at the Third National Conference
on Methadone Treatment, Nov. 16, 1970, accepted for publication in J. Am.
Med. Assoc, 1971.
Table 1. — The number of opioid overdose deaths each month from, July through
December 1970
July 9
August 5
September 9
October 8
November 7
December 4
Total 42
Average per month 7
171
i<\urd CncL. Ch&r&ckris-l-ics Crf' fheCfiCcl OOc'i^JoSd Ocaih GrcLi^p
27%
13%
/,•
":>^ ■■• ,
Caucasian NeQro
IL'%
AH%
/■ ,'
/ -
Female tAo-lc
RACJ^
SEX
^"fVa
3i>7c
I'SVa
V%
v%
/ ^
/
7%
t?%
1
ll-iS' It^'JO ai'QS M-30 31-35' 3L^iD Hl-h
Age:
3S9o
0%
13%
SLC%
"1%
ili%
0%
(o^Jr:
1 1
3 V
SBHUiCk pif^ea OF REbiPkNCE
172
Table 2. — Selected characteristics of the NT A patient population (N=2T59)
Percent
Reporting regular heroin use prior to treatment 99
Average number of arrests reported prior to treatment 4. 7
Average number of convictions reported prior to treatment 1. 7
First drug used :
Heroin 9
Marihuana 49
Heroin and marihuana in same year 7
Other 35
Average age at first heroin use 19
"Voluntary admissions 76
Referred from agencies of the criminal justice system 24
Civilly committed 0
Reporting prior treatment for heroin addiction 41
Martial status :
Single 58
Married 23
Separated 13
Divorced 4
Widowed or deserted 2
Last year of school completed, average 10. 4
Receiving welfare at start of treatment 7
173
Fi'aard To-c. 0.h:irac-hirjs4/ct> of -Hie MT/} Pafi'ttif fc pal ail on
9o-/c
S%
Cauf-viSiMA A/ euro
^'
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gO'7c
a.0%
FemoJc Mde.
JJ.: 7.
>;^ve?^
/^-%
717.
J /I
/%
'
//-/6 /t-^6* khJ^' .Zrjc' 3i---ii}' ik'fC ilr
^Gfc
;i*fVo ^I'k.
■?%
11%
Hl%
H%
n^/c
^7c
i9c ^ 1
V v^' 6 y ^^ 7
S/t/^U^fc /^A't/? OF /)£^/O^Ac£
174
TABLE 3.— HEROIN ADDICTION RATES BY SERVICE AREA
Heroin overdos
e deaths
from April through
NTA clients (random
Estimated
Number
November,
1970
sample
of 500)
total
number
of addicts
per 1,000
Number
Percent
Number
Percent
of addicts 1
population 2
3
6.5
33
6.6
1,109
13.3
0
0
17
3.4
571
10.9
6
13.0
19.6
55
62
11.0
12.4
1,848
2,083
19.9
9
18.0
4
8.7
71
14.2
2,385
27.7
13
28.3
121
24.2
4,066
40.2
10
21.7
121
24.2
4,066
30.8
0
0
2
0.4
67
0.8
1
2.2
18
3.6
605
14.6
Service area
1
2
3
4
5
6
7
8.
9.
Total
46
100
500
100
16,800
21.2
1 Based on 16,800 estimate of total number of addicts distributed according to percent of NTA patients or service area.
2 Based on 16,800 estimate of total heroin addicts and distributed according to percent of NTA patients by service area.
Note.— Service area population used were 1967 estimates.
^ff-
90^
o
2
FIGUHE THREE
2^
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Vfcat- o-^ Rrs-I- Htrom US£
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C 'Rar\dom Savnpie o-P a.30o
lUTH patients
AJumbtr in sampit = iioo 3
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175
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176
Number "BcoKs-d
W.a^^cc-V.c Cffv..AdF-ro ftcoKjLd
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ta 6-7
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TABLE 5.— CITYWIDE HEROIN ADDICTION RATES BY AGE-SEX GROUPINGS i
(In percent]
Males
Females
Total
15tol9 12.9 2.0 7.1
20to24.... 18.9 3.0 10.5
25to29 _ 6.3 4.7 5.5
30to34 5.4 3.4 4.4
35to39 4.3 .9 2.5
40to44 2.5 .7 1.5
45 to 49
50 to 54 _.. .7 .4
' Based on 1968 population statistics, age-sex distributions of 91 overdose deaths (August 1968 through November 1970),
and total estimated addict population of 16,800.
177
Number In
Thousands
40
38
36
34
32
30
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
FIGURE FIVE
CRIME INDEX OFFENSES
1959 THRU 1970
SIX MOKTH TOTALS
'
■
'■ \ \ ' • 1
—
!"
'
-—
CRIME INDEX OFFENSES
Murder
Rape
Robbery
Agg. Assault
Burglary
Larceny (over $50)
Auto Theft
__j.^_i. i
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, '^ \
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^ 1
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/
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'
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'
DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC
58 59 60 61 62 63 64 65 66 67 68 69
D. C. SERVICE AREAS
AND
ns7o
CENSUS TRACTS
PREPARED BY THE D C GOVERNMENT
AND
NATIONAL CAPITAL
PLANNING COMMISSION
fi^oKt S"i)C
^0
IS'
rercjtnt'
178
6V f\QrK-'SEt G^ouP/AJ6S
MALES
FEMALES
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[Exhibit No. 11(b)]
GOVEBNMENT OF THE DiSTBICT OF COLUMBIA, NABCOTICS TbEATMENT
Administbation, Office of the Dieectob, Washington, D.C.
Januaby 12, 1971.
SUMMAEY of 6-MONTH FOLLOWTJP STUDY
There were 1,060 heroin addict patients in treatment with the Narcotics Treat-
ment Administration on May 15, 1970. iSix hundred and twenty-five (625) of these
were randomly selected and followed for 6 months by the Research and Develop-
ment Division of the NTA.
The Youth Division of NTA differed significantly from the adult programs and
is therefore considered separately.
There were 475 patients in the adult program sample on May 15, 1970. Six
months later, on November 15, 1970, 217 (46 percent) of these people were still
active and reportable* with their original NTA program. In addition, 43 (9 per-
cent) were active and reportable in other NTA programs into which they had
transferred. Thus, a total of 55 percent of the clients reportable to NTA as of
May 15 remained reportable to NTA 6 months later (table 1). Eighty -nine (19
percent) of these 475 had been arrested for a new charge during the 6 months
followup period.
The highlights of this followup study are reported in tables 1 through 4.
It is noteworthy that there is a much higher retention-in-program rate in high
dose methadone treatment than in other treatment classifications (table 1).
The high dose methadone group not only achieves this high retention rate (86
percent) , but also has the lowest arrest rate (12 percent) (table 2) .
The arrest data was also examined comparing the arrest rate of individuals in
the NTA programs with the arrest rate of those who left the program. The former
♦A patient Is "reportable" If he has been seen at least four times In the 14 consecutive
calendar days preceding the weekly NTA census.
179
had an arrest rate of 2.8 percent per patient-month of treatment while the latter
(the dropouts) had an arrest rate of 5.7 percent per month after leaving the
program.
Table 3 reports arrest rates after 6 months in the community for heroin addicts
released from the Department of Corrections before the start of NTA in 1970.
This table is included for comparison purposes.
Tables 4 and 5 contain data on employment rates and dirty urine rates. Both
are encouraging but suggest the need for increased counseling and job placement.
The 150 patients in the youth program fared less well (see client's functioning
in the Youth Division programs — ^May 15, 1970 — Nov. 15, 1970). Only 1 percent
of these youths received methadone maintenance treatment while an additional
10 percent received either methadone detoxification or emergency short-term
methadone treatment (methadone hold). Thus 89 percent of the sample never
received methadone. Forty-two percent of the youth clients were arrested during
the course of the 6-month followup. Sixty of the 150 youths remained in the pro-
gram after 6 months (40 percent retention rate) but only 18 of these were still
giving regular urine samples (12 percent of 150).
The results of the Youth Division program were generally similar to the
results of the abstinence programs for adults. The results of the abstinence pro-
grams are not as encouraging as the results from high dose methadone mainte-
nance treatment. However, it must be emphasized that while there were many
failures in the abstinence programs there were at least a few apparent suc-
cesses— for example while 42 percent of the youths were arrested during the 6
months followup, 58 percent were not arrested.
This summary relates to NTA's performance with patients who were in the
program from May 15 through November 15, 1970. 'Since May 15, there have been
some improvements in our programs and a great enlargement. On January 8, 1971,
NTA had 2,670 reportable patients. Of this total 1,402 receiving methadone main-
tenance treatment, 526 were on methadone detoxification, and 35 were on emer-
gency doses of methadone (methadone hold). Thus 1,963 (74 percent) were
receiving methadone and 707 (26 percent) were abstinent.
180
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183
[Exhibit No. 11(c)]
Dr. DuPont's Numbers
Of 1,060 patients in NTA on May 15, 1970, 450 were randomly selected for
foUowup.
Of these 450, 56 percent remained in the program for 6 months, and 40 per-
cent remained for 11 months.
Of those on methadone maintenance, 86 percent remained 6 months as com-
pared to 15 percent who received no methadone (or were abstinent).
After 11 months, 22 percent of the 450 were rearrested. Of the people who re-
mained in the program, 13 percent were rearrested. Of those who dropped out,
28 percent were rearrested in 11 months.
In the last 8 months, 23 people have died of overdoses with methadone. Only
five of these got their methadone from NTA.
[Exhibit No. 11(d)]
Administration Order
1. purpose
The purpose of this administration order is to provide medical and program
guidelines for methadone treatment in Narcotics Treatment Administration pro-
grams and cooperating programs.
2. DEFINITIONS
New admissions are persons who have no previous record in Information
Central.
Readmissions have l)een previously known by NTA central information but
their cases have been deactivated.
Reportable patients are defined as patients who have been seen at least four
times in the preceeding 14 consecutive calendar days.
Reportable patients will be considered to be in one of the following four
categories :
1. Abstinence
2. Methadone maintenance
3. Methadone detoxification.
4. Methadone hold.
Nonreportahle patients are seen at least once in the preceding 28 days but do
not qualify as reportable.
Transfers are any patients known to Information Central who undergo an
approved change in treatment centers.
Inactive patients are defined as those who have no face-to-face contact during
the preceding 28 days.
Abstinence is defined as any continuing treatment contact with the Narcotics
Treatment Administration program or cooperating program in which the indi-
vidual patient does not receive methadone.
Methadone maintenance is a treatment classification to be used for all pa-
tients who receive regular doses of methadone when the dose of methadone is
not consistently reduced. That is, any patient who receives a regular dose of
methadone at the same dose level or increasing dose level is to be considered
a methadone maintenance patient.* All patients in the methadone maintenance
category should be urged to stay on methadone maintenance until their life
situations have been stabilized for a period of 6 months to 1 year or longer. Any
patient who comes off methadone maintenance should be strongly urged to stay
in the treatment program while he is being detoxified and after he is abstinent
for a period of not less than 2 months. During this time, urine testing and coun-
seling should continue while the patient is considered an "abstinence patient."
If there are signs of renewed drug hunger and the patient feels he cannot con-
trol this urge, or if there are signs of renewed drug use, the patient should be
* The only exceptions to this definition are the special youth detoxification schedules
which have a period of Increasing doses, a plateau, and a programed detoxification within
6 months of the first dose.
184
encouraged to return to methadone maintenance treatment for another pro-
longed period of time. Experience has shown that patients who stop meihadone
mamteuance have a high relapse rate, especially it ihey have been on the metha-
done maintenance program less than a year. Therefore, every effort shuula be
made on the part of program staff to retain patients in continuing treatment for
a period of weeks or months after the patient begins a detoxification program.
Patients in methadone maintenance should be treated with regular doses of
methadone between SO and 120 milligrams a day. Dose levels less than SO mini-
grams are discouraged because of the likelihood of continued drug abuse. Doses
above 120 milligrams are to be discouraged because it is unlikely that they will
produce additional benefits to the patient. Under no circumstances are patients
to be given more than 150 milligrams of methadone a day.
Methadone detoxification should in no circumstances be prolonged for more
than 3 months. A patient on detoxification should not receive more than 50 milli-
grams a day unless he is being detoxified from methadone maintenance. The
physician in charge of the patient's treatment should establish a schedule for
gradually decreasing doses with abstinence to be achieved between 2 weeks and
3 months after the start of methadone detoxification. Urine results must be
monitored carefully in this group because of a strong likelihood that they will
experience renewed drug hunger and return to illegal drug use, particularly at
dose levels below 40 milligrams a day. Evidence of renewed illegal drug use or
drug craving beyond the individual patient's ability to control it are indications
for the patient's going on methadone maintenance. Under no circumstances
should a person be classified as methadone detoxification for more than 3 months.
Methadone hold patients are classified in this group if they are given doses of
methadone on an emergency basis prior to appropriate examination, diagnosis
and disposition. Under no circumstances should a patient be retained in the
methadone hold category for more than 2 weeks.
Authorized medical representatives. Only physicians can sign prescriptions.
Others, including nurses, medical assistants etc., may dispense methadone and
sign NTA Form 6 (attachment 5).
3. POLICY
Because people who are addicted to heroin often have many psychological and
vocational problems requiring vigorous and effective treatment, IsTA's goal for
each patient is social rehabilitation. Methadone treatment must be considered
within this context as only one part of the total treatment program.
The heroin addict patient may suffer from a number of medically treatable
illnesses and for each of these, of course, the appropriate medical treatment is
indicated. For example the heroin addict may have clinical schizophrenia with
the common symptoms of that illness. In this case, the most appropriate medical
treatment includes a phenothiazine.
Nevertheless, the only drug that has been shown to be useful in the treatment
of heroin addiction itself is methadone. Therefore, no other drug should be
prescribed for treatment of heroin addiction. For example, there is no evidence
that tranquilizers or hypnotics are useful in the treatment of heroin addiction
or heroin withdrawal. Furthermore, these drugs are specifically contraindicated
in the treatment of heroin addicts since they are likely to become drugs of
abuse in their own right. This is particularly true of the hypnotics (such as
Seconal and doriden) but it is also true of the antianxiety tranquilizers (such
as librium and meprobamate). The heroin addict has, in part, gotten himself
in serious trouble because of his tendency to medicate himself and to treat
his unpleasant feelings with a variety of drugs, especially heroin. Therefore,
the physician dealing with heroin addicts can anticipate requests from the addict
for medications of all kinds. The doctor should be armed with the knowledge
that no tranquilizer or hypnotic has been shown to be useful in the treatment
of heroin addiction. He should share this information with the patient. How-
ever, the physician should avoid routine use of either type of drug. The physician
should never prescribe these drugs for more than a few days because of the
likelihood of producing dependence on, or even addiction to, these drugs.
Meth<idone maintenance, on the other hand, has been demonstrated to be
effective in achieving specific results. The primary drug result is blocking the
"drug craving" which usually occurs at a dosage of about 40 to 50 milligrams
a day. When maintenance levels reach about 100 milligrams a day, there is
an additional important drug effect : the suppression of euphoria from intra-
185
venously administering heroin. These are the two effects that are most desirable
in the use of methadone maintenance for chronic heroin addiction. Methadone
maintenance does not produce the suppression of all anxiety, depression, or
other uncomfortable bodily feelings. Neither the addict nor the doctor should
expect these results.
Methadone in adequate doses, blocks the drug hunger for heroin and the
high of heroin. It does not alter other forms of drug abuse. Therefore, the
clinician should be watchful for signs of other drug abuse such as amphetamine,
barbiturate, and most especially alcohol abuse. Each of these conditions is serious
and requires prompt, appropriate, and vigorous treatment.
4 PR0CE3)URES
Methadone may be used in three treatment categories : methadone mainte-
nance, methadone detoxification, and methadone hold. The following are in-
dividual discussions of each :
I. Methadone Maintenance
A. Indications for methadone maintenance
The indications for methadone maintenance are :
1. The patient volunteers for methadone maintenance;
2. The patient has used heroin continuously for at least one (1) year ;
3. The patient is at least eighteen (18) years old. (Exceptions to this
ruling are discussed in section I, I. Methadone Maintenance Treatment for
Youth.)
B. Preparing the patient for methadone maintenance treatment
Methadone maintenance treatment is entirely voluntary for all patients. No
one should be forced or coerced into methadone maintenance. If the patient ex-
presses the desire to go on methadone maintenance, the implications of treat-
ment must be carefully and completely explained to him.
Prospective methadone maintenance patients should be encouraged to think
of it as, at least, a 6-month commitment to continue the treatment. For most
patients it makes sense to continue methadone maintenance for years until
their social, psychological, and biological life has been satisfactorily stabilized.
The preliminary results of our investigations into program performance indi-
cate that the premature discontinuance of methadone maintenance and dose
levels under 80 milligrams per day are often associated with the patient's re-
turn to heroin addiction and criminal behavior.
C. Consent to take methadone maintenance treatment
Before beginning methadone maintenance treatment, each patient must sign
NTA Form 19 "Informed Consent to Take Methadone Treatment" (see attach-
ment 1). If a patient is under 21, every effort should be made to get either a
parent or guardian signature on the consent form, although this may not be
possible or practical in every case. In addition, NTA Form 7 (see attachment
2) must be completed on each patient and registered with Information Central
before any medication or treatment services are provided.
D. Dose level
For all NTA treated patient's receiving methadone maintenance treatment,
the physician should attempt to give a "blocking" dose of 80 to 120 milligrams a
day. There is good reason to be'ieve that lower doses are associated with signifi-
cantly hisher failure rates and that lower doses do not produce any advantage
to the patient.
Methadone maintenance programs have been shown to be effective only when
methadone is used in a specific manner. The drug is given to the patient once
a day, and the patient's dose is modified on the basis of his response to the medi-
cation. The initial dose level should be moderate, in the range of 20 to 50
milligrams.
NTA medication schedules (see attachment 3) provide all necessary informa-
tion for raising or lowering doses, depending on the treatment indicated, by age,
size and duration of habit, et cetera. Since the duration of action of methadone is
24 to 48 hours, the drug lends itself to daily administration.
The dose level should be increased to a level of about 100 milligrams a day
in those patients who can tolerate this dose level without excessive drowsiness
60-296 0-^71— pt. 1 13
186
or other side effects. This increase should occur gradually over a 3- to 6-week
period.
Patients are not to be told their dose level since this leads to an unhealthy
'"competition" among the patients for the highest doses. Dose level is a medical
issue and it should be managed by the medical staff.
E. Side effects of methadone
Side effects of methadone include excessive sweating, constipation, edema,
drowsiness, dermatitis, and relative impotence in men. None of these symptoms
are serious, and, with the exception of excessive sweating, they usually disappear
as treatment is continued and tolerance is attained. However, some patients con-
tinue to suffer from constipation. This can be treated symptomatically with a
laxative, but even this is usually not needed once a tolerance develops.
F. Take-home medication
Methadone is to be administered to the patient daily (6 or 7 days per week
depending on the number of days the center is opened) on the premises of an
NTA facility for the first 3 months of his treatment. Once the patient's drug
use has ceased for at Idast 1 month and he has demonstrated stability in his life
patterns, he may take home his weekend medication at the discretion of the
appointed person in charge and after signing NTA Form 22 "Statement of Re-
sponsibility for Take-Home Medication" (see attachment 4).
Individual doses to take off NTA premises must be properly labeled with the
patient's name, the date the dose is to be taken, and the specific program name
and telephone number. The label must also state that the bottle contains metha-
done and that it is dangerous and may be fatal if taken by anyone other than the
patient.
Patients are to return all empty bottles before new bottles are given. If the
patient fails to return his bottle, loses or breaks it, or reverts to drug use, he will
be required to report in daily again for at least 4 weeks.
Because methadone may be fatal when taken by a nonaddicted person in doses
conventionally given to methadone maintenance patients, patients taking medi-
cation home must keep it in the locked container provided by the center. The
fact that methadone is packaged in a liquid form makes it particularly attractive
to children. The patient must be impressed with the danger involved in taking
medication home and be strongly encouraged not only to lock up his methadone,
but to place it out of children's reach.
In addition, the patient should be reminded that methadone should not be
refrigerated.
G. Urine testing
Every methadone maintenance patient must submit a monitored urine speci-
men a minimum of once a week.
These urine collections must be monitored by an NTA staff member or a staff
member of a cooperating program under the general direction of the program
chief. Unmonitored specimens are worthless for our purposes and should be
discarded.
All staff who are monitoring urine should sign the urine specimen label found
on the back of NTA form 6 (see attachment 5). These staff members should be
trained so they recognize an adequate quantity of urine. No urines should be
reported back from the laboratory as quantity not sufficient (QNS) : the staff
should discard urines of inadequate quantity.
In unusual cases, or where there is special concern about the possibility of
patients continuing to use illicit drugs, three or more samples a week may be
sent to the laboratory for analysis.
H. Suspension from methadone maintenance program
Patients failing to report for treatment for 30 consecutive days will auto-
matically be suspended from treatment. The suspended patient will have to
wait 30 days before he is eligible for treatment or the waiting list again.
If the center physician and/or the center administrator suspends a patient
before 30 consecutive days without treatment have elapsed, the physician or
administrator must complete NTA form 0 "Report of Pntirvt Chnnor of Status"
(see attachment 6) 'and send it to Information Central. Tr^ this case, the patient
will not be accepted back into treatment or placed on the waiting list for 30 days
after the suspension date.
187
I. Methadone maintenance treatment for youth
For purposes of treatment planning (as opposed to legal considerations re-
garding consent) patients are considered adults if they are 18 or over.
Individuals who are less than 18 may receive methadone on short or long
detoxification schedules (none longer than 6 months) after notifying the director
of NTA.
In the future, NTA may try an experimental maintenance program for youth
under 18 but our experience is too limited to make a final decision on that issue
at this time.
II. Outpatient Methadone Detoxification
A. Eligibility
Outpatient methadone detoxification should be attempted with the following :
1. Any patient who has a history of less than 1 year addiction to heroin ; or
2. Any patient who is under 18 years of age ; or
3. Any patient who requests this treatment.
B. Dose level
Methadone detoxification should begin by "catching" the addict's habit, usual-
ly with doses in the range of 20 to 50 milligrams per day. ( See medication sched-
ules, attachment 3.)
Initially, this may require doses more than once a day until the proper dose
level is achieved so that the patient does not experience vdthdrawal symptoms
(too little methadone) or excessive drowsiness (too much methadone). This
holding dose should then be reduced very gradually over a 2 to 12-week period.
Drug hunger should be anticipated at dosages of less than 40 milligrams per day.
C. Urine testing
Regular urine testing and monitoring should be followed as in the methadone
maintenance program. ( See section I, A for details. )
Reemergence of regular heroin use is a sign of withdrawal treatment failure.
If this occurs, the patient should be encouraged to switch to a methadone main-
tenance program (if he is eligible) at blockading doses of about 100 milligrams
per day.
D. Exceptions
If a patient fails at outpatient withdrawal even if he has used heroin for
less than 1 year or if he is less than 18 years, he may be considered for
methadone maintenance if he volunteers for this treatment. However, under
these circumstances, the director of the NTA must be notified of each such ex-
ceptional patient.
III. Physical Examinations
Every patient receiving methadone must have a physical examination per-
formed by a physician within 30 days after the first dose of methadone. Physical
exams should occur as soon as possible.
IV. Records
A. Medical records
Patients who take methadone must have physical examinations and medical
histories performed by a licensed physician or medical student working under
the supervision of a physician. The results of these examinations must be in-
cluded in the patient's clinical record and the date of physical examination must
also be noted on NTA Form 10 (see attachment 7. )
Form 10 "Record of Patient Prescription" must also be used by the physician
to record all new NTA patients' medical treatment, or major changes in treat-
ment of an existing NTA patient.
B. Accountability of methadone
Each bottle of methadone liquid (1,000 cc. ) disbursed to the centers for pa-
tient treatment will contain an envelope showing the same registered number as
that appearing on the label affixed to the bottle.
Everytime a patient has received a dose of methadone, a copy of NTA form 6,
"Record of Patient Activity," (see attachment 5) used to record the amount of
methadone disbursed, will be filed in the envelope containing the same registered
188
number as that on the bottle. When the large bottle is emptied, the envelope
containing the NTA forms 6, showing total disbursements (1,000 cc. ) will be
sealed and returned to Information Central via messenger. The forms in the
envelope will tell the pharmacist the date, the dosage level, and names of the
patients who were served out of that particular bottle. All doses of methadone
dispensed must be strictly accounted for at all times.
C Discrepancies
NTA form 14, "Director's Discrepancy Notice" (see attachment 8) will be
used to notify the physician of any discrepancies in recordkeeping or NTA pro-
cedures as noted by the computer.
The following are some items which may be noted :
1. Dosage level higher than that prescribed by the physician.
2. Irregular dosage level.
3. Consistently dirty urine.
4. No physical examinations within 30 days of initial intake.
5. Discrepancy in methadone medication disbursement.
6. Lack of proper patient evaluation.
7. Apparent lack of patient progress.
8. Exception to take-home medicine policy.
D. Confidentiality of records
The Narcotics Treatment Administration respects the basic right of patients
to have all information and treatment records maintained with strict confiden-
tiality. NTA regards this effort as vital to the establishment of an effective treat-
ment relationship with its patients.
For this reason, only Information Central is authorized to release information
on patients to vertified requestors. With the exception of criminal justice and
civil commitment patients and patient-employees, no information on any patient
will be released unless :
1. The patient has signed and Information Central has received NTA
form 28 "Patient Consent for Release of Treatment Information" (see
attachment 9) specifically authorizing the requestor access to information:
2. Information Central has received the request for information in writ-
ing ; and
3. Information Central has verified the current status of the patient vis-
a-vis the requestor.
Criminal justice system patients are those who have been formally referred
to NTA by the police, courts. Department of Corrections, or parole board as a
condition of release to the community. Requests for information on these patients
by the agency must be honored immediately by the program chief or his designee.
The request and the response should preferably be made in writing and the
current status of the patient vis-a-vis the requestor verified before the informa-
tion is released. Information should be released in the form of treatment sum-
maries whenever possible.
Civil commitment patients are those brought to an NTA facility under signed
pickup orders by the Narcotics Squad of the Metropolitan Police Department.
The results of their diagnostic evaluation and determination of their treatment
status is automatically forwarded to the referring agency — the Metropolitan
Police Department.
Patient-employees are staff members of NTA who also remain in a treatment
status with NTA. They will be required, as a condition of employment, to remain
free of illegal drugs, and must agree to release information on their urine
surveillance reports and pertinent medical summaries to their immediate super-
visors, program unit chiefs, and the coordinator of counselors. Such information
will not be shared with other staff members but can be used as a basis for
disciplinary action or suspension of employment if confrontation does not result
in termination of illegal drug use.
Minors under 21 years of age should be encouraged to authorize a parent or
guardian to receive at least a summary statement of their treatment status.
Emerfjcneirs arising when an NTA patient is confined because of arrest, ill-
nes.s, or accident will receive immediate attention. Every effort will be made to
assure the patient immediate medical assistance to maintain his medication
level for the duration of the emergency upon request from the medical authori-
ties attending the patient.
189
Attachment One
Informed Consent to Take Methadone Treatment in the Narcotics
Treatment Administration
I, , understand that methadone treatment for chronic heroin
addiction and its consequences is a new use of an established drug. I further
understand that methadone is a powerful and addictive narcotic drug and that
if I stop taking it I will experience serious withdrawal symptoms. Although
methadone treatment has been used successfully by thousands of people through-
out the country, I also understand that the long-term effect of this drug on
humans is not entirely known at this time.
I willingly give my informed consent to take methadone under the careful
supervision and control of the NTA staff or NTA cooperating agency staff. I
have tried to stop using illegal drugs and I now think that methadone is neces-
sary for me to avoid further use of illegal drugs.
I have not been forced or pressured into this dec' '■ion. I understand that I
can stop methadone treatment at my own discretion and that the staff may
terminate me at their discretion. If I do stop methadone treatment for any
reason, I understand that for my own safety I should withdraw from methadone
by using gradually reduced doses of the medication under the control of the
medical staff.
Signature and date
Printed or typed name
NTA patient number
Program name
"Witness
Signature and date
NTA FORM 19(10-70).
ATTACHMENT TWO ,
1.0. NO.
PATIEfJM!) NAM ■ " -
^OCRGE NC Y . ADDRESS iMoTJiERyRtLAIiyEO " ..
CENTER ASSIGNED
TRANSFERRED TO (Cente,^ Date)
SOCIAL SECURITY NO.
BIRTHOATE
DATE NO. ASSIGNED
PHONt NO.
WgiKING NOW?
□ YES □ N8
EXMRATION DATE
EMPLOYER'S NAf€ 4 ADDRESS (If WORKING) '
DATE PICTURE SCHEOUlfO
DATE PICTURE TAKEN
NTA FORM 7 (8.70) RECORD OF PATIEKT 1.0. NUFfiER ASSIGNED
190
Attachment Three
To all medical staff
On schedules 10, 11, and 12, the value of X (the initial dose) must be speci-
fied on the initial prescription along with which schedule is being used.
On schedule 12, it must be specified at what does the schedule stops.
Day
1 .
2 .
3 .
4
5 .
6 .
7 .
8 .
9 .
10
Detoxification schedule 1
Milligrams Day :
20
11
20
12
20
13
15
14
15
15
15
16
15
17
15
18
10
19
10
20
1 Detoxification completed.
Day
1 .
2 .
3 -
4 .
5 -
6 -
7 .
8 -
9 .
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
Detoxification schedule 2
Milligrama Day :
50
27
50
28
50
29
50
30
50
31
45
32
45
33
45
34
45
35
45
36
40
37
40
38
40
39
40
40
40
41
35
42
35
43
35
44
35
45
30
46
30
47
30
48
30
49
30
50
30
51
25
Milligrams
10
10
10
0
0
Milligrams
25
25
25
25
20
20
20
20
20
15
15
15
15
15
10
10
10
10
10
5
5
5
5
5
(')
1 Detoxification completed.
Detoxification Schedule S
Day : Milligrams Day :
1 20 43
15 15 50
29 10
Milligrams
5
0
Detoxification Schedule 4
Day:
1 _
15
29
43
Milligrams
30
25
20
15
Day:
57
71
85,
Milligrams
10
5
0
Day;
191
Maintenance Schedule 10
Day:
1 X mgs. 10.
2 X mgs. 11.
3 X+5 mgs. 12.
4 X+5 mgs. 13.
5 X+10 " 14.
6 X+10 " 15.
7 X+15 " 16.
8 X+15 " 17.
9 X+20 " 18_
X+20 mgs.
X+25 "
X+25 "
X+30 "
X+30 "
X+35 "
X+35 "
X+40 "
X+40 "
To 100 mgs. total or until otherwise stopped by adding 5 mgs. to dose every
other day.
Maintenance Schedule 11
Day:
1.
2.
3-
4.
5-
6.
Day:
-.X mgs.
..X mgs.
-X mgs.
-.X+5 mgs.
- X-i-5 mgs.
-.X+5 mgs.
7-
8__
9_-
10-
11_
12.
. X+10 mgs.
-X+IO mgs.
-X+IO mgs.
-X+15 mgs.
-.X+15 mgs.
.X+15 mgs.
To 100 mgs. total by increasing by 5 mgs. every third day or until stopped by
prescription.
Maintenance Schedule 12
Day:
1 X mgs.
8 X+5 mgs.
15 X+10 mgs.
Day:
22 X+15 mgs.
29 X+20 mgs.
Attachment Four
Statement of Responsibility for Take Home Medication
I, , understand that methadone is a powerful drug which
can seriously harm or even kill a person who is not on methadone maintenance.
For this reason, I agree to put my methadone bottle in a locked container, out
of children's reach. I also agree to tell my family how dangerous methadone can
be and take all necessary precautions to prevent its accidental use.
In addition, I understand that I must not lose, break or fail to return my
methadone bottle to the clinic or revert to drug u.se. If I do, I will not be able
to take methadone home but will have to I'eport into the clinic daily for at least
30 days.
Patient signature and date
Printed or typed name
ID number
Program name
NTAForm 22 (11-70).
Clinic administrator, piiysician
or nurse signature and date
192
ATTACHMENT- FIVE,
•■ I HI
E - <
ofo
Oo
PATIENT'S IDENTIFICATION
J: I
NARCOTICS TREATMENT ADMINISTRATION
CENTER ADDRESS
PATIENT'S SIGNATURE
ADMIN. BY (Sign Below)
METHADONE
COUNSELING
DOSAGE LEVEL
NARCOTICS TREATMENT
ADMINISTRATION
STATUS
□ hold □detox. □ MAINT. □abstinence □ SURV. ONLY
TESTS REQUESTED
COCAINE
AMPHETAMINE
BARBiTURATES
TEST RESULTS
^^^^y^,Lj.U^
''<M/////MyMmy/yM:/,ymA''/Z
OTHERS (Specify)
I I ALL TESTS NEC.
I I REPEAT
CHECK APPROPRIATE BOX
E SURVEILLANCE
-j I URINE
D'
lETHADONE
n
COUNSELING
z
UJ
<
Z
UJ
U
ATTACHMENT SIX
^ 5
UJ D
0 J
1 o
3 U
0 u.
•" o
UJ L>
a I-
zy
15
1 o
u. UJ
O I
°^
< °
PATIENT'S IDENTIFICATION
1. PATIENT TRANSFERRED
I
1
FROM(Pf*>:irnt Cfnlot)
TO(New Ccntci)
2. PATIENT'S CLASSIFICATION (Check approptiale blocks) j
Participating }n Pvogram 1 ;'
Voluntarily withdrew from program a/rer completrng treatment
i
i
CENTER ADDRESS
DATE
1
involuntarily withdrew from program- incarcerated
o
Involuntarily withdrew from program-/josp/fa//>edor other medical reason
1
t
ST
5
cr
Disniisied from program -alcoholism oi drinking problem
COUNSELOR'S
SIGNATURE
Dismissed from program— bad conduct or disciplinary problem
1
0
L.
Deceased
1
J ADMINISTRATOR'S SIGNATURE
Other (specify) i
t/J
(D O
•fi ^ ^
3 4- uj
< E
SI::
193
ATTACHMENT SEVEN
PATIENT'S IDENTIFICATION
DOSAGE LEVEL
NARCOTICS TREATMENT
ADMINISTRATION
PATIENT'S PROGRAM SPECIFICATIONS
1 I DETOXIFICATION SCHEDULE
1 ' '
CENTER ADDRESS ,,
DATE , ,
n MAINTENANCE SCHEDULE
R.
o
n~]HOLD ' j
1
o
5
cr
0 ,
DATE OF PHYSICAL
r] OTHER MEDICATION
"■ DOCTOR'S SIGNATURE
Z
QfHANGEOF MEDICATIONS 1
o
ATTACH>ffi:NT EIGHT
DIRECTOR'S DISCREPANCY NOTICE
PATIENT'S NArt
DATt
TO: The Center Administrator
FROM: Director, Narcotics
Treatment Administration
CE.^ER
1.0. NO.
PLEASE ADVISE WITHIN 24 HOURS, THE REASON(S)
FOR THE DISCREPANCIES LHLCXED BELOW.
1. MEDICATION
PERIOD COVERED
□ record not R£CEIVEO(nt» form 6) r]"0 RECORD CF PATIENT'S PHYSICAL EXAM. QoTHER (explain)
(lITA FORM 10)
QrECORD REC'D LATE(nt« form 6) QoOES NOT t€CT ftDICAL GUIDELINES
n NO RECORD CF OR'S PRESCRIPTION Q I (CONSISTENT WITH OR'S PRESCRIPTION
" — ' (nTA form 10) INTA FORM 10)
PERIOD COVERED
URINE ANALYSIS
PI HOST RECENT RECORD NOT REC'D (Submit nta form 6) jZI QUANTITY NOT SIFFIC lENTdjNs)
Q RECORD RECEIVED LATEInta form 6) LH CONSISTENTLY DIRTY (Th8 or i«re Tii*s)
3. CHANGE OF STATUS
PERIOD COVERED
n
NO ACTIONS INDICATED IN PAST TW0(2) WEEKS
(rJTA FORM 9)
QnO /CTIONS INDICATED IN PAST FOlf) WEEKSd.) (nta form 9)
PERIOD COVERED
COUNSELING
n NO CONTACT INDICATED IN PAST WEEK(mt« form 6) 0 NO CONTACT INDICATED IN THE PAST
(nta form 6)
□counselor's REPORT OVERDUE (Counselor's NA^c , )
{
I I TWO WEEKS
I I MONTH
5. SERVICE AT OTHER CENTER
NAf€ CF OTHER CENTER
DATE
PERIOD COVERED
Q NO REFERRAL INDICATED (nta form 9)
^ETHADONE DISBURSEMENT
TomniuFBEr
PERIOD COVERED
n
TOTAL A:iOUrn REPORTED DOES NOT AGREE WITH Tt£
AMOUHT DISBURSED IN TfC BOTTLE
AMOUNT OF DISCREPANCY (-HJR .)
SIGNATJiE OF THE DIRECTOR
DATE
TO: DIRECTOR, NARCOTICS TREATMENT ADMINISTRATION
CENTER AOnl'IISTRATOR'S REPLY(USE REVERSE SIDE IF NECESSARY)
SICNATlFE OF THE CENTER AOMI')ISTRAT0R
DATE
194
ATTACHMENT NINE
GOVERNMENT OF THE DISTRICT OF COLUMBIA
Narcotics Treatment Administration
PATIENT CONSENT FORM FOR RELEASE
OF TREATMENT INFORMATION
I hereby authorize the following person/agency:
Name
Address
Telephone
I vmderstancT'tEair'ohlyTnformation Central is authorized
to release this information. This consent form is void after
PATIENT SIGNATURE,
DATE
WITNESS
195
A.O. 202.1
Addendum
April 7, 1971
OD
Administration Order
1. Purpose
The purpose of this administration order is to provide additional clarification
for the medical and program guidelines as originally issued for the Narcotics
Treatment Administration programs and cooperating agencies.
2. Procedures
Anyone missing 3 days medication at any center is to have his medication dis-
continued until he sees the doctor at the center, at which time he will need a new
prescription signed by the physician. If a physician is not immediately available,
the patient may be given an emergency dose not to exceed 25 mgs. to hold him
until he can see the physician.
No new patient can be given a dose in excess of 50 mgs. on the first day of his
program, whether it is maintenance or detoxification, unless it can be verified
that he is being transferred from a maintenance program and is currently on a
higher dose.
[Exhibit No. 11(e)]
A Study of Narcotics Addicted Offenders at the District of Columbia Jail
(By Nicholas J. Kozel, Barry S. Brown, and Robert L. DuPont, Narcotics Treat-
ment Administration, Washington, D.C.)
(An acknowledgement of appreciation is made to Charles Rodgers, Superintendent of the
District of Columbia Jail, for his cooperation and assistance in this study and to the
research assistants for their unremitting effort to collect data under extraordinary
conditions. )
A study was conducted at the District of Columbia Jail between August 11 and
September 22, 1969, in an effort to determine the parameters of heroin use in the
District of Columbia. Findings of the study are based on responses to interview
schedules personally administered by a team of research assistants and the re-
sults of urinalysis conducted separately by the research assistants.
METHOD
Interview schedules were completed on an accidental sample of 225 of the resi-
dents present at the District of Columbia Jail during the time the study was con-
ducted. In addition, urine specimens were collected from 129 of those interviewed.
Urine specimens were collected from as many new offenders as possible at the
time of their admission. The research team subsequently attempted to intersnew
as many of these new admissions as they could reach — usually within the first
few days of incarceration.
To determine whether the sample interviewed was representative of the larger
offender population from which it had been drawn, comparisons were made on se-
lected personal and .social characteristics. Comparisons made on age, race, number
of prior commitments, and offense for which presently incarcerated indicated that,
in terms of the.se characteristics, the sample was representative of the District of
Columbia Jail population.
RESULTS
Drug use
Among the 225 offenders interviewed, 45 percent were identified as addicted to
heroin. Forty-three percent admitted using heroin and having been addicted to it.
An additional 2 percent of the total sample — 3 percent of the sample of urinal-
yses— reported never haviD<r used heroin or refused to answer the question con-
cerning lieroin use, but had positive urinalysis results for morphine and/or
quinine — the components of heroin (table 1).' Thus, 45 percent of all per.sons ad-
mitted to the District of Columbia Jail can be described as addicted to heroin.
Among nonaddicts, 22 percent stated they had u.sed drugs at some time in the
pa.st (table 2). Of these, most started out on marihuana. At the same time, almost
^ This veracity among narcotics addicts supports Ball's findings in his study of addict
interview responses. Ball, John C. "The Reliability and Validity of Interview Data Obtained
from 59 Narcotic Drug Addicts." The American Journal of Sociology, 1967, 72(6), 650-654.
196
half of the addicts stated that marihuana was the first drug they had ever used.
About a quarter of the addicts, however, started out directly on heroin (table 2a).
Cocaine. — The great majority of self-reported addicts — 85 percent — have used
cocaine, usually trying it for the first time after they had turned 20 years of age.
More than half of those who have used cocaine in the past admit to still using it.
At the same time, 29 jiercent of the nonaddicts who admitted using drugs liave
tried cocaine (tables 3, 3a, and 3b).
Marihuana. — Marihuana has been used by far more nonaddict drug users —
68 percent. — than any other drug. Similarly, 75 percent of the self-reported addicts
have used marihuana. Among addicts, around a third had used marihuana for
the first time before age 17. but when both groups are combined, 50 percent report
having used marihuana for the first time when they were older than IS years.
About half of the nonaddicts and a third of the addicts who had tried marihuana
in the past are still using it ( tables 4, 4a, and 4b ) .
Barbiturates. — Eighteen percent of self-reported addicts admit having used
barbiturates. Like marihuana, barbiturates were, for the most part, "first tried
after the user had reached 18 years of age. Five of the 17 addicts who have used
barbiturates state they are using them at present (tables 5, 5a, and 5b).
Methadone. — Street methadone has been used by 16 percent of self-reported
addicts. None of the nonaddict drug users report ever having used street
methadone.
Amphetamines. — Among self-reported addicts and nonaddict drug users, 18
percent mention having used amphetamines. Use of amphetamines begins at
about 18 and half of those who have used them in the past continue to use
them at present (tables 7. 7a, and 71)).
Heroin. — Though not addicted, four of the 28 nonaddict drug users have
used heroin. By definition, all of the addicts have used heroin. In terms of age,
half of the addicts had used heroin for the first time before they were 20 years
old. Indeed, 26 percent had used heroin by 17 ( tables 8 and 8a ) .
Heroin addiction
Withdrawal. — The overwhelming majority of self-reported heroin addicts —
88 percent — stated that they had experienced withdrawal symptoms (table 9).
At the same time, only 38 percent recall ever receiving treatment for their
addiction problem (table 9a ) .
Off drugs during past 5 years. — Eighty -five percent of addicts report having
been off the drugs for some period of time during the past 5 years (table 10).
The number of times drugs have been voluntarily or involuntarily given up
ranges from one to more than 10, with over half of the addicts claiming to have
been off drugs three times or less during the past 5 years ( table 10a ) .
Support of habit. — The average reported cost of a heroin habit is .$44 a day.
Not surprisingly, the majority of heroin addicts have resorted to crime as a
means of supporting their habit (table 11). Crime, hustling, and pushing drugs,
alone or in combination with legitimate employment are the usual ways in which
habits are supiwrted (table 11a ) .
Stop own drug use. — Eighty-eight i>ercent of addicts believe that they can
stop using drugs (table 12). A variety of ways of stopping drug use were men-
tioned including changing environments, methadone or other treatment, work,
and jail. However, 26 percent of those who believe they can stop feel they could
just stop without outside assistance, while an additional 11 percent either could
not answer or did not know how to stop their own drug use (table 12a).
Drug use among family. — There is reportedly little drug use among members
of the addicts' families — ranging from 5 percent among si>ouses to 10 percent
among siblings. At the same time, there is a relatively high incidence of don't
know/no answer responses to questions about family drug use (tables 18. 13a,
and 13b). This suggests that, while inclined to l>e candid about their own history
of drug use, addicts may be less than willing to revenl information about their
family which they feel would, in some way, place their family in jeopardy.
Drug use among friends. — The preponderance of addicts report that at least
some of their fHpnds usp drugs. Indeed, a third state that all of their friends
are drug u.sers, while 2 T)ercent deny having any friends who u.se drugs (table 14).
Age of drug users. — Slightly more than a third of the addicts reiwrt that most
heroin iisers today are between 16 and 25 years of age. At the same time, an-
other third either don't know or didn't respond lo the nuestion (table 15). Drug
use, according to a majority of the addicts, presently begins among youtlis between
15 and 17 years old ( table 1 5a ) .
Methadone treatment. — Eighty-six percent of self-reported heroin addicts have
197
heard of methadone treatment as a way of overcoming illegal drug use (table 16).
Of these, almost three-quarters believe methadone treatment is good without
qualification, while an additional 7 percent feel that, on the whole, it is good,
but still have some reservations about it (table 16a) .
Personal and social characteristics
Age and education. — About a third of addicts and nonaddicts are 21 years
old or younger and two-thirds are under 30 (table 17). More than 75 percent
of the two groups have had some high school education, and 25 percenit report
graduating from high school (table 18).
Parents. — Approximately 80 percent of addicts and nonaddicts claim to have
been reared by their biological parents (table 19). At the same time, a greater
number of addicts as compared to nonaddicts report that both of their parents
are stSll living (table 20).
Among those whose parent (s) are deceased, about 50 percent of the addicts
were less than 16 when one or both parents died, while about half of the non-
addicts were between 16 and 21 when death of parent (s) occurred (tables 20a
and 20b).
Siblings. — Compared to addicts, nonaddicts tend to have more brothers and
sisters. Thirty percent of nonaddicts have four or more brothers and 20 percent
have four or more sisters compared to 15 and 11 percent respectively for
addicts (tables 21 and 21a).
Religion. — Both addicts and nonaddicts are more likely to be members of
Protestant seots than other religious groups. At the same time, a significantly
greater number of nonaddicts compared to addicts report religious aflBliation
(table 22). Furthermore, while there was noticeably more frequent attendance
at religious ser\iees during childhood among both groups, significantly more
nonaddiots compared to addicts claim to attend services at present (tables 22a
and 22b).
Martial status. — The majority of both addicts and nonaddicts are single (table
23). Among those who are married, slightly more addicts report having been
married for 2 years or less (table 23a). Both groups have experienced a high
incidence of separation from their spouses — 60 percent on the average (table 23b).
Employment status. — Significantly more nonaddicts than addicts were employed
at time of arrest (table 24). The majority of both groups were employed by tht*
time they reached 18 years of age (table 24a) and the usual type of employment
for both groups is unskilled labor (table 24b) . More than half of both groups have
been employed at three or le.ss places during the past 5 years (table 24c).
Residence. — Neither group is very mobile. Twenty-three percent of the non-
addicts and 33 percent of the addicts have resided at the same home for the
past 5 years. Over 70 percent of the two groups have changed their residences
less than three times during the past 5 years (table 25). Further, about half
of both groups resided for more than 1 year at the home in which they were
living at the time of their arrest ( table 25a ) .
Income. — Almost two-thirds of addicts and nonaddicts supported themselves
financially at time of arrest. Twenty percent were dependent on their parents
(table 26). About half of both groups reported that the weekly income of the
home in which they were living when arrested was between $51 and $150 (table
26a).
City of Birth. — Significantly more addicits were born and spent most of their
childhood in large cities as compared to nonaddicts (tables 27 and 27a).
Military service. — Between 25 and 29 percent of the two groups served in the
military (table 28). Nonaddicts had slightly more years of service (table 28a)
and 70 percent of both groups, on the average, reported having had honorable
discharges (table 28b) .
Criminal offenses. — In terms of pre.sent offenses, addicts are charged with
more offenses against property and drug violations — 37 and 15 percent respec-
tively as comapred with 30 and 6 percent respectively for nonaddicts. Non-addicts
are charged are larceny and theft, while nonaddicts are not charged with any
addicts (21 percent). However, three of the four criminal homicides reported
were charged against addicts. The most frequent crimes with which addicts
are charge are larceny and theft, while nonaddicts are not charged with any
single offense with outstanding frequency ( table 29 ) .
198
CONCLUSIONS
Certain patterns emerge from the results of this study. One of the most
relevant is the alarmingly widespread use of heroin in the District of Columbia.
Forty-five percent of offenders entering the District of Columbia jail are heroin
addicts. Further, there is reason to believe that hard narcotics are l>pginning
to reach a younger population. Although addicts at the District of Columbia
jail started using drugs in their late teens or early twenties, drug use today is
starting at about 15 or 16 years of age. The profound implications of this problem
for society are apparent. Addicts must turn to antisocial behavior, at least in
part, to support their habit. And this deviant behavior will continue to increase
as a function of addiction.
Another important finding is the lack of difference between addicts and non-
addicts in the criminal justice system. It appears to be a widely held belief that
addicts belong to a subculture with its own unique membership characteristics
quite distinct from the nonaddict criminal subculture. However, the similarity
between addicts and nonaddicts in terms of personal and social characteristics
and, to some extent, drug use (marihuana) suggests that both addict and non-
addict offenders may. in fact, belong to a single subculture characterized by a
variety of illegal activties, one of which is use of hard narcotics.
Although, for the most part, addicts and nonaddicts share common character-
istics, there are a few areas in which they differ. For example, nonaddicts tend
to have more ties to the community — come from larger families and attend
religious services with much greater frequency — than addicts. These indica-
tions of a closer relationship with the community may, in effect, provide addi-
tional support which the addict finds lacking.
Addicts, on the other hand, appear to be more urban, having been born and
reared in large cities to a much greater extent than nonaddicts.
The results a' so point out a difference between addicts and nonaddicts in terms
of the offenses with which they are charged. This provides some support for the
idea that addicts do not commit crimes against people with the same frequency
as nonaddict offenders.
Contrary to the stereotype of an unstable, highly mobile personality, the nar-
cotics addict appears to be able to retain employment. A surprisingly high per-
centage of addicts were employed at the time of arrest and. indeed, almost half
of the addicts claim to have supported their heroin habit in part through work.
Further, adicts showed a certain stability of behavior — at least to thf extent of
not differing from nonaddicts — in maintaining themselves in the military.
One further point that deserves mention is the apparent interest that most
addicts have in stopping their own drug use. The great majority have been off
drugs at some time during the past several years. Most addicts al.so l)elieve.
realistically or not. that they can give up drugs on their own. In addition, even
before the city wide narcotics treatment program was imniemented in which
methadone was used as one technique of treating heroin addiction, most addicts
had heard about methaone. and a majority of these believe it was a good form
of treatment. This favorability toward methadone may provide a treatment
climate which could facilitate rehabilitation.
In conclusion, it should he mentioned that intensive research in narcotics addic-
tion and treatment has, in a sense, very recently begun. Very little seems to be
known about the addict. This study provides some basic descriptions of a specific
addict population. Hopefully, those findings will suggest new areas of research
aimed at combating the problem of heroin addiction in the community.
TABLE 1.— POSITIVE URINALYSES FOR MORPHINE AND OR QUININE AND SELF-REPORTED HEROIN DEPENDENCE
Urinalyses and self-reoorts:
Interview positive; urine oositive
Interview/ positive; urine negative
Interview positive; no urine
Interview negative; urine positive
Interview negative; urine negative...
Interview negative; no urine
Total 100 100
Addict
Non-
addict
Total
Number
Percent
Number
Percent
Number
Percent
42
42 .
42
19
10
10 .
10
4
44
44 .
44
20
4
4 .
4
2
73
52
58
42
73
52
32
23
125
100
225
100
199
TABLE 2.— SELF-REPORTED USE OF DRUGS
Addict
Non-addict
Total
Number Percent Number Percent Number Percent
Ever used drugs:
Yes
No
No answer
Total.
First drug of abuse:
Marijuana
Heroin
Cocaine __-
Other
No answer; don't know
Total
96
2
96
2
2 ...
28
97
22
78
124
99
2
55
44
2
1
100
100
45
23
13
3
16
125
17
4
2
1
4
100
61
14
7
4
14
225
60
26
14
4
20
100
43
49
22
21
12
U
3
16
3
16
96
100
28
100
124
100
TABLE 3.— PROFILE OF COCAINE USE
Addict
Nonaddict
Total
Number Percent Number Percent Number Percent
Ever used cocaine:
Yes
No
Total
(a) Age at 1st use of cocaine:
14 years
15years
16 years _
17 years _
18 years..-
19 years...
20 years
21 years or older
No answer; don't know
Total
(b) Presently using cocaine:
Yes
No...
No answer
Total
82
85
15
8
20
29
71
90
34
73
14
27
96
100
28
100
124
100
1
2
4
7
6
7
12
35
8
82
1 _
2
5
9 2
7
9
15 1
42 3
10 2
8
4
4
100 8
1
2
4
9
6
7
13
38
10
I
2
5
10
7
8
14
42
11
82
100
8 ---
90
100
46
56
23
21 ....
4
4 _
50
23
17
56
19
25
17
19
90
100
TABLE 4.— PROFILE OF MARIHUANA USE
Addict
Nonaddict
Total
Number Percent Number Percent Number Ferceil
Ever used marihuana:
Yes -.- 72
No 23
No answer.. 1
Total ___. 96
(a) Age at 1st use of marihuana:
13 years Of younger... 2
14 years 5
15 years 8
16 years... 8
17 years 6
18 years or older 34
No answer; don't know 9
Total....
(b) Presently using marihuana:
Yes
No
No answer... _
Total 72
100
75 19 68 91 73
24 9 32 32 26
1 1 1
100 28 100 124
2 2 2
7 5 5
11 I 5 9 10
11 1 5 9 10
9 2 11 8 9
47 11 58 45 50
13 4 21 13 14
72
100
19
100
91
100
22
31
47
22
9
7
3
47
37
16
31
41
19
34
34
45
16
21
100
19
100
91
100
200
TABLE 5.— PROFILE OF BARBITUARATE USE
Addict
Nonaddict
Total
Number Percent Number Percent Number Percent
Ever used barbituarates:
Yes -
No...
Total.
(a) Age at first use of barbituarates:
14 years or younger
ISyears...
16 years..
17 years
18 years or older
No answer; don't know
Total.
(b) Presently using barbiturates:
Yes
No. __
No answer..
Total.
17
18
82
1
27
4
96
18
106
15
79
85
96
100
28
100
124
100
1
1
1
1
12
1
17
5
10
2
17
1
1
1
1
12
2
18
5
10
3
18
TABLE6.— PROFILE OF STREET METHADONE USE
Addict
Nonaddict
Total
Number Percent Number Percent umber Percent
Ever used street methadone:
Yes _
No -
Total.
(a) Age at first use of street methadone:
18 years _
19 years
20 years
21 years or older
No answer ; don't know
Total.
(b) Presently using street methadone:
Yes...
No
No answer
Total.
15
81
16 ...
84
.........
""""ioo"
15
109
12
88
96
100
28
100
124
100
15
15
15
15
TABLE 7.-PR0FILE OF AMPHETAMINE USE
Ever used amphetamines:
Yes
No
Total.
(a) Age at 1st use of amphetamine:
16 years
17 years...
ISyears
19 years or older
No answer; don't know
Total.
(b) Presently using amphetamine:
Yes...
No
No answer
Total.
Addict
Nonaddict
Total
Number Percent Number Percent Number Percent
12
84
13
87
4
24
14
86
16
108
13
87
96
100
28
100
124
100
12
5
5
2
12
1
2
9
2
2
16
8 .
6 .
2 .
201
TABLE 8.-PR0FILE OF HEROIN USE
Addict
Nonaddict
Total
Number Percent Number Percent Number Percent
Ever used heroin:
Yes -
No..._
Total...
(a) Age 1st use of heroin:
14 years or younger 1 1
ISyears 5 5
16years 8 8
17years 11 12
ISyears 12 13
19years 11 12
20years 8 8
21 years 6 6
Over21 years 34 35
Total. 96 100
96
100
4
24
14
86
100
24
81
19
96
100
28
100
124
100
1
1
1
i'
4
1
1
5
5
8
8
11
11
13
13
12
12
9
9
6
6
35
36
100
100
TABLE 9.-HER0IN WITHDRAWAL
Addicts
Number
Percent
Ever withdrew:
Yes
No
No answer; don't know
Total..
(a) Treatment for heroin addiction:
Yes..
No
No answer; don't know
Total
84
88
11
11
1
1
96
100
36
38
55
57
5
5
96
100
TABLE lO.-OFF DRUGS DURING PAST 5 YEARS
Addicts
Number
Percent
Off drugs:
Yes
No
No answer; don't know
Total
(a) Number of times off drugs during past 5 years:
4to5
6 to 10
More than 10...
No answer; don't know
Total
82
85
13
14
1
1
96
100
19
23
26
32
10
12
7
9
1
1
19
23
82
100
60-296 O — 71 — pt. 1-
-14
202
TABLE ll.-SUPPORT OF HEROIN HABIT
Addicts
Number
Percent
Ever commit a crime to support habit:
Yes
57
27
12
59
No
28
No answer
13
Total
96
100
(a) Usual way habit was supported:
Hustling (N =96)
55
45
42
27
57
Work (N =96)
47
Crime (N =96)
44
Pushing (N =96) ..
28
TABLE 12.-
-BELIEVE OWN USE OF DRUGS CAN BE STOPPED
Addicts
Number
Percent
Can stop:
Yes
84
1
8
3
88
No
1
8
No answer
3
Total
96
100
(a) Way in which own use of drugs can
Just stop
be stopped:
22
16
15
12
6
4
9
26
Change environment
Treatment; therapy..
Methadone
19
18
14
Work
7
Jail . .
5
No answer' don't know
11
Total
84
100
Addicts
Number
Percent
TABLE 13.-DRUG USE BY SPOUSE
Addicts
Number
Percent
Drug use:
Yes .
2
29
9
5
No
73
No answer' don't know
22
Total
40
100
(a) Drug use among siblings:
Yes
9
62
16
1
No ....
71
No answer; don't know
19
Total
87
100
(b) Drug use among other members of the family:
Yes:
Father - -- -.-
3
3
3
65
26
3
Mother
3
Other
3
No ...
65
No answer; don't know
26
Total
100
100
203
TABLE 14— DRUG USE AMONG FRIENDS
Addicts
Number
Percent
Drug use:
Yes:
All
Most
Some _
No
No answer; don't know.
32
32
7
7
49
49
2
2
10
10
Total
_ 100
100
TABLE 15.-
-AGE OF MOST HEROIN USERS TODAY AS REPORTED BY ADDICTS
Addicts
Number
Percent
Age:
Less than 10 years.
11 to 15 _
16 to 20 _
21 to 25... ._
26 to 30..
31 to 35
36 to 40
More than 40 years
No answer; don't know __
Total .
(a) Age at which most drug use presently begins as reported by addicts
12 years or younger..
13 _
14
15.
16 -
17.. _
18 years or older..
No answer; don't know
Total _
3
3
6
6
20
20
16
16
8
8
5
5
3
3
7
7
32
32
100
100
2
2
5
5
11
11
17
17
28
28
12
12
13
13
12
12
100
100
TABLE 16.-FAMILIARITY WITH METHADONE TREATMENT
Addicts
Number
Percent
Heard of methadone:
Yes
No
No answer
Total
(a) Favorability concerning methadone treatment
Believe methadone treatment is good:
Yes (unqualified)
Yes (with reservations)...
No
Don't know..
No answer
Total.... _
86
9
5
100
100
63
73
6
7
4
5
11
13
2
2
86
100
204
TABLE 17.-AGE OF ADDICTS AND NONADDICTS
Addict
16 to 17 _
18tol9 _ 16 16
20to21 14 14
22to23 7 7
24to25 _ 9 9
26to27 9 9
28to29. 9 9
30to31... _. 9 9
32to33 _ 4 4
34to35.. 4 4
36to37. _ .55
38to39 _... 2 2
40orolder 12 12
Total.. 100 100
Nonaddlct
Total
Number
Percent
Number
Percent
2
1
2
1
25
20
41
18
18
14
32
14
11
9
18
8
11
9
20
9
11
9
20
9
5
4
14
6
4
3
13
6
6
5
10
4
6
5
10
4
1
1
6
3
7
6
9
4
18
14
30
14
125
100
225
100
TABLE 18— HIGHEST GRADE COMPLETED
Addict
Nonaddict
Total
Number Percent Number Percent Number Percent
LessthanS 10 10 19 15 29 13
8 __._ __ 8 8 7 5 15 7
9 - 13 13 22 18 35 16
10 22 22 16 13 38 17
11 21 21 25 20 46 20
12 19 19 19 15 38 17
Some higher education 6 6 12 10 18 8
No answer 115 4 6 2
Total 100 100 125 100 225 100
TABLE 19.— REARED BY NATURAL PARENTS
Addict
Nonaddict
Total
Number
Percent
Nui
Tiber
Percent
Number
Percent
79
79
102
82
181
81
20
20
17
13
37
16
1
1
6
5
7
3
Yes
No
No answer.
Total
100
100
125
100
225
100
TABLE 20.-PARENTS LIVING OR DECEASED
Addict
Nonaddict
Total
Number
Percent
Number
Percent
Number
Percent
49
49
45
36
94
42
25
25
37
30
62
28
11
11
16
13
27
12
11
11
18
14
29
13
4
4
9
7
13
5
Living or deceased:
Both parents living
Father deceased _
Mother deceased
Both parents deceased
No answer, don't know
Total
(a) Age at time of mother's death
5 years or younger.
etc 15
16to21....
Over 21
No answer; don't know..
Total
(b) Age at time of father's death:
5 years or younger
6tol5_
16 to 21 ^...
Over 21.
No answer; don't know..
Total ._
100
36
100
100
125
55
100
100
225
91
100
4
18
3
9
7
13
7
32
8
24
15
27
2
9
8
24
10
18
7
32
13
38
20
35
2
9
2
5
4
7
22
100
34
100
56
100
7
19
4
7
11
12
12
34
20
37
32
35
6
17
7
13
13
14
7
19
21
38
28
31
4
11
3
5
7
8
100
205
TABLE 21.— NUMBER OF BROTHERS
Addict
Nonaddict
Total
Number Percent Number Percent Number Percent
Number:
0 18 18
1 21 21
? - 24 24
3. _._. 14 14
4.. _.- 9 9
5 3 3
6 _.__
7 _ 2 2
More than 7 _._ 1 I
No answer; don't know 8 8
Total ._ 100 100
(a) Number of sisters:
0 16 16
1--- - -- _.__ 28 28
2 22 22
3 14 14
4.. __ 5 5
5 3 3
6...
7 1 i
Morethan7 2 2
No answer; don't know 9 9
Total 100 100
21
17
39
17
22
18
43
19
25
20
49
22
11
9
25
11
17
14
26
11
8
6
11
5
6
5
6
3
3
2
5
2
5
3
6
3
7
6
15
7
125
125
TABLE 22.— RELIGIOUS AFFILIATION
100
100
Addict
Nonaddict
225
225
Total
100
12
10
28
13
31
25
59
26
35
28
57
25
13
10
27
12
9
7
14
6
7
5
10
4
1
1
1
1
7
6
8
4
1
1
3
1
9
7
18
8
100
Number Percent Number Percent Number Percent
Affiliation:
Protestant 43 43
Catholic... 24 24
Other 10 10
None _ 23 23
No answer; don't knowi
Total 100 100
(a) Childhood attendance at religious services:
At least once a week 82 82
Less than once a week 5 5
Notatall 12 12
No answer; don't know _ 1 1
Total 100 100
(b) Present attendance at religious services:
At least once a week 26 26
Less than once a week 10 10
Notatall 63 63
No answer _ 1 l
Total __.. 100 100
63
50
106
47
32
26
56
25
17
14
27
12
11
9
34
15
2
1
2
1
125
125
125
100
100
100
225
225
225
100
99
79
181
80
11
9
16
7
9
7
21
10
6
5
7
3
100
58
46
84
37
17
14
27
12
47
38
110
49
3
2
4
2
100
206
TABLE 23.— PRESENT MARITAL STATUS
Addict
Nonaddict
Total
Number Percent Number Percent Number Percent
Status:
Married
Single
Separated or divorced
No answer...
Total...
(a) Length of time married:
1 year or less...
2 years
3 to 4 years
5 to 6 years
7 toSyears
9 to 10 years.
More than 10 years
No answer
Total J
(b) Ever separated from spouse
Yes
No. -
No answer
Total
21
21
24
19
45
20
57
57
68
54
125
56
15
15
32
26
47
21
7
7
1
1
8
3
100
100
125
100
225
100
6
15
5
9
11
12
6
15
4
8
10
11
4
10
9
17
13
14
5
13
9
17
14
15
7
18
3
5
10
11
3
7
4
8
7
7
8
20
12
23
20
22
1
2
7
13
8
8
40
100
53
100
93
100
25
62
33
5
31
20
2
58
38
4
56
33
4
60
13
36
2
4
40
100
53
100
93
100
TABLE 24.— EMPLOYMENT STATUS
Addict
Nonaddict
Total
Number
Percent
Number
Percent
Number
Percent
Status:
Employed
41
41
76
61
117
52
Unemployed _.
55
55
48
38
103
46
No answer
4
4
1
1
5
2
Total _
100
100
125
100
225
100
(a) Age at which first started working:
15 years or younger
15
15
13
11
28
12
16 years
19
19
33
26
52
23
17 years
20
20
22
18
42
19
18 yea rs
21
21
18
14
39
17
19 years
4
4
8
6
12
5
20 years. . _
6
6
8
6
14
6
21 years or older
8
8
11
9
19
9
No answer; don't know
7
7
12
10
19
9
Total
100
100
125
100
225
100
(b) Usual level of employment:
Unskilled...
45
24
22
4
45
24
22
4
65
25
22
7
52
20
18
5
110
49
44
11
49
Semi-skilled..
22
Skilled
19
Other
5
No answer; don't know. . . .
5
5
6
5
11
5
Total :.
100
100
125
100
225
100
(c) Number of places employed during past 5 years:
0 .
7
7
3
2
10
4
1
17
17
16
15
33
15
2
19
19
28
23
47
21
3
23
23
24
19
47
21
4
9
9
17
14
26
11
5
6
6
9
7
15
7
More than 5
17
17
26
20
43
19
No answer; don't know
2
2
2
2
4
2
Total _
100
100
125
100
225
100
207
TABLE 25.— NUMBER OF PLACES RESIDED DURING PAST 5 YEARS
Addict
Nonaddict
Total
Number
Percent
Number
Percent
Number
Percent
33
33
29
23
62
27
46
46
60
48
106
47
8
8
12
10
20
9
2
2
5
4
7
3
1
1
3
2
4
2
5
5
1
1
6
3
5
5
15
12
20
9
Number:
1
2 to 3
4 to 5 -
6 to 7 -..-
8 to 9 -
10 or more
No answer; don't know
Total
(a) Lengtti of time resided at home in which living
at time of arrest:
Less than 1 month _ _.
1 to 3 months
3 to 6 months
6 to 12 months
1 to 3 years
3 to 5 years
More than 5 years _
No answer, don't know..
Total _
100
100
100
100
125
100
125
100
225
225
100
17
17
20
16
37
16
10
10
13
10
23
10
8
8
7
6
15
7
11
11
17
14
28
13
17
17
24
19
41
18
8
8
7
6
15
7
27
27
28
22
55
24
2
2
9
7
11
5
100
TABLE 26— MAIN FINANCIAL SUPPORT OF PEOPLE IN HOME IN WHICH LIVING AT TIME OF ARREST
Addict
Nonaddict
Total
Number
Percent
Number
Percent
Number
Percent
Financial support:
Self
Parent(s)
Friends
Relatives .
63
21
6
4
2
1
3
63
21
6
4
2
1 .
3
81
25
2
5
4
8"
65
20
2
4
3
6
144
46
8
9
6
1
11
64
20
3
4
Spouse
Other
No answer..
of home in which living
3
1
5
Total
100
100
125
100
225
100
(a) Total weekly income
at time of arrest:
$50 or less
$51 to $100
3
21
27
10
5
6
4
5
19
3
21
27
10
5
6
4
5
19
7
35
31
12
7
7
1
2
23
5
28
24
10
6
6
1
2
18
10
56
58
22
12
13
5
7
42
4
25
$101 to $150
26
$151 to $200 .
10
$201 to $250
5
$251 to $300
6
$301 to $400
2
More than $400
No answer; don't know
3
19
Total
100
100
125
100
225
100
TABLE 27.-SIZE OF CITY IN WHICH BORN
Addict
Nonaddict
Total
Number
Percent
Number
Percent
Number Percent
Size:
Large city (over 500,000)
72
6
7
4
1
1
9
72
6
7
4
1
1
9
62
6
19
15
5
4
14
49
5
15
12
4
3
12
134
Medium city (100,000 to 500,000) .
12
Small city (10,000 to 100,000)
26
Town (1,000 to 10,000)
19
Village _._ _
Farm _
No answer; don't know...
6
5
23
Total
100
100
125
100
225
(a) Size of city in which most of childhood was spent :
Large city (over 500,000) _
74
5
5
2
1
1
12
74
5
5
2
1
1
12
67
2
18
10
2
5
21
54
2
14
8
1
4
17
141
Medium city (100,000 to 500,000)
7
Small city (10,000 to 100,000)...
23
Town (1,000 to 10,000)
12
Village
Farm... _.
3
6
No answer; don't know
33
Total...
100
100
125
100
225
208
TABLE 28.-MILITARY SERVICE
Service:
Yes
No
No answer
Total
(a) Years in military service:
1 year
2years
3 years
4 years
More thaa4 years
No answer _
Total
( b) Type of military discharge:
Honorable
Dishonorable
Medical
General.. ..-
Other.
No answer; don't know
Total _.
Addict
Nonaddict
Total
Number Percent
Number
Percent
Number
Percent
25
25
36
29
61
27
73
73
88
70
161
72
2
2
1
1
3
1
100
100
125
100
225
100
5
20
6
17
11
18
8
32
9
25
17
28
6
24
7
19
13
21
1
4
5
U
6
10
4
16
7
19
11
18
I
4
2
6
3
5
25
100
36
100
61
100
18
72
25
70
43
70
2
8
3
8
5
8
1
4
3
8
4
6
1
4 .
8
4
"l"
3
.....
8
1
4
4
2
2
7
1
7
25
100
36
100
61
100
TABLE 29.-OFFENSE FOR WHICH PRESENTLY CHARGED
Addict
Nonaddict
Total
Number Percent Number Percent Number
Percent
Offense:
Larceny; theft 21 21
Drug law violation 15 15
Robbery 10 10
Possession of implements of crime 5 5
Burglary 6 6
Receiving stolen property _ 3 3
Carry/possess weapon 5 5
Housebreaking
Assault (other than aggravated) 5 5
Soliciting (for lewd and immoral purposes) 4 4
Criminal homicide 3 3
Forgery; counterfeiting... 3 3
Fraud; embezzlement 2 2
Autotheft 2 2
Armed robbery 1 1
Bank robbery 2 2
Disorderly conduct; drunkenness 1 1
Escape 2 2
Destroying private properly
Assault (with a deadly weapon) _.
Offense against family. . _
Traffic violation. 1 1
Obstructing justice
Parole/probation violation 1 1
Unlawful entry.... 2 2
Resisting arrest
Sex offense
Manslaughter
Gambling
Contempt
Civil action
Ball Act
No answer; don't know 6 6
Total _ 100 100
11
8
32
8
6
23
15
12
25
5
8
6
14
3
2
6
12
9
14
1
1
1
11
9
16
1
1
5
1
1
4
3
2
6
2
2
4
6
5
8
2
2
3
1
1
3
6
5
7
2
5
4
5
4
3
4
1
1
1
4
3
5
3
2
3
1
2
1
1
1
1
1
1
2
2
2
1
I
1
1
1
1
1
1
1
1
I
1
9
7
15
14
10
11
2
6
2
6
125
100
225
100
(Thereupon, at 2:45 p.m. the hearing adjourned, to reconvene to-
morrow, April 28, 1971, in room 2253, at 9 :45 a.m.)
NARCOTICS RESEARCH, REHABILITATION,
AND TREATMENT
WEDNESDAY, APRIL 28, 1971
House of Representatives,
Select Committee on Crime,
Washington^ D.C.
The committee met, pursuant to notice, at 10 :00 a.m., in room 2253,
Ray burn House Office Building, the Honorable Claude Pepper (chair-
man) presiding.
Present : Representatives Pepper, Waldie, Brasco, Mann, Murphy,
Rangel, Wiggins, Steiger, Winn, Sandman, and Keating.
Also present: Paul Perito, chief counsel; and Michael W. Blom-
mer, associate chief counsel.
Chairman Pepper. The committee will come to order please.
The Select Committee on Crime today continues its hearings into
what science and medicine can do to help us fight heroin addiction in
the United States.
Yesterday, we heard impressive testimony from Dr. Frances Gear-
ing of New York and Dr. Robert DuPont of the District of Columbia
on the effectiveness of methadone programs.
Today we are continuing our examination of methadone with testi-
mony from Dr. Jerome Jaffe, director of the Illinois Drug Abuse
Program.
Dr. Jaffe was originally scheduled to testify yesterday, but was
kind enough to stay over until today as we ran behind schedule be-
cause of several votes on the floor.
We will also hear testimony today from Dr. Harvey Gollance, as-
sistant medical director of Beth Israel Medical Center in New York.
Both Dr. Jaffe and Dr. Gollance have had wide experience in the
administration of methadone maintenance programs.
We also have with us today Robert F. Horan, Commonwealth at-
torney for Fairfax County, Va., who will tell us about the special
drug-abuse problems of his suburban county.
We will also hear from Dr. Daniel Casriel about a new treatment
program for heroin addicts that employs a rapid-acting detoxification
drug.
And, finally. Dr. Gerald Davidson, of Boston City Hospital, will
explain the workings of his program.
We hope that the information we receive from these witnesses and
others yet to appear will help us formulate recommendations to the
Congress on what the Federal Government can do to fight addiction, in
addition to what we are now doing.
(209)
210
The committee is pleased to call now Dr. Jerome H. Jaffe, a dis-
tinguished doctor and the director of one of the Nation's largest drug-
abuse programs.
Dr. Jaffe is associate professor of psychiatry at the University of
Chicago, and director of the drug abuse program of the Illinois De-
partment of Mental Health.
Dr. Jaffe holds both a bachelor's and master's degree in psychology
from Temple University and an M.D. from the Temple University
School of Medicine.
He has been the holder of a U.S. Public Health Service Post Doc-
toral Fellowship in Pharmacology and has twice received the U.S. Pub-
lic Health Service Career Development Award.
Dr. Jaffe is a member of numerous scientific and honorary organi-
zations. He is a member of the editorial board of the International
Journal of the Addictions; a member of the Review Committee of
NIMH's Center for Studies of Narcotics and Dangerous Drugs; a
consultant to the Illinois Narcotic Advisory Council and the New
York State Narcotic Addiction Control Commission. He also serves
as secretary of the section on drug abuse of the World Psychiatric As-
sociation; a consultant to the Department of Health, Education, and
Welfare; and special consultant to the World Health Organization's
Expert Committee on Drug Dependence.
He is also the author of numerous articles on drug addiction.
Dr. Jaffe, we are indeed pleased to receive your testimony today.
Mr. Perito, will you inquire ?
Mr. Perito. Thank you, Mr. Chairman.
Dr. Jaffe, I understand that you have a prepared statement; is
that correct ?
STATEMENT OF DR. JEROME H. JAITE, DIRECTOR, ILLINOIS
DRUG ABUSE PROGRAM ^
Dr. Jaffe. That is correct.
Mr. Perito. Would you care to present that to the committee ?
Dr. Jaffe. Yes. I would like to comment briefly on four areas re-
lated to the problem of narcotics addiction and drug abuse :
First. The spectrum of treatment services required to treat narcotics
users, and our experiences in the State of Illinois in developing a
multimodality program for delivering such services.
Second. A progress report on acetyl-methadol, a drug that we be-
lieve may have significant advantages over methadone in the treatment
of heroin users.
Third. Our current estimates on the effect of treatment in reducing
antisocial activity.
Fourth. My own views on the kinds of research that will be re-
quired if we are to avoid another pandemic of drug use similar to the
one we are now experiencing.
1 Subsequent to Dr. Jaffa's appearance before the committee. President Nixon, on June 12,
1971, named Dr. Jaffe as his chief consultant on drucr abuse and drnp dependence and
proposed his name for consideration by the Senate as Director of the President's proposed
Special Action OflSce on Drug Abuse Prevention.
211
In the State of Illinois our efforts to develop treatment programs
began in 1966. Our approach to treatment was based on a very clear
set of premises and principles :
(1) Narcotic users are a heterogeneous group requiring different
treatments.
(2) To determine which treatments were most appropriate for a
given community required a community diagnosis.
(3) Treatment programs should be located in the communities
where patients lived.
(4) No program, no matter how sound it might appear to be theo-
retically or how appealing it was emotionally, would be continued
unless objective evaluation revealed it to be effective and to justify
the expenditure of public funds.
Initially, our program could be called a controlled comparison of
several different approaches, somewhat competitive, but friendly. We
developed a therapeutic community — Gateway Houses — modeled after
Daytop Village. We explored the use of narcotic antagonists such as
cyclazocine ; we developed halfway houses, a specialized hospital unit ;
and we used methadone for maintenance at both high doses and low-
doses.
Later we began to wonder why it was necessary to have a separate
unit for each approach. It became obvious that such separatism was a
relic of old rivalries and philosophical disputes that had no place in
a scientifically run and evaluated program. With some effort we were
able to get most of our units to offer all of the available approaches in
a more or less eclectic fashion.
In other words, at a single facility a patient could participate in a
methadone maintenance program, later withdraw, live in a residential
self-regulating community, reenter the community at large on an
abstinent basis, or elect to take cyclazocine and in the event of a
relapse, move back into a residential facility, or if he was holding a
job merely start again on methadone on an ambulatory basis. He
rnight then wait for a number of months — until it was his vacation
time — move into the facilities and then withdraw from methodone.
Not every unit is able to sustain specialized treatment services. For
example, we have one unit under the leadership of Dr. John Chappie
that specializes in the care of addicts with serious medical problems,
alcoholism, psychosis, and pregnancy. Yet this unit serves the entire
network and a patient who needs such treatment is merely transferred
without any interruption of treatment.
We believe that to reach the majority of addicts it requires more
than one approach or modality. We also believe that we have dem-
onstrated that all of the modalities can be accommodated within a
single administrative structure. The advantage to this approach is
that program planning and expansion can then be based on the results
of a fair and uniform evaluation system imposed by the administra-
tive structure rather than by emotion, rhetoric, and a political trial
at arms in the lists of the mass media. This kind of eclectic program
has come to be called the multimodality approach.
Currently lodged in the department of mental health and operated
with the cooperation of the University of Chicago, the program con-
212
sists of a network of 21 geographically distinct facilities across the
State serving more than 1,600 narcotics users.
Our present primary goal is to eliminate the waiting list so that
every patient who seeks treatment can get it immediately. We have
enjoyed the full support of the Governor, the legislature, and the
department of mental health. We should reach our primary goal with-
in the next 6 months.
11.
Almost from the beginning of the work with methadone, it was
obvious that if we expected patients maintained on methadone to lead
normal, productive lives it would be impossible to demand that they
come to a clinic every day in order to ingest their medication under
supervision. Eventually patients would have to be permitted to take
their medication home, and although we might hope that 95 percent
of the patients would not abuse this privilege, it would be naive to
hope that there would not be a small minority who would give away
or sell their prescribed medication. Among the potential solutions
to this problem would be a longer acting methadone-like drug.
In 1966, I proposed to study one such substance, acetyl-methadol,
but the project was shelved when I moved from New York to the
University of Chicago.
After a 3-year delay we resurrected the project and last year my
colleagues and I reported that acetylmethadol seemed to be as effec-
tive as methadone in facilitating the rehabilitation of heroin addicts.
Advantages includes its longer duration of action and its lower abuse
potential. Its longer duration should also mean reduced program oper-
ating costs since, obviously, you don't have to give out the medication
every day, but need only give it three times a week. Several months
after our first report, one of my collaborators. Dr. Paul Blachly at
the University of Oregon, sent us a confidential report in which he
observed some advei-se side effects with 1-acetvl-methadol.
By that time our group, including Drs. Charles Schuster, Edward
Senav, and Pierre RenauU had alreadv repeated our controlled dou-
ble-blind studies and had found no such side effects ; since that time
we have carried out still additional studies — so that our total experi-
ence includes well over 75 patients studied for at least 4 months. Thus
far our conclusions are the same — acetyl-methadol is as effective as
methadone.
I want to caution, however, tliat we have not used very high doses.
We have used it primarily and solely in males and we cannot be
certain at this point that at such higher doses we would not see un-
wanted effects.
III.
From the bejiinning of our program one of the criteria by which
we measured effectiveness was the extent to wliich treatment reduced
antisocial behavior. We have done at least four separate studies in
which we have compared the &t;lf- reported arrest rates of patients
prior to treatment and their arrest rates during treatment. In every
one of these studies we have observed a very substantial drop in the
arrest rates. In some instances the rates were reduced to one-half of
the pretreatment rate. In others, the rates were reduced to one-third
213
of the pretreatment rate. Until recently, we were unclear about how
to evaluate these results.
First, they are considerably less dramatic than those reported by
other workers. However, this could be due to our policy of taking
all applicants regardless of our estimate of how well they will do.
But second, for technical reasons, we were unable to examine the
actual arrest records of our patients, but were forced to rely on their
own reports to our legal unit. The only penalty for a failure to report
an arrest was that if it was later reported the legal unit would offer
no assistance with respect to that arrest.
More recently our program wrote a contract with the University of
Chicago Law School to conduct an independent assessment of the
impact of treatment on crime.
Mr. H. Joo Shin and Mr. Wayne Kerstetter were able to obtain
the arrest records of a sample of a little over 200 of our patients.
We then gave them access to all of our data. Their findings are still
being analyzed, but thus far they have found that official arrest rec-
ords do not record all of the arrests that our patients have had.
The study conducted by the University of Chicago Law School re-
vealed that prior to treatment this sample of patients had recorded on
their arrest records approximately 84 arrests per 100 man-years ; dur-
ing treatment, they accumulated only 31 arrests per 100 man-years.
Depending on how you want to calculate the percentage, this would
be viewed as a 61-percent reduction in arrest rate. Self-reported data
indicated that prior to treatment our patients had 148 arrests per 100
man-years. After treatment the arrest rate was 76 arrests per 100
man-years.
Thus, it appears that whether we use arrest records or patients self-
reports, arrest rates decrease dramatically. We do not have at present
a more detailed qualitative analysis of the change, but we suspect that
the crimes committed by patients in treatment are less impulsive and
more benign.
IV.
Lastly, we come to research :
It may be that I am too close to the issue to see it in perspective. To
a certain extent I consider myself a displaced person.
I left my laboratory and my research in order to develop a much
needed program in the State of Illinois and I look forward to returning
to full-time research.
The projects that I personally think deserve high priorities are :
(1) Further studies on the use of antagonists in facilitating the
withdrawal from methadone and in treating young people who have
begun to use heroin but have not become physically dependent. We
need to develop long-acting forms of nontoxic antagonists.
(2) An expanded investigation into the safety and utility of acetyl-
methadol and similar agents.
(3) The development of a system under the aegis of a health-care
authority for monitoring trends in drug use and addiction so that we
can mobilize earlier and more rationally to abort epidemics.
(4) Experiments to determine whether early intervention can abort
a microepidemic.
(5) Further studies on the natural history of the drug-using syn-
dromes; for example, we still do not know how many individuals stop
using various drugs spontaneously.
214
(6) Basic studies on the nature of the biochemical events involved
in tolerance and physical dependence.
Research requires people. It is simply inadequate to make money
available and expect that trained and competent researchers -will ma-
terialize from the ether. These individuals require support before they
are ready to conduct their own research and not all of those who re-
ceive such support will develop into able researchers. Thus, some sup-
port for training of new researchers or the retraining of researchers
from other fields is a prerequisite to a long-run attempt to conduct the
research I have described.
Thank you.
Chairman Pepper. That was a very able and comprehensive state-
ment. Dr. Jaffe.
Mr. Perito, do you have any questions ?
Mr. Perito. Thank you, Mr. Chairman.
Dr. JafFe, you started the program in Illinois in 1967 ?
Dr. Jaffe. Well, the legislature passed the appropriations bill and
it was signed in August of 1967. It took us a number of months to find
out how to use that appropriation because we were an entirely new
agency in a sense.
We took the first patient, under the aegis of the Department of
Psychiatry of the University of Chicago in January 1968, and that
began in my own office at the university. We sort of got started in an
unusual way.
Mr. Perito. You have gone from one patient to 1,590 patients from
January 1, 1968, up until the present time ?
Dr. Jaffe. We have at least doubled our patient load every year, and
intend to double it again this year. It is, we think, a very orderly rate
of growth.
Mr. Perito. Does your program or programs, rather, have a waiting
list at the present time?
Dr. Jaffe. Yes ; it has had a waiting list from the first day that we
took in the first patient. No matter how fast we expand, we have al-
ways had people waiting for treatment.
Mr. Perito. Your program is the largest in Chicago ; is that correct ?
Dr. Jaffe. Yes.
Mr. Pepito. Are there other large programs working in conjunction
with yours ?
Dr. Jaffe. Well, we have no mechanism for monitoring the size of
other programs. Unofficially, I think the largest program that does
not come under our aegis has 50 or 60 people.
Mr. Perito. Do you receive any Federal moneys for your program ?
Dr. Jaffe. There is one grant from the National Institute of Mental
Health to the University of Chicago.
Mr. Perito. Is this a research or a service grant ?
Dr. Jaffe. There is a service grant.
Chairman Pepper. How much Federal assistance do you receive?
Dr. Jaffe. The first year it was about $450,000 to $500,000. It was
a matching grant. It has decreased by 10 percent each year thereafter.
Mr. Perito. What do you figure the cost is, per patient-year, to iim
your program at the present time ?
Dr. Jaffe. Well, I can give you some exact figui-es, but I would
like to give you some context in which to put them.
215
About 20 percent of our patients are living in a residential setting.
At present, we use no traditional hospitals at $80 per day, but we
have developed more efficient — and we think more rational — ways of
handling patients who are drug abusers, since for the most part, cor-
rectly handled they are not acutely ill. Our residential settings still
cost us about $10 to $12 per patient per day, or $3,500 per year.
Our outpatient methadone program costs between $800 and $1,500
per patient per year.
Again, I give you this range because the longer somebody is in
treatment, if they remain continuously in treatment, the less costly it
is to treat them. Once they become stabilized they get a job and they
are functioning reasonably well.
At that stage, it does not take as much personnel or staffing to main-
tain that person in a functioning state. So that for a patient in the
early stages of treatment, you have to have more input. As our pro-
gram has matured, our outpatient cost per patient have actually gone
down in spite of inflation.
Now, if you want an overall cost for treating 1,600 people with the
research we have conducted, with our evaluation with our equipment
costs, the cost is a little over $2.4 million to treat 1,600 people.
Again, I caution you that we only reached 1,600 January 1, so you
are going to look at a mean patient load of about 1,400 over an entire
year.
In a program that is expanding it is more rational to look at the
projected cost when it stabilizes. At that point we expect that resi-
dential costs will be in the neighborhood of $3,000 to $3,500 per patient
per year, and outpatient costs will be about $1,200.
Mr. Perito. Do most of your funds emanate from the State of
Illinois?
Dr. Jaffe. The State of Illinois.
Mr, Perito. Do you receive any money for your program from the
University of Chicago ?
Dr. Jaffe. Only to the extent that the University of Chicago makes
commitments to faculty people and provides fringe benefits to those
faculty people, and these benefits that are very difficult to charge to
grants. In that sense we are supported primarily by the Federal
grant and the State of Illinois.
On the other hand, we sort of cannibalize a lot of the brainpower
at the University of Chicago and have no way of compensating them
for the unofficial consultation time and the time that we take up in
trying to plan strategy.
Mr. Perito. Doctor, how large is your staff at the present time,
that is your full-time staff ?
Dr. Jaffe. Well, there are approximately 135 total State positions
at this time. At the university there are perhaps 40 positions. Our
program was designed to maximize where possible community par-
ticipation and the co-opting of whatever community resources could
be brought to bear on this problem. Since there is a great reluctance
of community people to donate their time to the State, we arrange to
contract with specifically developed not-for-profit corporations to op-
erate certain components of this program. Although we evaluate them
and although we consider them operating arms of the program, they,
216
in fact, constitute autonomous or semiautonomous not-for-profit
corporations.
For example, Gateway Houses Foundation, which now runs three
residential facilities for young polydrug users and heroin users, oper-
ates on a contract with us and Gateway, I believe, employs 18 staff
people.
We have several other small organizations that are contracting with
those.
I would guess, in the aggregate, their staff may come to a total of
perhaps 30 people. So that if you want to total it all- up it is perhaps
about 220 people, give or take a few, to take care of this patient load.
Mr. Perito. Doctor, in your prepared statement you mentioned the
use of acetyl-methadol. Do you foresee that this long-lasting drug will
someday be a replacement for methadone?
Dr. Jaffe. Not entirely as a replacement for methadone. Any new
drug has its advantages and disadvantages.
First, I would like to emphasize that acetyl-methadol requires fur-
ther study. It may very well be that an attempt to use it at much
higher doses would cause some side effects. Furthermore, it is a drug
whose primary advantage is its long duration of action. This means
that it is a drug that can be given three times a week. No drug need
be taken home and therefore no drug can be illicitly diverted. It has
its advantages.
Mr. WiGGixs. Doctor, who developed this drug ?
Dr. Jaffe. This drug has been around since the 1950's. It was origi-
nally developed by Merck, tested at Lexington, but because it was so
long acting there was no further use for it in medicine. I was about
to say its advantage turns out to be its disadvantage. Many people are
not familiar with a drug that should not be given every 24 hours.
If you give it every 24 hours you get cumulative toxicity, the drug
lasts for several days, so that you have some overlap. Before this drug
can be widely used it will take an educational program.
Mr. Wiggins. You make an interesting point, and that is drugs that
are really effective sort of price themselves right out of the market,
don't they, because there is no longer a need for them if they solve
the problem that they are created to solve? Is that really what you
are saying here about this, that it was so effective that there was no
market for it ?
Dr. Jaffe. No; I am saying it was tested as an analgesic agent, a
painkiller, and in some instances people were unaware that this was
a drug that should not be given every day. When they gave it every
day some patients developed cumulative toxicity. In effect, by taking
it every day they received overdoses. This made it virtually useless
as an analgesic. It was just too tough to use.
Mr. Wiggins. This drug was developed by a private pharmaceu-
tical house ?
Dr. Jaffe. That is correct.
Mr. Wiggins. For sale for profit, I take it ?
Dr. Jaffe. It never reached the market in any meaningful way.
Mr. Wiggins. Are you satisfied that we can or should rely i:)rimarily
on the private researchers and pharmaceutical houses to develop a
drug that you may need ?
Dr. Jaffe. No.
217
Mr. Wiggins. "\Yliere else is it being done or should it be done ?
Dr. Jaffe. Well, my experience has been that we do not have an
effective mechanism for developing drugs which don't have a poten-
tially significant commercial market. Drug houses do not want — and
at least in my own experience — to develop drugs which have no
market, utilizing their own resource and their own personnel and their
own laboratory facilities.
On the other hand. I think we have precious little in the way of that
kind of resource within the public sector. Generally, universities are
not in the business of developing drugs.
Mr. WiGGixs. What suggestions might you make to the committee
if we are interested in encouraging the development of such drugs?
Dr. Jaffe. Well, I am not sure that I know enough about the devel-
opment of pharmaceutical preparations to make really meaningful
suggestions on it. I suspect there is some difficulty with respect to
patent problems. As soon as you give subsidies to a commercial or-
ganization, it then loses the possibility of distributing and marketing
that product for profit.
Mr. Wiggins. Well, could it be done alternatively or together at the
National Institutes of Health or at universities operating under
grants ?
Dr. Jaffe. I think it could be, but traditionally universities have
not been in the drug development business and it would mean think-
ing about what would be necessary to develop that capacity within
a university. J
The difficulty with many universities, at least until recently, is
that Govermnent encourages universities to apply for grants that
run for 3 or 4 years. The university recruits people and brings them
from wherever they were to the university. Their families are there.
And then the grants run out. The Government just says, well, we have
other priorities now. The university is left with the problem of staff
people who nobody wants any more. They are surplus. This is a hu-
man problem.
If the university doesn't teach the development of pharmaceutical
products, then, you know, it is very difficult to get it involved in de-
veloping this kind of thing.
There are, you know, schools of pharmacy, but whether or not they
are in the business of developing drugs, I can't say. The development
of new pharmaceuticals is npt^^y area^of expertise.
Mr. Wiggins. All right. ' -v ...^ ., ^ r ( ^ ■• r^^ ^
Chairman Pepper. Excuse me;"^,, ^.
Apropos to what Mr. Wiggins was asking you, the suggestion was
made the other day that it might be possible for the U.S. Government
to give grants to drug houses to carry on approved research in areas
where the Government desired such research be carried on, with the
understanding that if the company ever profited from the distribu-
tion of that drug, the United States would get its money back, and in
that way you would allow the company to retain the ownership of
the patent while reimbursing the Government should the research
produce a drug that is economically profitable. ,
Dr. Jaffe. That sounds like a very creative approach to me. I won-
der whether or not it can be accomplished. Certainly it is the first
time I have heard that suggestion. I know it has been a stumbling
block for most pharmaceutical houses.
60-296— 71— pt. 1 15
218
Chairman Pepper. Mr. Perito?
;; Mr. Perito. Thank you. Mr. Chairman. I have a couple of more
questions along that line for Dr. Jaft'e's consideration.
You had mentioned earlier during staff interviews that one of the
problems was in developing new research techniques involving possi-
ble development of antagonists that researchers become terribly spe-
cialized, but then when the problem is solved there is no need for them
any longer.
I wonder, could you expand upon this for the committee's benefit?
Dr. Jaffe. Yes; my point was simply that I think the situation is
somewhat analogous to the space program. If Government decides it
has a priority and wants to have a crash program, we can give out a
great deal of money and get people to drop a secure position where they
are teaching something or doing research on something which has
long-range value. Those people come into the field and they get in-
volved in the crash progi'am. As soon as the problem is solved, they are
out of business, and it is a human problem. I think it causes some re-
luctance for the best people to drop their work and get involved in it.
What you often get with this kind of crash interest is that you move
marginal people who haven't done well in more traditional fields than
this, which is precisely what won't get the job done. I have no specific
suggestions as to how to get the job done. I think it remains a problem
for Government to examine what it does about its human excess bag-
gage, particularly when that excess baggage turns out to be its best
brainpower that it recruits into solving public problems and then
abandons.
I can say for myself that at this point I would have to stop for a
number of months to review the literature, to prepare a grant applica-
tion, to get caught up with a research field in order to get a grant.
Since I moved into the public service sector in order to develop a
delivery system that made use of known research which existed in
1967 and 1968 I, at least, have a university base. Other researchers
may not have such an affluent base — I am not sure our university is
affluent — but at least universities are willing to make that commit-
ment of saying, "You may now sit back and get caught up with your
own field in order to compete for a grant."
This is the difficulty. You move people into one thing, then you want
them to switch. Nobody supports them during that interval while
they are trying to reacquire the tools and get caught up with the tech-
nology in order to compete for other grants.
We certainly have gutted the universities in many respects with
respect to their capacity to support people. They are very dependent
on research grants. When these things are cut back they have no way
of supporting those people who then are looking to find out what are
the new areas that are of interest to the public.
Mr. Perito. Have you found an appreciable difference on your crime
studies and the efficacy of your program in reducing crime or anti-
social behavior? Have you found a principal difference betAveen the
arrest records that you have checked, and the actual instances of crimi-
nal behavior that you have found out through interviews with addicts?
Dr. Jaffe. Well, I can say that our interviews with addicts indicate
that a great deal of crime occurs that is not reflected in an arrest. It is
a very interesting kind of thing. 'V^Tien we establish rapport with
219
somebody who, almost as a professional, engages in antisocial activity,
they will be very honest with you.
We have seen that when we get people into treatment, even A\-hen
they don't give up their antisocial activity entirely in the early months
of treatment — and get a legitimate paying job — their antisocial activity
still drops dramatically. They may not be arrested at all, yet we know
they are committing crimes. Nevertheless they are committing them
at half the rate they were committing thom. So that sometimes you
can get a great deal by talking to people that the arrest records will
not reveal.
The arrest records are only a very approximate index of what is
actually happening. There are discrepancies and they go in both direc-
tions. Sometimes people who commit virtually no ciime manage to
get arrested for some charge anj^way, and somebody else who is more
skilled continues to engage in antisocial activities for long periods and
is not arrested at all. We have seen both of these kinds of things go on.
Mr. Perito. Do you regard the coiicept of narcotic antagonists like
cyclazocine and naloxone as a hopeful aiea in multimodalit}' approach '{
Dr. Japfe. Do I regard the concept of narcotic antagonists as a hope-
ful area ? The answer is that I do.
HoAvever, as I said several 3'ears ago, it is quite clear that in order
to be effective in treating narcotics users a more appropriate form of
narcotic-antagonist will be required. We will require an antagonist
with minimal side effects that can be given in a way that will produce
a blockade of narcotic effects for at least several days. Unlike metha-
done, patients don't want to come back to a clinic every day just to
take a drug that blocks narcotic effects.
Some will. Some will for a number of months, but for the most
part, after a few months they are convinced they don't need the an-
tagonist any more, so they stop.
Chairman Pepper. Excuse me a moment.
The effect of this antagonist drug is to prevent them from getting
any sensation of satisfaction or euphoria from the taking of heroin?
Dr. Jaffe. That is correct.
Chairman Pepper. Now then, could you add to that drug the quality
of making the taking of heroin, again within a reasonable time, repul-
sive to the system; that is, causing a reaction of an unfavorable
character?
Dr. Jaffe. I am not sure that we have such a drug, nor am I really
certain that it would be useful. It would be interestmg if we had one,
but you see, they do have something comparable to that in alcoholism
with Antibus. and the results have not been overly dramatic. If the
revulsion reaction is severe enough it may be endangering somebody's
life and you have an ethical question.
The antagonists have the advantage that you can perhaps persuade
somebody to become involved with the antagonists, because it will not
hurt him if he takes a narcotic. It merely blocks the effect.
Obviously, what it does not do is in any way allay this kind of
narcotic hunger, this craving that some addicts seem to feol when
they are not actively using or during the first year or so after they
stop taking narcotics.
I want to get back to your question about naloxone and cvclazocine.
Cyclazocine I think we have explored. It is a difficult drug to use. It
220
is not a very forgiving drug. Its side effects require that the treaters
have a considerable degree of skill. It still lasts only 24 hours. Given
the effort required and given the level of patient acceptance, I don't
think cyclazocine is a drug that in its present form we can hope to
see widely employed.
Naloxone is a very promising substance, theoretically, in that it has
no side effects at all. For most people it is entirely inert. The problem
is that it is not very effective orally and it is short acting. Its cost is
such that even if you wanted to take it every day in huge quantities, it
would probably cost as much as the heroin habit that you are trying
to treat. Therefore, naloxone in its present dosage form, to me, is not
a very useful or a hopeful approach. ■ r ■
I might say that our hope lies with the entire family of narcotics
antagonists, and there are literally dozens that could be investigated,
one of which I am sure will be extremely potent, orally effective, and
have minimal side effects.
If that then proves to be promising it could be converted into some
kind of dosage form that might be effective for at least several days
or weeks.
This is a matter of product development. I am sure it can be done if
people are willing to put the effort into it.
Chairman Pepper. And the money.
Do you think it would be in the public interest for the Federal Gov-
ernment to expand its research funds to encourage the appropriate
people to develop those leads that you are talking about ?
o Dr. Jaite. I think if we do not look into them we will be remiss.
Chairman Pepper. Mr. Blommer, do you have any questions ?
Mr. Blommer. Thank you, Mr. Chairman.
Doctor, I believe Dr. Dole of New York has said he believes that
about 25 percent of the heroin addicts in New York would benefit from
methadone maintenance. I wonder if you could comment on that state-
ment and tell the committee what type of heroin addict you believe
should be put into a methadone-maintenance-type of program ?
Dr. Jaffe. Well, I will comment first on the 25 percent. I don't know
how Dr. Dole obtained his figure, but we came out with almost the
same figure, based on a very empirical 2-year study of heroin users in
the Chicago area. ^
In other words, we admitted everybody who came. If you came to
the door, you were admitted. We thought, based on epidemicologic
studies in the commounity, that about half of known active narcotics
users would seek treatment, and, of those, over tlie long run about lialf
would obtain substantial benefits. So half of half is 25 percent. This
is based on or data of several years and several thousand patients.
What kind of patient would benefit is much more difficult to answer:,
because it is very hard to predict. ^ - '
Mr. Wiggins. I^et me interrupt, because I want to get somethilig^^^
my mind. > i ■ m
Dr. Jaffe. Yes, sir.
Mr. Wiggins. Would you say that any person who is inclined to
take heroin would be better off taking methadone instead of heroin ?
Dr. Jaffe. I am not sure what you have in mind when j-ou say any
person inclined to take heroin.
22l
"''Mr. Wiggins. A lot of people are inclined to take heroin for very
poor reasons, but they do it, nevertheless. Is methadone better than
heroin t
Dr. Jaffe. Well, oral methadone is a lot safer than heroin bought
from a pusher on the street without any question. If I had someone
absolutely committed to finding out how a narcotic drug felt and
you presented me only two alternatives, either they wanted to buy
some heroin on the street, cook it, or take a swallow of oral methadone,
I think the answer would be obvious. They would be a lot better off
and safer taking methadone. But I don't know if that is what you
are driving at. .
Mr. Raxgel. Let me ask this : Would your answer be the same it
the heroin was being taken orally, notwithstanding the difference m
reaction?
Dr. Jaffe. No; if these were known dosages of heroin and metha-
done, both taken orally, I don't think that it really makes much ciiffer-
ence at all.
Mr. RaXgel. Would it make much of a difference if the methadone
were injected?
Dr. Jaffe. Oh, yes. Injectable narcotics produce some very rein-
forcing effects in the sense that you can do research on animals and
you can show that animals, given an opportunity to inject _ intra-
venously any one of the narcotics, learn very quickly to keep injecting
those drugs.
Mr. Waldie. Doctor, may I interrupt you at this moment ?
In response to Mr. Wiggins and Mr. Rangel's question, I under-
stood you to say that if you had the same control over heroin in terms
of quantity and the manner in which it is administered as you have
over methadone, the man taking heroin would be ill no better or worse
position than the man taking methadone ?
Dr. Jaffe. No. The question was in response to a single dose.
Further, j'ou are talking about chronic administration.
Mr. Waldie. Let me phrase the question this way, then : There is a
concern among some people, and I share it, that we are substituting
one addictive drug for another. Is there some advantage to that sub-
stitution, to substitute methadone for heroin, other than the advan-
tages that you have stated, that there might be an infection because of
the intravenous injection and there might be adverse effects because
of the impurity of the heroin ?
Dr. Jaffe. Oh, yes. .
):Mr. Waldie. Are there other results that are beneficial for use of
methadone rather than heroin ?
Dr. Jaffe. In our present context, without a,nj question. There are
two; ■'' ■ '
First of all, the oral absorption of heroin is somewhat erratic. Fur-
thermore, the drug— and I am not sure this has been studied in de-
tail— is probably not even in significant quantity going to have smooth
duration of action if you were to give it once a day under observation.
: 1 mean, if you were still in the position of looki'^o- for something
which lasts 24 hours, of letting peonle take it home for their own use.
As soon as you begin letting people take it home to]H,have trouble
with illicit diversion and accidental ingestion. ■■'
"ff ! y rfCMJoefiii Y< •: ;o ii.Mcj v.-'I'.
222
Furthermore, in our present context we are deeply concerned about
tlie intravenous use of illicit heroin. The use of methadone provides
one very pragmatic possibility of knowing when patients continue to
use illicit heroin. In our program, patients on methadone have their
urine tested. We know a patient is taking heroin in addition to metha-
done. If we weren't giving them methadone — but were giving them
oral heroin — we would have no way of knowing whether they continue
to take intravenous illicit heroin.
Mr. Waldie. Let me ask one question. Are the results on the indi-
vidual of taking methadone less debilitating than the results on the
individual of taking heroin ?
Dr. Jaffe. Let me try to state this as precisely as I can.
Mr. Wiggins. That is a clinical setting, right ?
Mr. Waldie. Eight.
Dr. Jaffe. No one. to my knowledge, has done adequate, careful,
controlled studies of large doses of oral heroin. So we are always
forced to compare the British experience with self -administered in-
travenous heroin with our own experience of regular administration
of oral methadone.
So the two situations are not comparable.
To the best of our knowledge, intravenous heroin is not a good drug
sociologically or psychologically, because the ups and downs of a
short-acting drug get people going from a "high" to a little bit "sick"
and then they want to be high again. It is not a drug permitting easy
stabilization and functioning — the stabilization of the kind that lets
citi7:ens take care of business.
Methadone does permit that when used orally.
Mr. Brasco. May I ask one question ? You sort of confused me as to
what was said, at least as I understood it, by Dr. Gearing yesterday
when we spoke about taking heroin orally.
If I understand correctly. Dr. Gearing said there would be no effect.
Exactly what is the effect of taking heroin orally ?
Dr. Jaffe. Taking heroin orally ?
Mr. Brasco. Yes ; has it the same effect that you get when you use
it intravenously ?
Dr. Jatte. No.
' Mr. Brasco. What effect does it have ?
Dr. Jaffe. Well, the effect you get when you take a drug intraven-
ously, a very short onset of action.
Mr. Brasco. No ; I am talking about taking heroin orally.
Dr. Jaffe. Heroin was given orally. It was used in this country until
about 5 or 10 years ago when we ran out of old stocks for cough
medicine.
Mr. Brasco. I understood her to say — and maybe I am laboring
under a misapprehension — that if you take it orally there was basically
no effect.
Dr. Jaffe. From oral heroin ?
INIr. Brasco. Right ; as opposed to taking the methadone orally, you
would have the stabilizing effect and it would prevent the cra\nng for
the heroin. "When you take the heroin orally, I got the impression that
you were sort of in the same position as not having taken it.
Dr. Jaffe. Well, I think you are asking two different questions. One
is: Is heroin as effective a drug taken orally as by injection? The
223
answer is that its oral to parental ratio is not as high, meaning that
it takes a lot of heroin orally to give you a blood level so that you
get an effect. That is also true of morphine. It is also true of many
of tlie standard narcotics tliat we use in medicine.
If somebody really has pain, you would have to give them a shot
of a drug like morphine. Methadone is one of the few drugs in the
narcotic analgesic group that has a good oral potency, meaning that
you don't have to give a tremendous amount of it by mouth to have
an effect.
Mr. Brasco. As a practical matter, what would one take heroin
orally for?
Dr. Jaffe. The same way you take codeine, you give a little
Mr. Brasco. We are talking about people addicted to drugs.
Dr. Jaffe. Nobody would ever take lieroin orally if they were ad-
dicted. It is too inefficient. People sniff it, some people smoke it, but
probably nobody would swallow it, simply because it is not efficient.
The body metabolizes it before it gets a chance to be active.
Chairman Pepper. Mr. Waldie, have you any questions?
Mr. Waldie. Just one question. Dr. Jaffe. If the Federal Government
were to participate in some way in this whole problem with which
you have been involved, would you discuss, No. 1, the areas in which
you think our participation would be most beneficial ; and No. 2, would
you believe in terms of priorities of expenditure, which would be the
nature of our participation, that there is one portion of this program
that is more deserving of expenditure than other portions? Could
you comment on those two areas ?
, . Dr. Jaffe. WTiich program are you referring to ?
Mr. Waldie. I don't know. I want you to tell me. I want to to tell
me what the Federal Government, in your view, should interest them-
selves in most in terms of priority or expenditures.
Dr. Jaffe. Well, in the entire area you could divide it into things
like direct support of treatment, development of research directed
toward the development of treatment and control systems, direct con-
trol of drug availability and training ; training both for research and
treatment.
Now, obviously there are some areas that you could say need priority.
Our experience has been that patients who are chronic heroin users
who want treatment with methadone should be given that treatment,
because it is better for them and everybody in the community, and
therefore that should be a high priority for the Federal Government
to see that the funds are there to provide sensible, rational treatment.
Now, if there are other treatment areas that can be demonstrated to
be effective for those people for whom we will say methadone is not
effective, such as young polydrug users who have not been on drugs
very long, people who just don't want to be on methadone, people
who want to come off methadone. In our experience many, many peo-
ple feel they have had their lives stabilized, they would like to come
off. Such treatments should be provided or developed if they do not
now exist. That should be done and the Federal Government should
see that they provide that.
There are some problems in communities. I cannot speak officially
for any State or community, but I do know there are certain obliga-
tory expenditures they cannot get out of. I read in the paper that wlien
224
the Federal Government decides it -svill not support welfare or some-
tliin^ else, the State must do that, and therefore it can only trim op-
tional kinds of things, mental health, treatment of addiction, and
education.
So that the Federal Government has to realize that as it shifts its
priorities, the States are in a reciprocal relationship. Communities
also set priorities and traditionally these treatment programs have
been viewed as optional; that is, it is optional rather than legally
required that there will be narcotic treatment programs.
Mr. Waldie. One final question. Doctor.
Do we have enough experience yet to knoAv whether it is more
difficult, at first, to an indi^ndual in setting off of methadone addiction
thn n heroin addiction, for example ?
Dr. Jaffe. The withdrawal syndrome from heroin, given the doses
that most people use in the street, is pretty much a thing that is over in
a matter of a few days. The difference is that the relapse rate is phe-
nomenally high. Certainly people who withdraw from methadone are
complaininir mildly, but somewhat longer. It is dragged out. ovqi: a
period of weeks or so. ?fj', .;:i(f,v. // .'ija
Howei^er. our experience has been when you stabilize someone on
methadone and he has gotten to the point where he has a job and is
back with his family, and thei-e are a number of social supports, and
he has been accepted by the community as a responsible citizen he
may have a tougher time when he withdraws from methadone in the
sense that it is sort of a dragged-out situation, but the probabilties
of being; able to remain stable may be slightly higher.
I don't think enough work has been done as yet with trying to take
people off methadone to try to answer that question in any definitive
wav; It is one of the research areas tliat will deserve attention.
Mr. Waldie. Thank you.
'Chairman Pepper. Mr. Wiggins.
Mr. WiGGT^rs. Doctor, I want to commence vHth a hypothetical
question. Let us suppose, hypothetically, that methadone were totally
substitued in our drug culture foi' heroin, but that it was used in exactly
the same way, the shooting of it, using dirty needles, cutting of it.
using impurities ond other things, let's suppose it happened that there
was a total substitution in, that war for heroin: would we be better
off or worse off? ^f^^^V- '''' ''^'''"■'' '" '' '■' '/^"'- ''■''^[^ '[■■■'"'.
^ Dr. JAffe. '"N'o; the advantages of methadone are not nearly as
pharmacologibally — —
Mr. Wiggins. Just respond to that question, better off or worse off?
Dr. Jaf*t.. We %oiild be no better off. T don't think we would be any
worse off. It is hard to picture a situatioh niuch woi'se off.
The advantage of the present situation is as mnch in the system by
which the methadone is controlled — its supervision — as in its "pharma-
cological differences. ^ ^^ .oifohKO loi.t !.■ oi,i v- -; ^."
INIr. Wiggins. I tliink it is an important question, because conceiv-
ably we could end up in that position. T would think there is a ])ossi-
bility we might be better oft'. At least the narcotic would be produced
by local manufacturers who would be subject to somewhat more con-
trol than Turkish farmers. Perhaps the Mafia or some other organized
criminal activity would not be so intimately involved in its distribu-
tion. These may not be insignificant advantages.
99;
zo
Dr. Jaffe. I would say that I can't conceive of a situation, in know-
ing what we laiow, where we would permit the situation to deterior-
ate to the point that methadone would be that readily available for
intravenous use. M'^-rr^ n >■•■■.
Mr. WiGGixs. Many of us have harbored the suspicions, at least,
that metliadone programs proceeded from the assumption that the
only way to take crime out of a drug business is to make the drug
available to addicts at a reasonable cost and to maintain their habits.
For many reasons, however, some of which Avere political, we just
couldn't bear to provide them heroin as did the British, so we came up
with a substitute called methadone; is there any truth in that
suspicion? .4^ Y^nr\y . f/ri')
Dr. Jaffe. I thnik that is an oversimplification that misses many
of the critical distinctions between methadone and heroin.
First of all, the pharmacology of this drug is such, as I pointed out
before, that you can get somebody psychologically stabilized and the
contrast between a fairly stabilized individual taking an oral medicine
which has very few peaks or valleys, and somebody taking a drug,
short-acting or intravenous, going up and down several times a day,
is dramatic. People on this smooth-acting drug can function iai terms
of devoting their energies to productive activity. ; . . >
People going up and down, taking intravenous doses, really do not
function Avell. ■<{ -t\':->
J Second, we can supervise a long-acting eilective oral drug, meaning
that if we want tQ, and if we feel it absolutely necessary, we can pre-
vent methadone from being on the street. Very often, frankly, at much
too ^reat a cost to the rehabilitated patient.
Mr. Wiggins. I would like to know your views on how we can pre-
vent methadone from being easily available on the stree^; subject to
being shotup, cut, sold at a profit just like heroin. ^
Dr. Jaffe. Well, No. 1, the dosage form of methadone could be so
uniform you can dissolve it in fruit juice and it is very hard to extract
,and to in any way dilute it and shoot it.
Mr. Wiggins. Say that again. Is it difficult to shoot it ? 5
Dr. Jaffe. H you dissolve methadone in 4 ounces of orange juice
and then try to concentrate it so that you can get it into a syringe, you
get a gummy, sticky mass. There is nothing you can do with it. That is
the original way it was developed, and many of the original programs
went to great pains to see that this was done.
Second — and I must say that as the volume of patient j.oad increases
it is becoming difficult to do this, and it may be a matter of funding
and other things — initially every new patient came to a clinic once a
day. He drank the methadone under supervision. The only medicine
on the street was in his belly. There was no medicine to sell or illicitly
distribute. Theoretically, only the most stabilized patients are given
the privilege of taking methadone home with them.
Mr. Wiggins. But the fact is that methadone is on the street.
Dr. Jaffe. I can't conceive of a situation where you get uniform
adherence to a set of regulations, no matter how sensible they may be.
You always have practitioners who won't adhere even to a very sensi-
ble, rational set of regulations; and you always have a very, small
minority of patients who are mavericks^ who don't have a sense of
responsibility.
I have presented one generic kind of solution to this problem. The
generic solution is a longer acting substance. If you had a methadone
that only had to be given three times a week, people for a while will
come three times a week, and there is no drug on the street — none,
zero.
Now, we have one such drug
Mr. Wiggins. Excuse me.
I take it that a private physician could nevertheless order from a
pharmaceutical house a case of methadone and dispense it subject only
to his personal medical judgment on the need for it; is that risrht?
Dr. Jaffe. No ; I would say there is some vagueness under the Fed-
eral regulations. Most States are able to delineate the difference be-
tween treating a temporary syndrome — such as somebody waiting to
go into treatment, or treating someone with a chronic painful illness —
and maintaining a narcotics user on methadone with greater precision.
Therefore, a physician would be in violation of State laws in most
States.
Mr. Wiggins. What controls operate on a private physician other
than his own judgment in dispensing of methadone ?
Dr. Jaffe. Well, in our State we have defined the chronic treatment
of addiction with narcotic drugs as not yet an established routine medi-
cal procedure. So that in a sense it is acceptable as medical treatment
only in programs approved by the department of mental health. If
that physician does not seek such approval and adhere to a protocol,
he may be subject to prosecution under our uniform drug law.
Now, it may be that he could fight that successfully. We don't know.
But — -
Mr. Wiggins. First of all, is this a matter of State regulation?
Dr. Jaffe. Yes.
IVIr. Wiggins. And, therefore, there may be 50 different sets of regu-
lations in the country ?
Dr. Jaffe. That might be the case. That is for 50 or so.
ISIr. Wiggins. Is there any legal prohibition against a doctor who is
so inclined from purchasing great quantities of methadone?
Dr. Jaffe. Not to the best of my knowledge.
Mr. Wiggins. If that doctor were so inclined, what legal prohibitions
preventing him from dispensing it at his front door or back door ?
Dr. Jaffe. I suppose the only prohibition would be his concern that
a promising medical career at which he earns a reasonable living could
be permanently terminated by successful prosecution under a felony
charge of illicitly selling narcotics.
Mr. AViggins. Is it a defense, so far as you know, to that charge that
the doctor believes in the exercise of his professional judgment that
the person before him was an addict and who would profit from the use
of methadone ?
Dr. Jaffe. It would be a defense, I suppose, onlj'^ if a substantial
number of his professional colleagues in that community stood up
and said this is the good i)ractice of the community and it is in the best
interests of tlie patient aiid comnumity. Tlie cluinces might be he
would be convicted of a felony.
Mr. Wiggins. Given the situation as you described it, are you satis-
fied that is an adequate control ?
227
Dr. Jaffe. I think that more work has to be done in delineating- the
conditions under which these drugs can be used for the treatment of
addiction. ,. . p xxtt^ • -•
I am not satisfied with our current apphcation ot a l^D, nivesti-
gational drug. . ,
On the other hand, I have no pat solution for the best way in wnich
our health care delivery system can become involved in delivering
the services to the advantage of the patient and the community.
I mean, we have to protect both, and we have to serve both. I think
more work has to be done on it. I am not satisfied with our present
controls, nor would I want to see us return to a purely repressionary
police state during which no physician would ever let an addict inta
his office for fear he might be some kind of local police informant,
and that if he treated him in any way he might be prosecuted.
That was an era of sheer terror for physicians, and the mere fact
somebody might be an addict was sufficient reason for them to pick up
the phone and call the police and say get this whatever-it-is out of my
office.
Mr. WiGGixs. As I recall it, when they operated under a system
of private dispensing of heroin the abuses were so widespread that the
only way to control it was to confuie it to a clinical setting.
Dr. Jaffe. Well, I have no personal knowledge of what went on. I
read the reports. I know the details. I am not sure that you w^U get
a consensus on what really went on.
It is obvious that there is no way of dispensing or prescribing short-
acting drugs without lisking significant illicit diversion. We have said
the best clinics under the best controls, trying to dispense heroin,
would open themselves up to illicit diversion, that you need a long-
acting drug that you can supervise and preferably one that can only
be used orally. We have such pharmacological substances available. It
has to be realized that methadone wasn't even known to be an effec-
tive narcotic drug until the late 1940's, in this country.
I mean, some of the pharmacological knowledge that we are talking
about never existed in the 1920's when they tried these clinics. So tliat
one couldn't even experiment with the possibility of a carefully regu-
lated controlled system of treating those people who are willing to be
treated in this way. I think that we are now in a different technologi-
cal ball park. We have to stop harking back to old days, when we used
old technology and look at what we can do now, what our potentials
are and what is the best way to strike the best balance in treatment
and still, at the same time, protect the community from widespread
illicit diversion of the drugs we are using for treatment.
Chairman Pepper. Mr. Brasco, do you have any questions ?
Mr. Brasco. Yes; I wanted to ask Dr. Jaffe: In connection with
the methadone program, would there be any great difficulty, given the
fact that there is agreement over the danger of abusing the use of
methadone in the street, why is it not possible, at least from the point
of view of stopping those who are in treatment from proliferating
use in the street, having users report once a day to take the methadone
at the clinic so we know we can stop that kind of abuse ?
Dr. Jaffe. I think it is a fine question. It has been raised a number
of times.
228
The answer tends to be a very practical one, which is that for the
first 3 or 4 months you do insist that somebody come every day.
But if you are successful, if he begins to view himself as a produc-
tive citizen, if he now has a job and he has to get to that job on time
and come back, and your clinic doesn't happen to be either near his
horne or near his job, you are asking him to somehow get to your
clinic once each day. It may be very difficult for you to keep the clinic
open long enough for him to get there every day. It may be, for ex-
ample, impossible to get nurses to work in certain communities after
sundown.
Mr. Brasco. It becomes a problem of logistics ?
Dr. Jaffe. Primarily a problem of logistics. It also becomes a prob-
lem of self-image. We have had people in treatment for 3 years, work-
ing every day, earning retirement benefits. They haven't used any
drugs and they are still wondering why everybody else is trusted with
phenobarbital for epilepsy, and other people are trusted with all kinds
of drugs. ■,.,.,,,
Mr. Brasco. Then j^ou are saying it has a definite effect in the re-
habilitation program if the program doesn't give that basic show of
trust?
Dr. Jaffe. I think for many people that is the case. But I am nqt
willing to push the logistics aside, because logistics happen to be para-
mouiit in a place lilje-I^os Angeles, which has virtually no public
transportation system. You are, in effect, saying, "We want you to get
rehabilitated, but so rehabilitated you can have a .(?ar to get to the
, clinic every day."
Chicago has its own transportation problems, as every urban area
does. They just can't afl^ord to come to the clinic every day.
Mr. Brasco. Doctor, one other thing now. ajio tjoy 1riIi s/nb snil- n
In connection with that, then, and I don't knowTf you have .aaiy
statistical information on it, but wliat is your experience for the po-
ten<:iality of abuse of allowing the methadone to get out on the street
illicitly, coming through those in treatment ?
; ,. , Dr. Jaffe. It is minimal, butifc.is'riot zero.
Mr. Brasco. Right. : (^ :• < ,■ ,
Dr. Jaffe. I want to emphasize that anybody who is riealistic knows
that we are not treating a group of Boy Scouts.
Mr. Brasco. So what you are saying is it is a tolerable risk ?
Dr. Jaffe. Let's ask what we are trading that risk in for. Tliet's'say
5 percent of people leak their methadone. Primarily 85 to 90 percent
of that leaked methadone is going into the people who are currently
using heroin. l
So, frnidamentally, the methadone will remain in competition with
the illicit heroin market for the time being, and that really doesn't
represent a major social catastrophe at this points' yiv^.r ■?.':( »,7
Mr. Brasco. You said something before that was interesting to me.
You said that when they dispense or when you dispense methadone
you use it in — or mixed with — orange juice. r -^iii ^
Dr. Jaffe. Fruit juice. ''rnui m '■y<\>
Mr. Brasco. And that it is most difficult to conctotrate,-tilaiat yoit get
a gummy substance ? > ■•■<,j. ■■>'
Dr. Jaffe. That is true. ■ ^ o
229
Mr. Brasco. Then for those who are shooting, what are they doing,
using the mixture of the juice with that or some other form of metha-
done which is dispensed, such as pills ?
;Dr. Jaffe. That is a fundamental point. Not everybody is as con-
cerned about this issue as we are, and therefore some people are using
different forms of methadone tablets, methadone diskets, which may,
in fact, at least in their presently constituted form, be so constructed
that it is possible to create an injectable form from jt. We knoM' that
when once dissolved in fruit juice of various kinds, it becomes impos-
sible to extract methadone with ordinary techniques.
Mr. Brasco. So then as a starter, if we got to the point where metha-
done was only dispensed with fruit juice, as you were talking about,
and I assume both are equally effective, then we would be taking a long
step in the right direction in terras of having abuse of it reduced?
Dr. Jaffe. May I make one comment? Let us avoid rigidity. It is
always the exception that makes life difficult. We have a patient who,
after Avorking for 2 years, wanted to visit his wife's family in
Europe. I would trust him with my life. I know him very well and his.
family and his wife. '^' ' ' '
If we gave him 21 bottles of juice — he is going for 3 weeks — No. 1,
it would spoil ; and No. 2, what do you think customs would say about
these 21 bottles of juice ? You tether him to a clinic. There has to be
some form used for the exceptional case, and 21 little tablets that would
handle the situation, make it possible for him to function as a human
being in the exceptional situation.
Mr. Brasco. Assuming that all of them are not going to Europe, and
I take thatto be a fact oini nni m
Dr. Jaffe. That is true for the overwhelmiilg majority.
Mr. Brasco (continuing). So that we still would be taking a long
step in the right direction wdth this little aside that you have in terms
of possible exceptions cropping up ? ^^''t^ -f '* ' ^■■' ' '
Dr. Jaffe. Eight. I am not unaware this is a legislative group. So I
am saying I want to avoid seeing thmgs couched in such language
that an exception automatically becomes a crime, because as soon as
you do that you really reduce the possibility of effective treatment.
Mr. Brasco. No ; I wasn't talking about that. I was trying to define
an area where we might recommend something.
Dr. Jaffe. With strong recommendation for the exceptional cases
it would be very helpful and would certainly reduce some of the
present problems.
Mr. Brasco. Just one last question.
"VVTien you use methadone intravenously, do you have the same expe-
rience in terms of it becoming a short-lasting kind of effect as with
heroin ?
By that I mean if you start to shoot it, would you have to use it
several times a day ?
Dr. Jaffe. To the best of our knowledge. It is a little longer acting,
but you certainly would have to use it several times a day. In practice,
people who use methadone could use it several times a day.
Mr. Brasco. Thank you. I have nothing else.
Chairman Pepper. Mr. Steiger.
Mr. Steiger. Thank you, Mr. Chairman.
230
I realize we are running late.
Doctor, I assume you have personally interviewed a good many of
these l.noo patients.
Dr. Jaffjl In the beginning I had enough time to see a lot of them
personally. I must say as the program grows I become progressively
more insulated from the direct patient care.
Mr. Steiger. Do you have any experience with a methadone addict
^ho reported into the program
Dr. J.\FFE. Using methadone?
Mr. Steiger. Yes. sir ; a man addicted to methadone?
Dr. Jaffe. Yes, certainly.
Mr. Steiger. "Were you able to ascertain how he became involved
with methadone or how he acquired it ?
Dr. Jaffe. Well, some of them buy it illicitly on the street. Where
they get it is not clear, but obviously some people have, as they have
for many years, come to doctors with stories of chronic pain, with
things that would justify the prescription of oral methadone'.
Furthermore, once in a while, before we had a program, there were
physicians who, I think in all good conscience, knew somebody who
was working and functioning and the alternatives were lieroin or
methadone. The physician would say, "I understand you are trying
to get into a program,'' and for a few months he would prescribe this
medication. He would call us up and say that this man was on metha-
done for several months, and say, "I have been prescribing for him,
this is the dose, and the sooner you take him into the program' the
better off we will all feel."
Mr. Steiger. Did you run into any heroin addicts who had beeir
acquiring a regular source of methadone from a licensed physician,
and because of either the death of a physician or his stopping, re-
ported into the program ?
Dr. Jaffe. Oh, that is not uncommon.
Mr. Steiger. I am not as concerned as my colleagues are that the
responsible clinics are going to leak a sufficient volume of methadone
to create a new hazard. I am very concerned that there are physicians,
regardless of their motives, who are continuing to prescribe methadone
and/or heroin. I wonder from your experience, again on the basis
of interviews, if you feel there would be any merit in legislatively
limiting the dispensing of methadone and heroin to licensed clinics
and thereby making an absolute prohibition against the private physi-
cian dispensing it ?
Dr. Jaffe. Well, first of all, there isn't any hei'oin ever dispensed
or prescribed. There is none in this country. It has been outlawed.
There was a little bit of stock in Philadelphia for a few years after it
was outlawed, but there is none at the present time.
I am generally opposed to any absolute legal prescription of some-
thing, because then you I'un into a situation where you ha^•e done
what you set out to do, you have rehabilitated former heroin users and
they are offered a job in some community where there is no clinic.
He can't accept that job, and he can't in effect, change his life style
and start all over again.. Under appropriate conditions, if there were
no absolute medical prescriptions, he might be able to make a private
231
arrangement with tlie physician who would handle this problem on an
individual basis in a carefully regulated way.^
Without that possibility this man is limited to any area that has
a clinic and largely these clinics arc limited to the large urban areas
that can sustain a clinic of a hundred or so people.
Mr. Stetger. But isn't it conceivable that we could extent the au-
thority to permit the clinic to approve the physician for that specific
patient '?
Dr. Jaffe. That becomes another issue. In other words, what you are
saying is that no physican unaffiliated with an approved program
would be permitted to prescribe methadone for addicts.
Mr. Steiger. Based on your experience, in terms of volume of il-
licit methadone, isn't there a far greater propensity for the private
physican to be the source of the illicit methadone than there is for
the clinic, the approved clinic ?
Dr. Jaffe. Well, I think in terms of the ratio of patients treated and
the amount they let leak on the street. I would say that may be true.
Obviously, in terms of absolute numbers, a program treating 1,600
people will be responsible for more leakage than any one physician
treating a few patients.
In other words, if he is only treating five or six people,
a single physician probably will not have as much leakage as a
j)rogram treating 2,000.
Mr. Steiger. If those five or six people are dealers, themselves ?
Dr. Jaffe. Well, the physician would have to be rather naive.
Mr. Steiger. How about dishonest? How about the dishonest
physician?
Dr. Jaffe. Dishonest physicians should be treated like any other
dishonest individual?
Mr. Steiger. But right now he is not violating anything?
Dr. Jaffe. As I said before, I think we have to think through our
regulatory procedures so that the dishonest physician is treated for
what he is. He is a pusher, operating under cover of his medical
license.
Mr. Steiger. Eight now, except for whatever State regulation may
exist, he would not be in violation, as Mr. Wiggins pointed out, he
could appeal to his medical judgment and say this, in my best judg-
ment, was what this particular patient needed, even if it obviously
wasn't ?
Dr. Jaffe. Well, I certainly think we have to think through how we
will control the dishonest physician, there is no (question about that.
Mr. Steiger. Would you agree there is a question of the dishonest
physician who could be a source of methadone ?
Dr. Jaffe. How could one deny it ?
Chairman Pepper. Mr. Mann.
Mr. Mann. No questions.
Chairman Pepper. Mr. Winn.
Mr. Winn. Two quick questions, Mr. Chairman.
Doctor, I missed the first part of your testimony. Are any of your
cases ambulatory when they come to you ?
Dr. Jaffe. All of our cases are ambulatory when they come to us.
232
' ']Vir. Winn. Tiien you mentioned, I gatiiered, tlios'e that are now on
methadone?
Dr. Jaffe. People who are in a residential setting can be on metha-
done or withdraw from methadone in the same facility. We have no
difficulty with that.
Mr. WINN. I missed the point. I thought you said these were not
people under hospital care.
Dr. Jaffe. No ; because it is not a hospital. It is a residential setting,
staffed, but we don't have round-thc-cloclt nurses or elaborate medical
equipment. This is one way of reducing the cost. We don't have, in a
residential setting of relatively healthy people, a little buzzer you press
and have three people running with an emergency cart.
Mr. Winn. After 3 days they can go home ?
Dr. Jaffe. In an emergency setting ?
Mr. Winn. Yes.
Dr. Jaffe. No ; they might live there about 3 or 4 or 5 weeks, trying
to straighten their lives out.
Mr. Winn. They come fropi all over the country, outside the com-
munity you serve ?' '"'''^ ®«^' ■^'"' ' .... 'T''^
Dr. Jaffe. Yes. We only have four or five residential facilities in
the State.
Mr. Winn. All right. Are these black or white, or both ?
Dr. Jaffe. We have all integrated facilities.
Mr. Winn. Thank youJ ''■ ■^' '
Chairman Pepper. Mr. Murphy.
Mr. Murphy. Doctor, I just returned from an around-the-world trip
with Congressman Steele from Connecticut, and the purpose of the
trip was to impress upon these countries that are engaged in opium
growing to curtail their production, and in fact eliminate it.
One distressing point we came across in Southeast Asia is that the
type of heroin that our troops are becoming addicted to is of a puritj^
of 94-97 percent. In fact, they don't even have to mainline it, they are
snorting it and thev are smoking it.
My question to you. Doctor, is : If this is compared to a 6 or 7 per-
cent purity injection of the United States, what is the outlook or the
prognosis for those fellows when they come back to the States. Would
you just have to increase your intensity using the methadone treatment ?
Dr. Jaffe. No; eventually you can stabilize people on moderate
doses. The doses of methadone that are normally used for the heroin
users that we now have, Avill be adequate to handle people who start
off using even pure quantities of heroin. Their habits aren't that great
and they can be brought down to a stabilization level with very little
difficulty.
I don't anticipate the need for modifying dosages in any way, if one
decides that is the best way to treat a young Vietnam veteran who has
never had any other treatment. I don't mean to imply that would be
the routine or immediate response to finding out that a veteran has
used heroin in Vietnam. It may be that you use this approach only
when other things have failed. This is still to be determined.
Mr. Murphy. Tliank you.
Cliairman Pepper. Mr. Sandman.
233
Mr. SANDMAxlTf ari'AcTcIi'ct had the choice'b'efween herein aii'dmetha-
'done — I gather there isn't any choice — he would choose heroin ?
Dr. Jaffe. Intra venbus heroin versus oral methadone ? I think most
addicts TTOuld do so : yelsi''^'" v,oii -.
Mr. Saxdmax. From whfft you say, methadone is used on some one
ah-eady addicted to heroin? '
Dr. Jaffe. That is how we lise it ;' yes.
Mr. Saxdiiax. Have you had any experience where you have liad
some people come in who are addicted only to methadone?
Dr. Jaffe. People' wlio ha,ve neyer used any other drug ? Yes ; a few
such cases. ia.3.^3 li^noij^y
Mr. Sa^'dmax. But they are rare ? ^^ •'; ^-^;- \/''', ,
. Dr. JxVFFE. In this country. They are not so rare in' EnglkiYd' where
people are beginning to prescribe, methadone tliat can be used
mtravenously. fe^v, ^h.oc. odi .n i
Mr. Wixx. Is it accurate for me to assume from your testimony that
in the absence of some other way or some other drug you feel metha-
done is serving its purpose in allowing the heroin addict to at least be
able to ciirry but his responsibilities of life: is tlikt j'bur position?
, I)r.„jAFFE. That .is (Sur primary position. It allows many of them
to function, but' we are hot prefeentilig' it as a panacea. Once you get
everybody who can be effectively treatfed with methadone, treated and
functioning, you will still need other programs for' those people who
have not "made it" with metha;dbne oi- whb are still not interested in
methadone. , , rf . j • . , '"".',]
. Mr. Wixx'tou 'm hot' Hlaimlhg'W is^^^ehd^ :^6s^t,:I understand,
^ut'in the absence bf somethiiig better you feel it'isf- '^" :""''*" ^I'' ^'^■'
"' Dr. Jaffe. I have made the pohit and I thiiik it 'should be available
to all those people who woi;ld like to.give it a try and who qualify
for it.' ' ' ''■ '' ■' ' ' "'■ ■ ■■ ■/' ■; ,,' "
'' Chairman Pepper, Mr. Rangel. ■Pif/Oi'-
f . Mr. Raxgel. Yes. ^ .,l,fr. ■ r. a ^ \
Doctor, about the 1,G0() hafcotics users, you[py "ifneT ai^e- integrated,
or were vou talking about staff' ? , ■ ■ •;
;., Dr. Jaffe. Staff , too.
^ Mr. Raxgel. Well, with the users, what would you consider the
ethnic breakdown of your State's program, in the patients?
Dr. Jaffe. Well, I haven't looked at it for several weeks. It was, for
the first couple of years, about 72 percent black. A small percentage are
Puerto Ricans, Mexican Americans, and the rest white.
Mr. Raxgel. Considering this ethnic breakdown and considering
the population of your State, this sampling reveals an overwhelmingly
high minority breakdown. Using minority as it is generally used,
this is an extremely high minority figure ; is it not ?
Dr. Jaffe, I think that might be misleading. Our program, as I said,
be^gan as a pilot program. We were going to diagnose the community.
We were not going to start treating the entire community or State,
The question was: AVhere shall we put our initial facilities"? The deci-
sion was made to locate this around the University of Chicago, where
the University of Chicago could lend its iDrainpower to the
development.
60-296 — 71 — pt. 1 16
234
So having put it in the area, having made our facilities immediately
available in a geographic area where 85 percent of the population is
black, it is not surprising that we had an overrepresentation for the
program as a whole. They had the most immediate access. They were
given first priority because they were there.
It wasn't until a year and a half later that we had the first treatment
facility on the northside of Chicago where Caucasians, Puerto Kicans,
and Mexican Americans could find it equally accessible.
Mr. Raxgel. But if you were to project not only your State's but the
Nation's methadone treatment programs, would not that same ethnic
breakdown be bound to exist on a national basis ?
Dr. Jaffe. It would be very hard for me to really project it nation-
ally. I would guess that in most of the large urban areas of the East
and perhaps the Midwest there would be an overrepresentation of
black patients. However, in the Southwest it would be Mexican
Americans.
Mr. Ranoel. But they would be people in the lower economic level
of American life ; wouldn't they ?
Dr. Jaffe. I think until very recently heroin addiction was primar-
ily a problem of the lower socioeconomic groups.
Mr. Rangel. Now, with all of your priorities in terms of where Fed-
eral money should be spent, I think you listed research and training.
Do you not think that perhaps the causes and the reasons why a partic-
ular economic group is prone to become addicted to drugs should not
be one of the priorities ?
Dr. Jaffe. That was assumed under research. I talked about research
into epidemiology, into what is responsible for the epidemics, what is
the natural history of these things, and how to respond to these to
epidemics.
Under the research I listed those questions and I recall saying the
first priority should be to make treatment available to everybody who
wants it.
Next we are to find out about why this happens m the neighborhood
it happens in and what the trends are.
Mr. Rangel. I am wondering. Doctor, if a different economic group,
that is, a more affluent economic group, were afflicted by a similar tyj^e
disease, whether or not we would be talking about ma king methadone
so available as a possible cure to disease or whether or not there would
be a concentration on research rather than just expansi< n.
Dr. Jaffe. Well, I can only tell you that everyone I h ave talked with,
given the option of waiting for more research with the possibility that
in the meantime their children or relatives might die of overdoses or
go to jail, opts for "Let's take what we think is most eff< ctive and make
it available."
Mr. Rangel. I don't see where you have too many choices, because
you have the problem that you have to deal with and the best thing
American research has come up with has been methador e ; that is vour
professional opinion ?
Dr. Jaffe. Well, for large-scale operation ; yes.
Mr. Rangel. But in terms of national research, are you satisfied that
this Nation is doing all it can to research a solution to the drug prob-
lem that we are having at the present time ?
235
Dr. Jaffe. Well, we have pointed out areas where more could be
done. I think that lookintr at it from the point of view of somebody
who has reviewed research grants and applications and looked at the
funding, all the good brainpower that wants to get into the field, you
know, is able to get involved.
The issue is getting more brainpower to bear on the subject.
Mr. Rangel. My last question is: Are you satisiied that the fact
that the victim of this epidemic happens to be in the low economic
strata of our society has not affected the determination of our Ameri-
ca's research in doing as much as it can ? You don't believe it would be
any different if we were dealing with a more affluent group ?
Dr. Jaffe. Well, I suppose that it is already dealing with a more
affluent group. There are a number of very wealthy suburbanites who
are extremely concerned. But I think if you escalate it into a crash
program, a tremendous amount of money into research per se, hoping
that the competent researcher will materialize, you may be disap-
pointed. You need to gear up for these things and support people. I
think all you would do with crash programs is bring in a lot of mar-
ginal people.
If you nave a phased planning and say, "Yes, we are concerned and
at this stage we will have to bring more people into it." Then, in fact,
you have a program that will bring more people into it.
I don't think that research in this area is being underfunded, to
answer your question more directly, because the problem of heroin
addiction affects primarily lower socioeconomic groups.
Mr. Ranget.. Thank you.
Chairman Pepper. We are running considerably behind here.
Do you have any questions? Mr. Brasco?
Mr. Brasco. I just wanted to ask Dr. Jaffe — and if he answered it
before I will get the information from someone else.
We were sort of interrupted when we were talking about the possi-
bility of developing a longer lasting drug, other than methadone, and
you said you didn't want to promise anything, and at that point you
went to something else.
Did you get to that, because I was a few minutes late and I am
wondering what the prognosis is for developing it.
Dr. Jaffe. I think the prognosis is excellent. I think it is only a
matter of time before we will be able to discuss which specific drugs
might be able to be used, and which would have significant advantage.
Mr. Brasco. Are you saying we have them now ?
Dr. Jaffe. Yes; we are working on them. We named one that is
under study, that has been under study for a year. There are still some
questions to be resolved that ; yes, this is a drug that can be used on a
Avide scale.
Mr. Brasco. And longer lasting?
Dr. Jaffe. Longer lasting than methadone.
Mr. BPtASCo. "Wliat is the dosage ?
Dr. Jaffe. Three times a week instead of seven times a week.
Chairman Pepper. Dr. Jaffe, you see from the questioning by this
committee how enormously interested we are in your vast knowledge in
this field.; We are very grateful for you coming today and giving us
your testimony. I am sure our committee would like to have the
236
privilege of continuing to keep in contact with you when we come
to the formulation of our recommendations as to what more the Fed-
eral Government can do to combat heroin addiction.
(The curriculum vitae of Dr. JafFe follows:)
[Exhibit No. 12]
CuRRicruLUiii; Vitae of De. Jerome Herbert Jaffe, Dieector, Illinois Drug
Abuse Program i
Formal education : Temple University; A.B., psychology, 1954 ; M.A., experi-
mental psychology, 1956 ; Temple University School of Medicine ; M.D., 1958.
Awards and honors : Temple University, College of Liberal Arts ; magna cum
laiide ; distinction in psychology ; alumni prize : highest academic average ; Psi
Chi Award (scholarship and achievement in psychology); Psi Chi, Honorary
Society.
Temple University School of Medicine : Summer Research Fellowship in Phar-
macology, 19i57; Babcock Honorary Surgical Society: Alpha Omega Alpha:
Merck Award : outstanding achievement in medicine during senior year ; Mosby
Scholarship Award : highest 4-year average in medicine.
Fellowships: USPHS Post Doctoral Fellowship in Pharmacology, 1961-1964.
USPHS Research Career Development Award, 1964 to 1966, 1967-70. ' '
^lajor interests : Psychopharmacology — use and abuse of psychoactive drugs —
biological and sociological aspects.
Experience and training : Rotating internship — ^U.S. Public Health Service
Hospital, Staten Island, N.Y., 1958-59. Residency in psychiatry— U.S. Public
Health Service Hospital, Lexington, Ky., 1959-60. Psychiatric staff— U.S. Pub-
lie Health Service Hospital, Lexington, Ky., 1960-61. Post doctoral fellow, inter-
disciplinary program — Albert Einstein College of Medicine, 1961-62. Post doc-
toral fellow and resident in psychiatry: Albert Einstein College of Medicine
and Bronx Municipal Hospital Center, 1962-64. Assistant professor, Departpient
of Pharmacology and Instructor, Department of Psychiatry, Albert Einstein
College of Medicine, 1964-66. Assistant professor. Department of Psychiatry,
University of Chicago, 1966-69.
.: Present positions : associate professor, Department of Psychiatry, University
of Chicago, 1969 to present. Director, drug abuse program, Department of
Mental Health, State of Illinois, 1967 to present.
, Memberships in organizations: Alpha Omega Alpha, Sigma XI, American
Medical Association. American Psychiatric Association, American Society of
Pharmacology and Experimental Therapeutics, American College of Neuro-
Psychopharmacology, New York Academy of Science, American Association for
the Advancement of Science, Illinois Medical Society, Chicago Medical Associa-
tion, Illinois Psychiatric Society, and World Psychiatric Association.
CONSULTANTSHIPS. ADVISORY PANELS AND EDITORSHIPS
Member, Editorial Board, International Journal of the Addictions, 196&-.
Member. Review Committee, Center for Studies of Narcotics and Dangerous
Drugs, NIMH, 1966-.
Visiting Assistant Professor of Pharmacology and Psychiatry, Albert Einstein
College of Medicine, 1966-.
Visiting Lecturer, University of Texas, Medical Branch, 1966-,
Consultant, Illinois Narcotic Advisory Council, 1966-68.
Consultant, New York State Narcotic Addiction Control Commission. 1967-.
Member, Committee on Narcotics and Dangerous Drugs, Illinois State Medical
Society, 1968-.
Member, Technical Advisory Board, National Coordinating Council on Drug
Abuse Education and Information, 1969-.
Secretary, Section on Drug Dependence, World Psychiatric Association, 1969-.
Member, Advisory Board, Psychopharmacologia.
Member, Committee of the Division of Clinical Pharmacology, American Soci-
ety for Pharmacology and Experimental Therapeutics, 1970-.
Member, Advisory Committee. Drug Abuse Training Center, California State
College, Hayward, California, 1970.
Consultant, Bureau of Drugs Advisory Panel Systems, Department of Health,
Education and Welfare, 1970-.
237
Special Consultant (Technical Adviser), Expert Committee on Drug Depend-
ence. World Health Organization, Geneva, Switzerland, 1970-
Member, American Psychiatric Association Task Force on Alcoholism, 1970-.
Consultant, Joint Information Service, American Psychiatric Association and
the National Association for Mental Health (Project on Current Methods for the
Treatment of Addiction), 1970-.
In addition to these on going advisory and consulting activities, Dr. Jaffe
has been, over the past three years, an invited participant in more than fifty
national and international conferences and symposia. He has also served as
special consultant to a number of State and Local Governments interested in
developing drug abuse treatment or educational programs and has been the
keynote speaker at three Governor's Conferences. Dr. Jaffe has also served as a
consultant to a number of temporary State and Federal advisory panels, as well
as school systems, not-for-profit corporations, and private industry.
PUBLICATIONS OF JEROME HERBERT JAFFE, M.D.
The electrical activity of neuronally isolated cortex during barbiturate with-
drawal. The Pharmacologist, 5:250, 1963 (Abs.) (with S. K. Sharpless).
The rapid development of physical dependence on barbiturates and its relation
to denervation supersensitivity. The Pharmacologist 5:249, 1963 (Abs.) (with
-S. K. Shariiless). ;•.•'•'
Drug^ addiction and drug' 'abuse. In, "The Pharmacological Basis of Thera-
peutics," 3rd edition, Goodman, L. and Gilman, A. (eds.), The MacMillan Co.,
-New York, 1965.
' Narcotic analgestics. In "The Pharmacological Basis of Therapeutics," 3rd
edition, Goodman, L. and Gilman, A. (eds.). The MacMillan Co., New York, 1965.
The rapid development of physical dependence on barbiturates, (with S. K.
Sharpless) /. Pharmacol, and Exper. Ther., 150 :140-145, 1965.
Changes in CNS sensitivity to cholinergic (muscarinic) agonists following
withdrawal of chronically administered scopolamine. The Pharmacologist 8 :199,
1966 (Abs.) (with M. J. Friedman).
The electrical excitability of isolated cortex during barbiturate withdrawal,
(with S. K. Sharpless) J. Pharmacol, and Uxper. Ther. 151 :321-329, 1966.
Research on newer methods of treatment of drug dependent individuals in
the U.S.A. Proceedings of the Fifth International Congress of the Collegium
International Neuropsychopharmacologicum, Washington, D.C., Excerpta Medica
Intern ational Congress Series, 129 :271-276, 1966.
Cyclazocine, a long acting narcotic antagonist : its voluntary acceptance as a
treatment modality by ambulatory narcotics users. Xwith L. Brill) Internat. J.
Addictions, 1 :99-123, 1966. o-'-'^i'
The use of ion-exchange resin impregnated paper in the detection of opiate
alkaloids, amphetamines, phenothiazines and barbiturates is urine, (with Dahlia
Kirkpatrick) Psychopharm. Bull., S :, No. 4, 49-52, 1966. ■
The relevancy of some newer American treatment approaches for England,
Brit. J. Addict., 62 :375-386, 1967 (with L. Brill). . .
Cyclazocine in the treatment of narcotics addiction. In. "Current Psychiatric
Therapies," Masserman, J. (ed.), Grune and Stratton, New York, 1967.
Pharmalogical denervation supersensitivity in the CNS : A theory of physical
dependence, (with S. K. Sharpless) In, "The Addictive States", Wikler, A. (ed.),
The V\'illiams and Wilkins Co., Baltimore, 1968.
Narcotics in the treatment of pain, Med. OUn. North Am,., 52 :33-45, 1968.
Drug addiction : New approaches to an old problem. Postgrad. Med., 45 :73-81,
1968 (with J. Skom and J. Hastings).
Opiate dependence and the use of narcotics for the relief of pain. In, "Modern
Treatment", Wang, R. (ed.), 5 :1121-1135, 1968. ^
Psychopharmacology and opiate dependence. In, " Psych opharmacology : A re-
view of Progress, 1957-1967," Efron, D. H., Cole, J. O., Levine, J., Wittenborn,
J. R. (eds.). Proceedings of the Sixth Annual Meeting of the American College
of Neurophyschopharmacology, San Juan, Puerto Rico, December, 1967.
Cannabis (marihuana). In "Encyclopedia Americana," Grolier, N.Y., 1969.
Drug addiction and drug abuse. In, "Encyclopedia Americana," Grolier, N.Y..
1969.
A review of the approaches to the problem of compulsive narcotics use. In,
"Drugs and Youth", Wittenborn, J. R. ; Brill, H. ; Smith, J. P. ; and Wittenborn, S,
(eds.), Charles C. Thomas, Springfield, 1969.
238
A central hypothermic response to pilocarpine in the mouse. J. Pharmacol, exp.
T/ier., 167:34-44, 1969 (with M.J. Friedman (1)).
Central nervous system supersensitivity to pilocarpine after withdrawal of
chronically administered scopolamine. J. Pharmacol, exp. ther., 167:45-55, 1969
(with M. J. Friedman (1) and S. K. Sharpless). .
Pharmacological approaches to the treatment of compulsive opiate use : iheir
rationale and current status. In, "Drugs and the Brain," Black, P. (ed), Balti-
more, 1969. ^ ,.^ ^ ^u
Experience with the use of methadone in a multi-modality program for the
treatment of narcotics users. Internat. J. Addictions, 4 (3), 481-i90, 1969 (with
M. Zaks and E. Washington).
Problems in Drug Abuse Education : Two Hypotheses. In, "Communication and
Drug Abuse: (with D. Deitch)." Proceedings of the Second Rutgers Symposium
on Drug Abuse, Rutgers University, New Brunswick, New Jersey, 1969.
Tetrahydrocannabinol: neurochemical and behavioral effects in the mouse.
Science, 163, 1464-1467, New York, 1969. (with Holtzman, D. (1) Lovell, R. A.,
and Freedman, D. X.).
The treatment of drug abusers. In, "Principles of Psychipharmacology", Clark,
W., and del Guidice, J. (eds. ) , Academic Press, New York, 1970.
Whatever Turns You Off. Psychology Today, 3, (12), 42^4, 1970.
A comparison of dl-alpha-acetylmethadol and methadone in the treatment of
chronic heroin users: a pilot study. JAMA, 211 (11), 1834-1836, 1970 (with C. R.
Schuster, B. Smith, and P. Blachly).
The implementation and evaluation of new treatments for compulsive drug
users. In, "Advances in Mental Science II — Drug Dependence" Harris, R. T. ;
Mclsaac. W. M. ; and Schuster, Jr., C. R. (eds.). University of Texas Press,
Austin, 1970.
Narcotic Analgesics. In, "The Pharmacological Basis of Therapeutics", 4th
Edition, Chapter 15, Goodman, L. and Gilman, A. (eds.). The MacMillan Com-
pany, New York, 1970.
Drug Addiction and Drug Abuse. In, "The Pharmacological Basis of Thera-
peutics", 4th Edition, Chapter 16, Goodman, L., and Gilman, A. (eds.). The Mac-
Millan Company, New York, 1970.
Further experience with the use of methadone. International Journal of the
Addictions, September 1970.
Development of a successful treatment program for narcotics addicts in Illinois.
Chapter 3, In, "Proceedings of the Second Western Institute on Problems of Drug
Dependence", Blachly, P. (ed.).
Drug maintenance and antagonists : limits and possibilities. Proceedings of the
November 24, 1969 Conference of the New York State Narcotic Addiction Control
Commission.
An identification of techniques for the large scale detection of Narcotics, bar-
biturates, and central nervous system stimulants in a urine monitoring program.
In Abstracts of the Academy of Pharmaceutical Sciences, (117) with K. K.
Kaistha.
An overview of the conference. Proceedings of a Conference on Methodology on
the Prediction of Drug Abuse Potential, Washington, D.C., September 8-10, 1969.
U.S. Government Printing OflBce.
In press
The heroin copping area : a location for epidemiological study and interven-
tion activity. Archives of General Psychiatry , (with Pat Hughes).
Developing in-patient services for community based treatment of narcotic
addiction. Archives of General Psychiatry, (with Hughes, P., Chappel, J.,
Senay, E.).
Methadone and 1-Methadyl Acetate in the management of narcotics addicts.
JAMA, (with E. C. Senay).
Effects of variation of methadone dose on the outcome of treatment of heroin
tisers, Proceedings of the Annual Scientific meeting of the Committee on the
Problems of Drug Dependence. February 16. 1071. (with S. DiMonza).
Experience with eyolnzocine in a nuilti-modality treatment prosram for nnr-
cotics addicts. International Journal of the Addictions, (with J. N. CbappeU
E. C. Senay).
239
Submitted or accepted for publication
Role of hospitalization in tlie treatment of drug addiction, (with J. N.
Chappel).
A double-blind controlled study of cyclazocine in the treatment of heroin
users, (with J. N. Chappel).
Extraction and identification techniques for drugs of abuse in a urine screen-
ing program. Presented to the Annual Scientific Meeting of the Committee on
Problems of Drug Dependence, Toronto, February 16, 1971, (with K. K. Kaistha).
In preparation
Successful withdrawal from methadone : a 1-year follow-up.
Minimal methadone support for narcotics addicts awaiting entry into a com-
prehensive addiction rehabilitation program.
(A brief recess was taken. )
Chainnan Pepper. The committee will come to order, please.
Our next witness is Dr. Harvey Gollance, assistant director, Beth
Israel Medical Center in New York City, with specific responsibility
for the center's narcotic programs.
Before assuming his present position, Dr. Gollance was deputy
commissioner for operations of the New York City Department of
Hospitals, in which post he was in charge of operations at 19 munici-
pal hospitals.
He has also served as supervising medical superintendent of Kings
County Hospital Center.
Dr. Gollance is a fellow of the American College of Hospital Admin-
istrators and the American Public Health Association.
Dr. Gollance has had extensive experience in narcotics treatment
programs, and is a member of the narcotics register advisory commit-
tee of the New York City Department of Health and the methadone
evaluation committee of the Columbia University School of Public
Health and Administrative Medicine.
Dr. Gollance, we are grateful for your appearance here today.
Mr. Perito, will you inquire ?
Mr. Perito. Dr. Gollance, I understand you have a statement which
you are going to offer for the record and briefly summarize.
STATEMENT OF DR. HARVEY GOLLANCE, ASSOCIATE DIRECTOR,
BETH ISRAEL MEDICAL CENTER, NEW YORK, N.Y.
Dr. Gollance. I would like to make a brief statement.
I know you have heard a lot about methadone. We run the largest
methadone program in the world. We are pioneers in this. The Beth
Israel Medical Center is the largest voluntary hospital for the treat-
ment of narcotics addiction in the world. We have 350 beds for nar-
cotic addiction treatment. We admit over 9,000 patients to our detoxi-
fication service, and over 3.200 patients are under active treatment in
our methadone maintenance program.
We sponsor this program in 12 other hospitals in New York City,
some of the most outstanding hospitals in the world.
I would like to start with a brief statement of how the methadone
treatment program came into being, because I think this is important.
We have had very serious heroin addiction in New York City for
over 20 years. It struck in the low-income areas of the city, Harlem,
240
South Bronx, Bedford-Stuyvesant, and it was different from any
addiction problem we had had before. Formerly addiction was some-
thing among doctors, nurses, people of some means.
In the early 1950's a demand arose that the city do something about
it because they had practically no facilities for the treatment of drug
addiction.
In response to this demand, the city did several things. It opened
a hospital for drug users called Riverside Hospital and in its early
years an earnest attempt was made with psychologists, psychiatrists,
social workers, et cetera. The board of education opened a school and
supplied an interested faculty. irOM*^
Riverside Hospital was opened in 1953. :
In 1958, the health commissioner of the State of New York wanted
to see what the State was getting for its money, and he had the Colum-
bia University School of Public Health do a survey of the patients
who had been in Riverside Hospital, and they took a certain time
period and then tracked down the cases treated in that period, 1955,
What this study found was an unusually high death ra-te ; but of
those who survived, none were off heroin. It was obvious Riverside
Hospital was a failure as far as getting anybody free of heroin. It
did give some social first {lid, a chance to reduce dope and stay away
from the police. It is obvious there was no single treatment allowed for
hard-core heroin addiction, , , r 'l, 'iroll-yt Si ^r /^•ji-pilU •- > .iii
In 1963, the health research council of New York City got Dr,
Vincent Dole, later joined by Dr, Nyswander, to do research in the
treatment of drug addiction; Dr. Dole went on the assumption that
whatever the psychological or sociological reasons that a person be-
came addicted, once he was thoroughly addicted there was a physio-
logical change and unless he did something about this he would not b^
able to rehabilitate the patient, the hard-core heroin addict, . .( ;
Dr. Dole's goal was rehabilitation. By that he meant the addict
could function in our society as well as he was capable.
Dr. Dole tried several things. He tried to see if he could stabilize
a patient on morphine, some other narcotics. It didn't work. Then
he used methadone in a new way. It is a synthetic narcotic that was
used in World War II by the Germans, when their supply of opium
was cut off.
After the war methadone was used mostly for the detoxification
of patients — to get them drug free in a humane way instead of suffer-
ing throuerh "cold turkey." In a week you can get any heroin addict off
heroin. The point is the addict won't stay off heroin. Dr. Dole wanted
to see what would happen if instead of reducing the dose of methadone
as in detoxification, he gradually increased the dose. He foimd two
things : Wlien a certain level was reached the addict lost his drug hun-
ger. He no longer had any craving for heroin, and if you went to a
still higher dose it blocked the effect of heroin.
Dr. Dole got pure heroin and .eventually injected Inr.o-e quantities
of heroin into patients on blocking doses of methadone. Xothiiig hap-
pened. This is called the blocking effect.
When we speak of the methadone maintenance treatment program
we mean the Dole-Nyswander technique of givmg blocking doses of
methadone — not just giving methadone in any haphazard sort of way.
MS
■ Methadone has properties that make it very useful for this woik. It
is fully effective by mouth, it is long acting; once you get a patient
stabilized, a single dose by mouth will last him 24-36 hours. It is a
safe drug. .a^j'-r ;->,>■. .
We haven't had any serious harmf ill' effects either medically, sur-
gically, or obstetrically in 7 years. The body develops great tolerance
for methadone in a relatively short tima It no longer acts as a nar-
cotic. By that I mean it does not make the patient high and it doesn't
make him sleepy. It is, however, addictive. If taken away from the
patient he would have withdrawal symptoms. '• ' ■
Dr. Dole did this work with six cases at Rockefeller Institute and
then came to Dr. Ray Trussell, who was then commissioner of hospitals
in New York City, and asked for facilities to expand his work.
Through Dr. Trussell 's efforts, Dr. Dole got the beds in what is now
the Beth Israel Medical Unit for Drug Addiction. We inaugurated
this program in 1965.
When Dr. Trussell set this program up, he insisted that a separate
contract be given to the Columbia University School of Public Health
to do an independent evaluation of what happened to every patient in
the methadone program. This is important. We now have records of
every single patient who has ever come into our program, and these
results have been independently evaluated by the Columbia University
School of Public Health. .i^i"bji bsmiiiuor) a >.i nn-nU]
If we are going to get ahywh'er^'in treafm'g driig addiction we must
know what works and what doesn't work. T think this independent
evaluation is an important part of this program. ,»it/.)!^'
- Originally the patient was taken into the hospital for 6 weeks. After
he was stabilized, he was sent to a clinic with a number of supporting
services : counselors, research assistants, social workers. The goal is re-
habilitation, not just to satisfy the drug hunger. .ip/iwrr:,
J Many of our patients started- very young. You now have help for
them with all their problems, help them with welfare, with the courts,
with their wives, get a job, all of these things. -You must help to get
the patient intothe square society f' if^^"' '^fut.'/ '.v^jiyrf o1 ojJIi [t
We do this. We believe that a methadone hlaiTitenarice program
should be done in a structured program. You must know whtit hap-
pens to your patient, and you work intimately with him. ■
_ As a matter of fact, we don't let an individual clinic exceed 150 pa-
tients. We want the staff to know the patient well and what is happen-
ing to him. At the present time we have almost 40 clinics scattered
throughout the New York City area. ; . ".i
When we reach a census of 150, we open a new' clinic. Wedobkat
the addict as an individual with a chronic illness. He is a m.edical pa-
tient. We base our program on a hospital. IMost all our clinics are out in
the community. They are considered an extension of the hospital. We
think this philosophy of medical en re is important.
Addicts have other problems besides their addiction. They have
medical problems. The medical profession has shunned treatment of
drug addiction for a number of generations now. In the past it was
too dangerous for a doctor to deal with drug addicts. He risked prose-
cution and possible jail.
We now have a medically based program with a hospital to take
242
€are of patient addicts. We have seen some very interesting byprod-
ucts of this other than the direct treatment of addiction. We find out
that when we set up a clinic associated with a hospital, the medical
staffs become interested in treatment of drug addiction. If we are go-
ing to get anywhere in this field we need to bring the best brains we
have into solving this difficult problem. Methadone maintenance has
set up a climate favorable for this.
Methadone is not the final answer. It happens to be the best answer
we have at this time for treatment of the hard-core heroin addict.
Dr. Dole's original criteria were that the patients had to be 21 years
of age and under 40, because there is a theory around that drug addic-
tion burns itself out as the patient gets older.
They had to have a history of mainlining heroin. They were hard-
core addicts. They all had criminal records and had tried other pro-
grams without success, to further confirm their serious addiction.
The original program, because it was new, excluded certain condi-
tions: alcoholism, pregnancy, mixed drug use. However, as we have
gained much experience we have broadened the criteria for admission.
We admit now a patient over the age of 18, there is no longer an upper
age limit. We have one man 87, one 82, and a number collecting social
security.
We now require 2 years of heroin addiction. We are very careful to
see that the applicant is a confirmed addict.
This is a voluntary program. In our experience it takes about 2
years before a heroin addict is first willing to do something about his
addiction. At the beginning the drug addict rather enjoys the high
he gets. He is a very busy individual supporting his habit by stealing.
He rather enjoys that culture at the beginning. We feel it takes 2 years
before he is willing to do something constructive by entering this
program.
For this group of cases, this program has proved very successful. I
believe you heard Dr. Gearing. She does our evaluation. She is a very
competent individual.
I would like to review what our experience has been. Basically we
liave an 80-percent retention rate in the program. We have a 20-per-
cent dropout rate. Very few of the patients drop out of their own voli-
tion. They are usually dropped out by us for administrative reasons.
These turn out to be severe alcoholics, a few get arrested early in the
program or use other drugs.
The work records are very interesting. I don't have the most recent
figures. I don't know what ejffect the present recession will have. Up to
about a year or two ago our patients were about 25 percent legit-
imately employed when they started. At the end of 6 months, about 50
percent are working and after 2 years 80 percent. For those in the
jDrogram 3 years or longer, 92 percent were either working, keeping
house, or going to school, and only 6 percent were left on welfare.
Tlie arrest records in our program have been phenomenal. Dr. Gear-
ing did a study of arrest patterns. She took a group before they came
into the methadone program and studied their arrest records. It showed
115 arrests per 100 patients in the course of a year, 48 convictions per
100 patients in the course of a year. She then followed the course of
these patients for 4 years after they started on methadone.
2fi3
The 115 arrests per 100 per year dropped to 4.5. The 48 convictions
dropped to 1 per 100 per year. The arrests practically disappear and
the longer in the program, the fewer the arrests.
Here was a program that took hard-core heroin addicts whose treat-
ment had been very unsuccessful before. I, myself, when I was deputy
commissioner of hospitals, tried setting up programs, pleading with
doctors to set up programs. I was not successful. The few programs in
existence were very unsuccessful and most physicians I knew were
very discouraged.
Now, we take a large number of severe heroin addicts and you have
them working, you keep them out of jail, you put tlieir families to-
gether.
That doesn't mean we have all angels in our programs. "We have
some who have problems. Some will do things they shouldn't, but on
the whole this has been a very successful program.
With that introduction, I would like to answer some questions.
Chairman Pepper. That is a very good summary.
Dr. GoLLANCE. Could I answer the previous question about dispens-
ing it ?
I would be against dispensing it just in pills. We have changed over
to what we call a disket. It is a large tablet that leaves a sludge, and
the patients can't inject it. We use diskets to prevent careless handling
so that children can't get them.
For this reason we have a tendency to use diskets dispensed in vials
with locking caps where they can be kept in the medicine chest away
from children.
Mr. Brasco. That is the question I asked. Doctor.
Do you agree with Dr. Jaffe, then, of the impracticality in New
York of having a patient come once a day for his dosage rather
than
Dr. GoLLANCE. Yes; when you are on a very large scale program.
Mr. Brasco. So you agree ?
Dr. Gollance. Yes ; and for the reason Dr. Jaffe said, we are trying^
to rehabilitate patients.
Mr. Brasco. The disket is something that cannot be injected; is
that correct ?
Dr. Gollance. That is correct.
Mr. Brasco. I was concerned about working with substances that
would be practical for carrying and used just as long as they could
not be used intravenously.
Dr. Gollance. That is right.
Mr. Brasco. But that disket is not something capable of being used
intravenously ?
Dr. Gollance. That is correct. I would like to answer Congressman
R angel on the ethnic distribution of patients in New York. We have
a narcotic registry run by the health department and the ethnic dis-
tribution of their list is 50 percent black, 25 percent white, 25 percent
Puerto Rican.
The patients in our programs approximate that ethnic distribution.
I would also like to say that this is no longer a situation of the low-
income group. Last week the daughter of a prominent professor and
the son-in-law of a prominent head of surgery in one of the leading
244
hospitals in the city, came into our program. In answer to your ques-
tion, two marines I know personally came back addicted. The reason
the marines snort heroin and don't inject it is so they won't leave
trackmarks. But when they come back here they will start injecting
heroin. This one Marine had gotten $6,000 from an automobile acci-
dent and wanted to return to the Orient for drugs. I got him into the
methadone program and he is doing very well, u; ruoiu i
Chairman Pepper. Mr. Perito, please proceed.
Mr. Perito. Thank you, Mr. Chairman.
First, Doctor, do you believe that private physicians should be per-
mitted to maintain addicts on a maintenance program ?
Dr. GoLLAxcE. At this time I would say no. Our feeling is that this
should be done in a structured program. We have given a lot of
thought to how to use private practitioners. For example, if we had a
well-stabilized patient he might be referred to a private practitioner.
If this were done, it would furnish a means of having the patient
checked, because there is possibility of abuse.
There is the program in New York City that disburses
Mr. Pertto. You mean dispensing of methadone by a private physi-
cian ; is that what you are talking about ?
Dr. Gollance. That is right.
Mr. Perito. What steps can be taken in order to avoid problems
of this nature ? , "' ' ^'''^ ^'^^^-'^ ^^''^ ■' '^ ' f^'^ ^ '•! i J o^
Dr. Gollance. Well, the thing is if you can set up enough programs
so the patient can come in and get it from established programs very
cheaply and receive good care. We g&t many patients from this private
doctor when we can reach him on our list. '^-^ ''^- ' "''' ^ ■o.iPj.i,:>. i .^i/:
Unfortunately, we have quite a long waiting list. The last time T was
before this committee, we were asked how can we expand the program.
I might say, since that time last year, we have taken as many patients
in 1 year as were taken in all of the previous 5 years. We have the
mechanism for expanding this widely if' we get the necessary funds
Mr. Perito. Do you believe addiction is a metabolic situation ?
Dr. Gollance. I think you have to make that assumption. At least
it has worked here. The psychological and sociological apiproaches
have not worked for this type of patient. We have tried all these
things without methadone and they haven't worked. Under methadone
you can use a number of successful aLppjcoac.hes, but without it we have
been very unsuccessful. 'c. ..,. ^.i. _ii;
Mr. Perito. What steps have you taken in your program to control
diversion?
Dr. Gollance. First of all, we limit the size of the clinic so we
know the patient. We constantly watch the patient, besides the urine
checks, to know that he is not using Other drugs, and if we have any
suspicion at all we will put him on a daily regime.
One of the interesting tilings is the patient develops a loyalty to tlie
program. I know addicts are not supposed to squeal, biit tliey will
come to us and toll us. look out for this f'^How. and avo will. Thoy will
give us information about our patients. We have a patient-phvsician
relationship. We don't take a punitive approach. We don't look at the
addict as a dope fiend or outcast. We encourage him to tell us when
he is abusinc:. In the first few weeks he will.
245
If he is using other drugs we will ask him to tell us so we can work
with him.
Mr. Perito. Finally, Doctor, to the best of your knowledge, is there
a black market for and in methadone in New York City?
Dr. GoLLANCE. I am sorry to say there is. We have asked the police
repeatedly, ever since we have had the program, do they thuik our
program is a problem for them.
Tliey have told us our program is not. But we do know it is getting
on the*^ streets from some very unstructured, unsupervised programs.
I appeared before a group of probation officers and a police officer,
and he said, "I know it gets on the street." I said, "I would like to see
it. I don't think it is any of ours." He pulled out a vial and there was
a label of this unsupervised program in New York City.
Chairman Pepper. Mr. Blommer.
Mr. Blommer. I have no questions, Mr. Chairman.
Chairman Pepper. Mr, Waldie.
Mr. Waldie. No questions.
Chairman Pepper. Mr. Wiggins.
Mr. Wiggins. Would you describe the workings of the central regis-
try for us ?
' ! Dr. GoLLANCE. The health department gets all the information.
Physicians are supposed to report to them and it is strictly confiden-
tial. I would say most of their records are gotten through arrest
records. When arrested, that is reported to the central registry. Also,
physicians and others with knowledge are required to report this to
the health department.
Incidentally, Dr. Dole has been working on detoxifying prisoners
in the New York City prison and at nights I have personally observed
that at least two-thirds of the prisoners are addicts under the influence
of heroin.
Mr. Wiggins. Can you describe the methadone registry for the
record?
Dr. GoLLANCE. That is a special methadone registry under the di-
rection of Eockefeller University. This registry for the methadone
patients is available to Dr. Gearing and Dr. Dole at Rockefeller. Any
patient we treat, or any hospital connected with us must report every
patient into this central computer. We finance and train hospitals.
One thing that we will not yield on in any way is that they must
report in their results in exactly the same manner as we do. There is
standardized reporting in our program.
However, there are programs that do not report to this central
registry.
Mr. Wiggins. That is all.
Chairman Pepper. Mr. Brasco.
Mr. Brasco. Yes. Could you tell us, Doctor, how long is the waiting
list for the program ? -.iuAj-"ji\r nfi : .■
Dr. GoLLANCE. It varies. It used to be very long. It has gotten much
shorter. We have set up a number of programs, including what we call
rapid induction. We are working now on what we call a holding pro-
gram. That will cut down waiting time. It varies from weeks "to
months, depending on the area in which the patient lives.
;;Mr. Brasco. That is another thing. I know it is localized. Coming
Irom- New. York, I had an opportunity to try to place a young man
246
that came into my office, and I was sort of distressed to find out that
the program he was talking about had longer than a 5-month waiting
period and over and above and beyond that there was this geographic
thino- where they said we don't service that particular area.
Apparently what had happened is one program that had some open-
ings said we don't service that area and the other program said we
don't service that program.
I thought it was all your program. ^
Dr. GoLLAXCE. No ; there are a number of programs m New York
City. We are in four boroughs. We have others besides ours. The city
has opened up several, the Bronx has a separate program.
In our own network we have 14 hospitals, 30 clinics, and 3,200 pa-
tients. If we get the funds, we will go to 6,000 patients. We have the
means now to expand. We have trained staff to act as a nucleus for
expansion. It is not only a matter of money. It is to get space, to train
stall's, to get people willing to do this work. I think we are over most
of that hurdle.
Mr. Brasco. You say you have the means. You say you have 3,200
patients. What does that mean ? How many patients can you convert
if you have the money and you have the staff ?
Dr. GoLLANCE. They have been making funds available now and
more and more are getting into
Mr. Brasco. How many additional patients would that be ?
Dr. GoLLANCE. If we get what we ask for from the State — for ex-
ample, we are financed entirely by the New York State Narcotics Ad-
diction Control Commission — if they give us the funds we will jump
from 3,200 to 6,000 this year. That is just our program.
Mr. Brasco. One last question.
The diversion of methadone, when it is diverted in the streets, it is
used, I take it, as a substitute for heroin, mainly because it is cheaper ;
is that the reason ?
Dr. GoLLANCE. From what I gather from all the addicts I have
spoken to, they do not take methadone as a drug of choice. After he has
become addicted, after a while, the addict is not looking for the highs.
He is looking to be comfortable. He doesn't want to be sick. Methadone
will prevent him from getting sick.
Mr. Brasco. So that what you are saying^ then, is that the addict
that is using this in the street, when methadone is diverted, is using it
in the same way that he would use it in your program, other than the
fact that it is
Dr. GoLL.\NCE. He is trying to do it that way by and large. There
are a number of psychotic individuals around. For example, our ex-
perience has been that anybody who takes heroin after 8 weeks in our
program, usually turns out to have a serious psychiatric problem. He
doesn't get any high from it. He is a needle addict.
Mr. Brasco. I have no further questions.
Chairman Pepper. Mr. Steiger.
Mr. Steiger. No questions.
Chairman Pepper. Mr. Mann.
Mr. Mann. Qualified personnel is a problem in the expanding medi-
cal field. How about your problems ?
Dr. Gollance. Well, there has been a great improvement in our
program. For example, we are getting young doctors now who are
247
interested, and I have applications from doctors to join the program.
I don't have spots for them right now. The nurses enjoy doing this
work. We are one of the few programs that doesn't have difficulty
recruiting nurses.
The counselors are flooded with requests from bright young people
now because of the job situation and we can get a good calibre of
counseling. We are not having problems getting personnel that we
had, maybe, 2 years ago, 3 years ago.
Our problem now is boiling down to money.
Mr. Maxn. To what extent do you use ex-addicts in your program ?
Dr. GoLLANCE. We use ex-addicts. We call them research assistants.
They are a very valuable part of the program. We have a very limited
number. In our requirement we will not take an addict right from
our program and hire him as a research assistant. He must get a job
and show he can hold a job on the outside. When he does, we can hire
him. They are very useful, they are useful as a model to the new patient
in explaining the program to the new patient, useful in explaining the
addict to the "square" staff that we hire. So they are very, very useful.
Mr. Mann. Thank you.
No further questions, Mr. Chairman.
Chairman Pepper. Mr. Winn.
Mr. Winn. Along that same line, what difficulties have you en-
countered in obtaining physical facilities for treatment of the addicts ?
Dr. GoLLANCE. We have had many problems in that area, and we
use any physical facilities we can get. We use stores, brick them up.
We don't call them storefronts because our addicts have had bad ex-
periences with storefronts. We use health buildings, office buildings.
We even set up a program in a church and are looking at another
church to get space. So we will use available space.
Now, there is a problem in getting space. We go into a community
and try to see if the community is going to back this program. They
are very much in favor of it but don't want it on their block.
So we have worked that out.
In the Harlem cormnunity, fortunately, we don't have that problem.
We have been able to open up a great many clinics and we are expand-
ing there.
But in certain other areas, it is a problem.
Mr. Winn. Do you use the residential system Dr. Jaffe referred to ?
Mr. GoLLANCE. No ; we haven't done that. Practically all our patients
are treated on an ambulatory basis. We have a certain number of beds
for those who have difficult problems and we will take them into the
hospital for 6 weeks.
We also have a medical service and obstetrical service to take care of
the patients.
I would also like to touch on that because this comes up. We think
it is important for the pregnant addict to be stabilized on methadone.
Our experience is that the pregnant woman stays on the street as long
as she can. She is a prostitute, gets no prenatal care, takes a shot of
heroin and tries ta smuggle some heroin in with her when she enters
the hospital for delivery. At least on methadone maintenance they
get prenatal care, we can follow them carefully, and I might say that
methadone has brought about a great change in climate. When I was
248
deputy commissioner of hospitals, it was recognized that pregnancy
in addicts was a problem. , i
We approached the chiefs of the obstetrical services and almost to
a man they said this is not their problem. Now, our obstetricians see
these cases. They are much interested in them and there is a much
better climate for the. pregnant addict than what existed 5 or 10 years
Mr. WioGiNS. Incidentally, does 'the child manifest withdrawal
symptoms?
Dr. GoLLANCE. We have watched them very carefully. We are going
to follow those infants for a long time. But the alternative would be
they would have heroin withdra,wal symptoms. ■ '. i
Chairman Pepper. Doctor, I have to go to the floor for a little while.
I will ai^k Mr. Walrlie if he will be good enough to take. the Chair.
I will ask you one question and make one comment..! iiL-o oi \
How is your program financed ? > ot/j ^oiijj'rt'p.rr vth e-ij; i :
Dr. GoLLANCE. Entirely by New York State Addiction Control
Commission, and we are worried very much about future financing.
Chairman Pepper. Secondly, on behn.lf of the committee I want to
express our very deep appreciation for your coming here and giving us
the benefit of j^our knowledge and experience.
Dr. GoiXANCE. Thank you. It is a privilege to. be here.
Mr. Waldie ( presiding) . IMt. ISIurphy. q 'jn'r
' Mr. Murphy. Yes. ii biifi 'jvorf
What experience do you know of that the Army has had with
methadone?
Dr. Gollance. I don't' know the Army's experience. I know the
veterans hospitals in our area have been very interested. I have spoken
to two of them. One of them is setting up a program. I would think
that this is a very serious problem. I am not an expert on the Army's
situation. q aiiH :;loj;J ot Bfiioi>. • /nmo'. sdi i vij i> v
I had one nian tell me the main reason for reenlistment in a certain
group was to stay in the Orient where they could get heroin.
" Mr. Murphy. That is all. - ,, ; ;
Mr. Waldie. Mr. Eangel. iiii /• qir k
Mr. Rangel. Do you know of any feasible way to dispense methadone
in such a form that it cannot be reduced to another substance so that
it can be used intravenously ? . ;> -
Dr. GoLLANCE. Well, if it is given dissolved in Tang, as we do, or
in disket form it can't be injected. - . > .j^i. . vi;.
Mr. Rangel. But we discussed tMte earlier 'aiid determined that it
was not practical to do this. Is there any other form, concrete form,
that you can create a methadone treatment or dosage so that it would
be impossible for the patient to later reduce it for injection?
Dr. Gollance. Well, I don't think they can reduce either of these
two forms we use. The type they inject are the pills usually gotten
from physicians. They are the usual* medical tablets and they are in-t
jectable. Perhaps do away with the injectable pills might be one way.
Mr. Rangel. Are you saying that in your treatment program you
don't give methadone in any solid form at all? if^b 7o'1 [■>;<!-»;[ ^(Fi
Dr. GoLLANCE. Only in this disket which is a sj^ccial form, certain
substances are put there so it leaved a sludge so it won't go through a
needle.
249
Mr. Hangel. That is a solid form ?
Dr. GoLLANCE. It is a solid tablet. It is dissolved in water. It is like
a large Alka-Seltzer and it fizzes up and it leaves a sludge and they
drink it when dissolved.
Mr. Eangel. If all of methadone was required by law to be dis-
pensed only in the form in which you dispense it, would that not
eliminate the possibility of injections ?
Dr. GoLLANCE. Yes ; and I might point out that methadone is a diffi-
cult drug to synthesize. There is only one manufacturer that I know
of in thi^ country, so it is not the type of drug that you can bootleg
and make it surreptitiously.
]\Ir. Rangel. Thank you.
Mr. Waldie. Thank you.
Are there any other questions ?
Doctor, we appreciate very much your appearance before the
committee.
(The following material was received for the record from Dr.
Gollance:)
[Exhibit No. 13(a)]
Methadone Maintenance Treatment Program
(Reprinted from Maryland State Medical Journal, November, 1970, Vol. 19, pages
74-77. © 1970 by the Medical and Chirurgical Faculty of the State of Maryland, Baltimore,
Maryland. Printed in U.S.A.)
By Harvey Gollance, M.D., Associate Director, Beth Israel Medical Center,
Administrator, Methadone Maintenance Treatment Program, New York, N.T.
Drug afldiction has reached epidemic proportions in Isfeio York City and in
other sections of the United States as well. An effective treatment for severe heroin
addicts known as the methadone maintenance treatment program has ieen
developed at Rockefeller University and has continued in a greatly expanded
program at the Beth Israel Medical Center in New York.
Facilities for the treatment of narcotic addiction were almost nonexistent in
New York until the 1950's. It was then that the increase in the number of addicts
in the low-income areas was recognized, as was the increase in the use of nar-
cotics by the young. Concerned city authorities prompted the department of
hospitals to establish facilities for adolescent drug users. As a result, a 140-bed
hospital. Riverside Hospital, was opened in 19.52. Psychiatrists and strong re-
habilitative and supportive services were provided. In addition, beds were ob-
tained in a proprietary hospital. Manhattan General Hospital, to detoxify nar-
cotic patients. With one exception, the chiefs of service of the municipal general
care hospitals resisted the treatment of drug addicts in their service. Few physi-
cians were interested, and almost all refused to treat the addicts.
A study was done by Columbia University in the late 1950's of 248 patients
discharged from Riverside Hospital. It showed that almost 100 percent of the
patients still alive became readdicted shortly after discharge. Ray E. Trussell,
M.D., director of the School of Public Health and Administrative Medicine of
Columbia University, during a sabbatical leave, had been appointed commis-
sioner of hospitals of New York City in 1961. Dr. Trussell, as a result of the
Riverside Hospital study, and because of additional serious administrative
problems, decided that Riverside Hospital should be closed, and that we should
seek new approaches to treat drug addicts. Riverside Hospital was closed in
196.3. Although it had given its patients some social assistance, it failed both in
preventing readdiction and in rehabilitating its patients. It seemed clear that
the answer to the treatment of narcotic addiction lay in new directions to be
determined by future research.
research encouraged
The Health Research Council of New York City was interested in encouraging
research in the area of drug addiction, and in 1963 they initiated a grant to
60-296—71 — pt. 1 17
250
two Rockefeller Institute physicians: Vincent Dole, M.D., a specialist in meta-
bolic research ; and Marie PI Nyswander, M.D., a psychiatrist with long experi-
ence in drug addiction.
Dr. Dole and Dr. Nyswander attempted to find a means of treating a patient
which would enable the patient to function productively in society. The research-
ers considered drug addiction as a psychological disorder and thought it reason-
able to ask whether some medication might control the drug hunger. At first
they attempted to maintain patients with morphine. While this did away with
much of the patient's antisocial behavior, it did not make him productive. Next,
they used methadone in an unusual way, giving their patients gradually increas-
ing doses until the tolerance level was reached, usually between 80 to lliO
milligrams daily. When patients reached this maintenance level, usually after
6 weeks of treatment, the physicians found that several things happened :
(1) The patient showed no harmful effects from methadone. He was neither
sleepy nor high. Medical examination and all types of medical, physiological,
and psychological testing showed no harmful effects from methadone.
(2) The patient lo:>t his drug hungei*.
(3) The effect of heroin was blocked. Even when given an injection of heroin,
the patient experienced no effects from it.
(4) The dosage of methadone, once established, remained stable. It did not
have to be increased, and was long acting (24 to 3G hours).
GROWTH OF THE METHADC>fE PROBLEM
After intensive study and experience with six patients. Dr. Dole went to Dr.
Trussell, showed him the histories of his six patients, and asked for facilities to
expand his work. In 19G5, through Commissioner Trusseli's efforts, beds were
obtained at the Manhattan General Hospital. This hospital of 386 beds later was
acquired and became an integral part of the Beth Israel Medical Center. This
was done through the help and cooperation of the president of the Board of
Trustees of the Beth Israel Medical Center, Mr. Charles H. Silver. In 19GG, the
center was renamed the Bernstein Institute of the Beth Israel Medici^.l Center.
It is the largest center for drug addiction under voluntary auspices. Methadone
maintenance is one of several narcotic programs of the Bernstein Institute.
In 5 years, the Methadone program has expanded to the point where over 1,300
patients are currently being treated in four hospitals and 15 clinics under the
sponsorship of the Beth Israel Medical Center. Several additional voluntary and
municipal hospitals and clinics are now almost ready to join the Beth Israel
Methadone Maintenance Treatment Program. The inpatient phases of the vrork
are done either at Beth Israel or at Harlem Hospital. Clinics have been estab-
lished at Beth Israel Medical Center, Harlem, St. Luke's, and Cumberland Hos-
pitals. In addition, a number of hospitals in New York City have established
their own methadone programs based on the work done previously at the Beth
Israel Medical Center.
This program considers the addict a patient with a chronic disease. The in-
dividual whom it treats is the hard-core addict who suffers from euphoria and
drug hunger, is unable to function socially or economically, and must take drugs
to relieve his physical misery.
Naturally, we realize that it would be best if the cause could be removed and
the patient made drug-free. But all programs which have attempted this in a
community setting have failed. This program deals with the symptoms. The
Methadone blockade against opiates frees the addict from his drug hunger so
that he becomes receptive to rehabilitation. It should be stressed that this
program deals with the long-term, usually ci'iminal addict, who has been unable
to make it in any other way. Our goal is social rehabilitation for those who have
been unable to achieve abstinence.
TREATMENT APPROACH
The Methadone program is not based on a psychiatric approach. While psy-
chiatric consultation is needed for a number of patients, it is not the primary
modality. Our experience has shown that the program is equally effective in a
department of psychiatry, medicine, or community medicine. The important fac-
tor is competent direction by an interested physician. Our experience has also
shown that there should be available good medical and obstetrical services by
251
pliysicians who are familiar with methadone patients and who are available for
back-up in program.
INTAKE OF PATIENTS
A central intake of patients for all the clinics and h-^spitals associated with
this program has been established under the direction of a skilled staff. This
staff has had experience working with addicts, and their backgrounds are essen-
tially in social service. They screen the applicants for acceptability in the pro-
gram. A research assistant (an addict in the program who has proven himself) is
of great assistance in this procedure.
Originally, because this was an experimental program, very rigid qualifications
for admission were established. These subsequent qualifications and their modi-
fications are :
1. Af7e.— Originally, age was set at 21 to 39 years. The patient had to be able
to sign a consent form but could not be over 39 because of the theory that drug
addiction decreases with age. The age requirement has now been changed ro 18
years with proper consent. No maximum age limit now exists. We even treat
patients collecting Social Security, and those registered with medicare.
2. Residence. — ^New York City residency is required because of reimbursement
aspects.
3. Addiction. — Only opiate addicts are accepted. Severe barbiturate an<l am-
phetamine users are rejected, as well as are those with multiple addiction (i.e.,
combination of opiates with barbiturates). Hov/ever, the final decision for accept-
ance may be modified by the clinician in charge.
4. Length of drug use. — Originally, a minimum of 5 years of mainlining heroin
was set. This has been gradually reduced and is now 2 years.
5. Psychiatry. — Any history of psychoses or severe mental disturbance is
usually cause for rejection. This may be modified by the clinician.
6. Addiction in family unit. — If the patient's spouse is addicted, both must be
eligible and admitted together. The same is true of any family members living
in the same household.
7. Alcoholism. — Severe chronic alcoholics are rejected.
8. Mental deficiency. — Addicts are rejected if intelligence quotient is so low
that they cannot handle the responsibilities of the program.
9. Medical. — Cirrhosis of the liver, diabetes, epilepsy, and terminal conditions
were originally reasons for rejection. We now have no medical exclusions.
10. History of previous unsuccessful treatment. — This has now l)een modified,
and a determination is made according to the judgment of intake personnel.
11. Acceptance of patients. — Finally, the physician in charge must approve the
selection of the patient.
PROCEDURE
When it has been determined that the patient meets the criteria and a vacancy
for treatment occurs, he is admitted into a phase I program. Originally, this was
a 6-week period of hospitalization on an open ward. This phase has been modi-
fied and now, in a high percentage of cases, it is done on a strictly ambulatory
basis. The patient is given divided doses at first. As the dosage is increased, and
there are no undesirable side effects, the dosage schedule is changed to a single
daily dose. The methadone is dissolved in an orange juice substitute and taken
orally.
After reaching maintenance level, the patient is next assigned to a phase II
clinic. At first, the patient reports daily. He leaves a urine specimen which is
tested for opiates (heroin and morphine), amphetamines, quinine, barbiturates,
and methadone. He drinks his dose of methadone in front of the nurse, and
periodically reports on his activities (for example, school, work), or problems. As
the staff is convinced of the patient's progress, he is required to report less often —
three times a week, twice a week, then once a week. However, when he does rei»ort,
he drinks that day's dose of methadone in front of the nurse (to be sure that he
is still taking it), leaves a urine specimen, and is given his daily supply of
methadone for those days when he does not report to the clinic.
We try to limit the size of our phase II clinic to less than 100 patients. Each
clinic has a part-time physician, a nurse, or nurses (depending on the hours of
the clinic), a supervisor, counselors, a research assistant (ex-addict), and clerical
personnel. Backup medical, psychiatric, pharmaceutical, social, legal, and other
services are provided when needed.
252
It is during pliase II that serious efforts are made in the rehabilitation of the
patient A wide spectrum of services is offered to the patient in the areas of
medical care counseling on problems of everyday life, social services m regard
to family living and ■community resources, vocational rehabilitation, and legal de-
fense advice. The older patients on the staff are especially helpful in this phase,
and are constantly available to help with problems peculiar to addictive patients.
After a year when the staff is convinced that the patient is doing well, at a
job, at school, 'or at keeping house, and the patient seems to have no problem
with alcohol or drugs, he is assigned to a phase III clinic. The treatment is essen-
tially the same, but the frequency of visits is much shorter and there is little
need for the counseling staff. These services, however, are available if needed.
EVALUATION
From the start, in 1964, this program has had independent evaluation of all
the patients who have ever entered it. Originally, when the city financed this
program, money was allocated to the Columbia School of Public Health to per-
form this evaluation. When financing of the methadone maintenance treatment
program was assumed by the State narcotic addiction control commission in
1967, a separate contract was given by the State to the Columbia University
School of Public Health and Administrative Medicine to continue this evaluation.
A highlevel committee was appointed. The charge to this committee was to
evaluate the results of this program in an objective manner, and to make recom-
mendations based on this evaluation. Frances Rowe Gearing, M.D., was appointed
the director of the evaluation unit.
In their report of March 31, 1968, the committee reached these conclusions :
"The results of this program continue to be most encouraging in this group of
heroin addicts, who were admitted to the program on the basis of precise criteria.
For those patients selected and treated as described, this program can be con-
sidered a success. It does appear that those who remain in the program have,
on the whole, become productive members of society, in contrast to their previous
experience and have, to a large extent, become self-supporting and demonstrate
less and less antisocial behavior. It should be emphasized that these are volun-
teers, who are older than the average street addict and may be more highly
motivated. Consequently, generalizations of the results of this program in this
population to the general addict population probably are not justified. There
remains a number of related research questions which need further investigation."
A report as of March 31, 1969, showed there were 153 women and 861 men who
had been under observation 3 months or longer.
"Among the women, 10 percent were employed on admission. After 12 months,
33 percent were employed. Fourteen percent were homemakers, and 3 percent
were in school. After 18 months, 65 percent were employed, in school, or home-
makers and, after 2 years, this percentage had increased to 73 percent.
"Among the men, tlie percent of those employed or in school increases from
26 percent on admission to 56 percent at 12 mouths, 70 percent at 24 months, and
S3 percent at 3 years. The percent of men on welfare or supported by others de-
creases proportionately from 54 percent at 6 months to 44 percent at 12 months,
30 percent at 24 months, and 17 percent at 36 months.
"The arrest records of those who enter the methadone program and those who
enter our detoxification program are similar. Patients who are accepted have to
wait a long period. Acceptance into the program does not have a marked effect
on their pattern of arrest in the 12 months prior to admission. Following admis-
sion, there is a marked decrease in arrests while the pattern of arrest among
the contrast (detoxification) group is very similar to earlier patterns."
None of the patients who remained in the program have become readdicted
to heroin. Problems with drug abuse (amphetamines and barbiturates) varied
from 4 percent to 12 percent.
The methadone maintenance treatment program is an effective, economical way
of treating hard-core heroin addicts who cannot be treated successfully with any
existing programs. It can now be done on an entirely ambulatory basis for most
patients. This makes the program feasible for those areas where inpatient beds
are difficult to obtain. We feel it is very important that this program be a struc-
tured one so that it i-emains carefully controlled.
Methadone maintenance treatment for heroin addiction is a public health pro-
gram. It should be accomplished under the direction of a public health deijart-
ment, a hospital, or an organized uiodical facility. Since rehabilitation and social
productivity of the patient is the prime objective of this program, it is important
253
that the means to do this must be an integral part of the program. It is not suffi-
cient to prescribe methadone alone.
Under these circumstances, the addict is given a chance in a program which he
is capable of handling, and which offers him a realistic path to living as a respon-
sible member of his community and of society without the crutch of heroin.
Mr. Lichtman, whose statements follow, is a research assistant at the Beth
Israel Medical Center. Before becoming an assistant there, he was a drug addict.
In conjunction with Dr. Gollance's article on the methadone maintenance pro-
gram, Mr. Lichtman tells how the program has helped him.
I am 29 years old. I started using heroin at the age of 15. I used it for a period
of approximately 10 years. Approximately 4 of those years were served as a
guest of the city. State, and Federal governments in any number of institutions.
After a period of 10 years, I found that a strange thing happened to me. I devel-
oped a certain motivation which I had not had during that time. I decided that
I wanted something more than I had had for those 10 years. I came to the Beth
Israel Medical Center in April 1966, at which time I applied for the methadone
maintenance program. The reason that I had originally applied for that program
is that I had unsuccessfully tried other methods of treatment when coming out
of institutions in other programs. I found that the same drug craving which I
liad in going into a program would return upon my release from an institution.
I had heard many stories about methadone. I heard that while taking methadone
you are still addicted, and you would not be able to function in the cuiiim unity.
But I decided that since I had not been able to function in the other prograni.s,
that I wonld try methadone.
As I said, I went into the hospital, and stayed there for a period of 6 weeks,
during which time the metl'adone level was increased.
After leaving the hospital, I returned to my family, who were skeptical. My
father owns his own business in Manhattan. He is a furrier and does make a
good living. During the 19 years I was using drugs, he did not allovs- me into
his place of business. When I returned there from the methadone program, as
I ?aii\. he was skeptical, but was willing to take a chance with me.
I lived at home for 4 months, at which time I met a young lady who was
also willing to take a chance with me and who knew my background. After
about 6 months, we were married.
I now have a lovely home in Riverdale, and a new car. I work for the pro-
gram in helping other addicts attain that which I have attained.
I find there is no real "hang-up" in using methadone. I leave a urine specimen
when I come into the clinic weekly and pick up six bottles of medication to
take hnme with me, which I take at my leisure. Methadone is a long-acting drug.
I take the drug at any time during the day, and sometimes forget to take it
and then overlap hours. The drug lasts anywhere from 24 to 30 hours. I have
never experienced any withdrawal symptoms.
As I say, there is no drug craving, and no outw^ard appearance of euphoria.
^Methadone does not produce these symptoms as other opiate drugs do.
In the time I have been on the methadone program, I find that there are many
people who are willing to take a chance on the addict population once they
(the addicts) are stable on it, that is, the maintenance drug. In New York City
alone we have many large organizations, such as the telephone company and
large construction firms, who are willing to employ some of our people in the
program.
It is difficult for me to tell you all of the things that have happened to me
in the past. I have a new life today and it is something that T was never able to
have before.
[Exhibit No. 13(b)]
Beth Israel Medical Center,
Methadone Maintenance Treatment Program,
New York, N.Y., May 7, 1971.
Mr. Chris Nolde.
Associate Covnsel, House Select Committee on Crime,
Washington, B.C.
Dear Mr. Nolde : Following are my comments concerning the statements of
Mr. Horan :
1. We agree that private physicians should be regulated in their use of metha-
done for maintenance ; but we should be careful not to impede the development of
254
well-structured methadone maintenance programs because of the improper use
of methadone by private physicians.
2. Methadone in injectable form (Dolophine) has been available in the legal
and illicit markets for a long time. It is inaccurate and misleading to ascribe
methadone overdoes in any community to the existence of methadone programs
alone since Dolophine has been available for many years and is still available
in the illicit market. Most structured programs do not use Dolophine in pill
form.
3. Although methadone maintenance is not the treatment of choice for all ad-
dicts, it should be available for those for whom it is the treatment of choice.
(a) We have changed our admission criteria as follows :
(1) Minimum age requirement has been reduced from 20 to 18 years.
(2) Number of years of verified addiction has been reduced from 4 to 2
years.
We made these changes in order to make this treatment available to the
younger patient who is already thoroughly addicted to heroin ; in this v\-ay we
can treat the younger patients who need the program without addicting persons
to methadone who are not already clearly addicted to heroin.
(b) We find that most, if not all of our patients, have been treatment failures
in other programs; but this is not an absolute prerequisite for admission.
4. We agree that every effort must be made to screen out any applicant v.'ho
is not already addicted to heroin.
5. Therapeutic communities and residential treatment mentors are modalities
of choice for young and nonaddicted users of heroin. Communities containing
a significant number of addicted persons should provide programs designed to
meet their specific problem, including heroin addiction.
6. Part 5 of the statement reads in part : "We find many provable cases of
injection directly into the vein of methadone mixed with juice or Tang." I have
checked with our clinical staff to make sure that my impression is correct and
it is their opinion that the following is correct : Methadone mixed with juice or
Tang is nouinjectable for several reasons which I think are too technical to go
into here, but the fact is that the drug in this form is not injectable and any
patient who succeeded in injecting it would become fatally ill.
I would emphasize that there is a large group of chronic heroin users for whom
all existing treatment programs except methadone maintenance have been a
failure.
The goal should be to set up structured, controlled programs and not to deny
the seriously heroin addicted this proven program which is literally lifesaving.
both for the patient and the community.
Sincerely yours,
HaPwVey Gollance, M.D.
Asfnciatc Director,
(In charge of narcotic trcatmcitt proyranis).
[Exhiliit Xo. 13(c)]
FoRTY-NiNTii .Judicial Distuict,
Counties of Dimmit, Wekb, Zapata,
Laredo, Tex., November 11, 1070.
Vincent P. Dole. M.D.,
Rockefeller I 'nirer.sity,
New York, N.Y.
Dear Sir: This is to notify you that a complete check of our district court
records reveal tiie following in connection with cases involving burglary and
theft, theft, aggravated assault, forgery, under the infiuence, and other' pettv
theft cases.
Our records reflect that since the inception of the methadone maintenance pro-
gram in Laredo. Webb County. Tex., the reduction in this type of crime has
dropped approximately 05 percent.
Very truly yours,
Carlos V. P.EXAvinES, Jr.,
A.'iS'Stant District Attorney.
Chairman PEPPEr.. The next witness is Mr. Robert F. Iloran.
Mi\ Horan is the Commonwealth attorney for Fairfax County, Va,
Mr. Iloran is a native of New Brunswick, N.J. He attended Mount
St. Mary's College, Emmitsburg, Md., where he received liis B.S.
degree in 1954. Following graduation, he was commissioned a second
lieutenant in the U.S. IMarine Corps and served as a Marine officer
until 1958. Upon leaving active service, he entered Georgetown Univer-
sity Law School and earned his LL.B. degree. He served as an assistant
Commonwealth's attorne_v during 1964 and 1965. In September 1965
he resigned as assistant Commonwealth's attorney to become a partner
in a Fairfax law firm. His law partnership terminated in March 1967,
when the circuit court appointed him Commonwealth's attorney to fill
an unexpired term, and in November 1967 he was elected to that office
for a term of 4 years.
Mr. Horan is a member of the Virginia State Bar, National District
Attorney's Association, Northern Virginia Trial Lawyers Association,
Delta Theta Phi Legal Fraternity, the Marine Reserve Officers As-
sociation, and the Young Democratic Club of Fairfax County. He is
a member and former secretary of the Fairfax County Bar Associa-
tion. Mr. Horan is first vice president of the Virginia Commonwealth's
Attorney's Association, and in March of 1970 he becam.e the first
elected chairman of the Northern Virginia Criminal Justice Advisory
Council.
Mr. Horan, we welcome your testimony.
STATEMENT OF EOBEET F. HOEAH, JE„, COMMOITWEAITI! ATTOE-
NEY FOE THE COTJI^ITY OF FAIRFAX, C0MM0IW7EALTH OF VIE-
GINIA
Mr. Horan. Thank you, Mr. Chairman.
I am the chief criminal prosecutor for a jurisdiction containing
upward of one-half million people. Prior to the year 1967, drug abuse
as a problem in what is essentially a suburban jurisdiction was prac-
tically nonexistent.
Commencing in the fall of 1966 and early 1967, we had our first
onset of drug abuse, as did most of suburban America. One of the
significant things that has happened to us and is pertinent for this
comniittee is that in the last 18 months in that jurisdiction we have
had five provable methadone overdose deaths. We have had tv/o others
that are probably methadone deaths. In the same period of time we
only had one heroin overdose death.
r am here today because of my increasing concern about the direc-
tion in which we are being pushed in the area of methadone main-
tenance. It seems that everyone articulates the position that metha-
done is not the panacea for heroin addiction, and yet in some quarters
it seems that that is exactly how we are treating it.
In my opinion, the news media has added massively to the con-
fusion concerning this drug. I sometimes get the feeling, and that
feeling was amplified by the WTOP editorial last week, that some
feel that methadone equals rehabilitation, and if a jurisdiction does
not have a methadone maintenance program they are simply not in
the rehabilitation business. WTOP's view, in my opinion, is patently
256
nonsense and serves only to add confusion to an already confused
situation.
The confusion is not alleviated when a physician can stand before
this committee, as one did in October of 1970, and state that the use
of methadone in treatment is "paralleled in importance only by the
discovery of penicillin during this century." I don't know what the
founder of the polio vaccine feels about that statement, but it strikes
me as grossly misleading.
First of all, I would like to make clear that I support a properly
run and properly controlled methadone treatment pi'ogram. Basically
I support the original concepts of the program of Dr. Vincent Dole,
in New York City. I firmly believe that with a certain class of addict,
there is nowhere to go but up. On the other hand, I believe that many
of the original Dole concepts have been prostituted on the altar of the
simple solution. Tliei'e is too much of an attitude in some quarters to
consign anyone and everyone who has used heroin to methadone main-
tenance, regardless of his state of addiction. Even Vincent Dole admits
that this method of treatment may consign its participants to a lifetime
of methadone addiction, since this compound is a physically addictive
one. I oppose such an easy consignment for two basic reasons :
One, because of the nature of hard narcotic use and the hard nar-
cotic users that we find in suburban Virginia — and I suspect that the
same would be true in most of suburban America — and two, the in-
creasing availability of this compound as a prime abuse drug.
In connection with the first reason, it is important to remember some
of Dr. Dole's original guidelines.
(1) The addict should be at least 20 years of age ;
(2) He should have at least 4 years mainline hard-narcotic addic-
tion; and
(3) Other methods of treatment must have been tried and failed
before he would be committed to maintenance.
I would suggest, members of the committee, that very, very few
addicts in sulmrban America would meet just those three guidelines.
In my jurisdiction. 77 percent of all our drug abuse cases, regardless
of drug, involves those aged 20 and below. The phenomena of drug
abuse hit us in 1966, while heroin abuse did not hit us until 1969, in
the spring. The net effect of this is that today virtually all of our
heroin users have less than 2 years' mainline addiction. Most, if not all
of them are below age 20 ; and when they first come to our attention,
no other method of treatment has been tried in an attempt to cure them.
Thus we can see that most of our addicts, and I use the term loosely, do
not meet Vincent Dole's original guidelines.
My concern is that in the search for the panacea for hard-narcotic
abusers we might consign to a lifetime of methadone maintenance
some very young kids without ever attempting another route of cure.
In my opinion, very few kids in my jurisdiction should be so consigned.
An analogy to "throwing out the baby with the bath water" might fit
our situation.
I would not for 1 minute contest the right of the District of Columbia
or New York City to commit themselves fully to massive methadone
maintenance programs. But please, for Heaven's sake, let's not commit
the rest of the country.
257
I guess I have read most of what Drs. DiiPont and Dole say about
their programs, and their writings certainly substantiate their commit-
ment— but their special jurisdictional needs appear to require it — my
jurisdiction does not, and I suspect that the rest of suburban America
is in my situation and not in theirs.
We presently have in Fairfax County a drug treatment program
based upon the therapeutic community concept.
We have been in the business for quite some time now. We are satis-
fied with our methods of treatment, and if there comes a time when we
have a large scale number of hard-narcotic abusers, then we are prob-
ably going to take a much harder look at methadone. But that is not
our situation today.
The second problem in northern Virginia involves the use of metha-
done as a prime abuse drug. Supposedly, the situation will be alleviated
by FDA regulations which may control the dispensing. I hope those
guidelines do that, because prior to any guidelines our situation was
atrocious. In the spring of 1970 the Fairfax Police Department and I,
after our second methadone overdose death, began to complain about
the availability of this drug in the marketplace. Unfortunately, three
more deaths were necessary before anything was done to tighten up
dispensing guidelines in the District, and two of those deaths involved
kids 16 years of age.
We have tried, through the treatment program, the police depart-
ment and my office, to evaluate our situation with regard to the avail-
ability of methadone. I would like to share with you some of the find-
ings that we made, based on a cold, hard look at it in the past year.
First. Large supplies of this drug have been coming out of the Dis-
trict of Columbia, primarily from private practitioners' offices. Much
of this methadone has been diverted into abuse circles and in some
cases it has become the drug of choice. Some of it is being sold right
in the syringe at $1.,50 a cubic centimeter. This makes it an excellent
profit drug and as much as in the case of at least one physician, he
distributes 50 cubic centimeters at a time at $15 a throw.
Upon resale of that at a $1.50 a cubic centimeter the profit is
apparent.
Mr. Peeito. Mr. Horan, has this doctor been prosecuted?
Mr. HoRAN. To my Imowledge he has not. We have no jurisdictional
control over him.
In the District of Columbia he can do exactly what he is doing.
Mr. Perito. Have you recommended to the District authorities that
he be prosecuted?
Mr. Horan. I have had a great deal of contact with the narcotics
squad over the year, and the district attorney's office, and they feel
their hands are somewhat tied. That is the impression I get.
Mr. Sandman. Why are they tied ?
Mr. HoRAN. Because, evidently, under the existing regulations he
can maintain an addict on methadone because he is making: a purely
medical iudgment, and. therefore, it is not criminal under District law.
Mr. Waldie. Mr. Horan, may I interrupt you ?
We are in the middle of a quorum call. I would like to have you
complete your statement before the end of the second bell. Perhaps
258
you best complete your statement and then we will come back for
inquiries.
Mr. HoRAX. The second thing we find is a number of cases of non-
heroin addicts being dispensed methadone in the District of Colum-
bia from private practitioners. These are kids that weren't addicts
to begin with, and they are getting methadone without being a true
addict.
You may have read about the reporter from the Northern Virginia
Sun who had never had a narcotic in his life, came over here, plunked
down $15 and he got methadone in a hand}' carryout dose.
Third. Methadone addiction appears to be growing at a faster rate
than heroin addiction. Our drug treatment program over the past
year found it necessary to engage in medical detoxification of 39 pa-
tients. Thirteen of these were detoxified for a heroin habit and 26
were detoxified for a methadone habit. A large majority of those de-
toxified were below age 20.
Fourth. Some of the users were obtaining methadone by going to
one physician on one da^?- and a different physician a couple of days
later. This resulted in their being able to obtain a weekly supply from
each physician in the same week.
Fifth. Dr. Vincent Dole originally felt that one of the main reasons
for dispersing methadone diluted in fruit juice was that nobody would
shoot it. We find many, many provable cases of injection directly into
the vein of methadone mixed with juice or Tang.
As a matter of fact, the interior of the lungs of one of the recent
death cases was coated with a material that was consistent with
methadone abuse. There is only one way to get that on the interior
lining of the lungs, and that is through a vein.
Many cases of nonfatal overdose began to show^ up simply because
methadone was entirely too much drug for the drug abusers in our
area, particularly when it was being injected rather than taken orally.
An addict may have been getting 2- or 3-percent heroin in his vein
and all of a sudden he is getting a relatively pure drug in methadone
and his central mervous system can't stand it. His respiratory system
fails, he stops breathing.
Sixth. A great number of our citizens were not even aware that
their youngsters were involved in a so-called methadone treatment
program in the District. Their kids were in treatment programs. They
didn't know the treatment involved the daily dispensing of phj-sically
addicting narcotics.
In conclusion I want to say that methadone maintenance probably
does have a proper place and is the only mode of treatment in sonic
cases. However, I strongly endorse the caveat of this committee, at
page 82 of its report of January 2, 1971, entitled "Heroin and Heroin
Paraphernalia," where in this committee said :
Every precaution against diversion mnst be olxserved. While we believe tliat
drug should be reclassified, we do not believe that individual private practitioners
should be allowed to prescribe methadone for prolonged maintenance of indi-
vidual heroin addicts.
The footnote to that caveat gets to the heart of tlie issue, in my opin-
ion, where tliis committee states: "Methadone maintenance must be
accompanied b}' proper psychiatric, social, and vocational services.''
259
- I would only add to that the suggestion that maintenance should not
be the original mode of treatment except in an isolated class of cases ;
and secondly, that in the case of many young suburban abusers proper
psychiatric, social, and rocational services will obviate/ tjiie necessity
of maintenance to begin with. \ ■, .,.
Mr. Waldie. Thank you, Mr. Ploran.
There will be, I am sure, a number of questions to be asked of you.
Hopefully we v^^ill reconvene at 1 o'clock.
The committee will remain in recess until that time.
(Thereupon the committee recessed to reconvene at 1 p.m.)
Afternoon Session
Mr. Mann (presiding). The committee will come to order.
Prior to the recess, Mr. Horan was testifying and we will resume
his testimony.
Mr. Horan, you had completed your statement in chief ?
Mr. Horan. Yes ; I have, sir.
Mr. Mann. All right ; Mr. Perito, will you inquire ?
Mr. Perito. Thank you, Mr. !Mann.
Mr. Horan, I assume from your testimony that you are not opposed
to properh^ run methadone programs ; is that correct ?
Mr. HoKAN. Tliat is correct.
j\Ir. Perito. It is the thrust of your testimony then, if I underst.md
it, that you consider that your problem is different from the problem
in the District of Columbia or in New York City; would that be
correct ?
Mr. HoRAN. I certainly think that is so, predominantly because I
think we have a different breed of addict than New York City has,
sir.
]Mr. Perito. Would NTA be the type of program that you point to as
an example that you could support ?
Mr. HoRAN. That may be a little far.
From the point of view of the one issue of the ability to di\'ert
methadone into drug abuse circles, I have no evidence that we have
ever seen any methadone in our area that has come out of NTA.
From that point of view I am satisfied with the NTA controls at this
point in time.
On the second issue, my difficulty with NTA is that they appefir to
be, on the surface, entirely too methadone prone. That seems to be
the big thing with them as opposed to what I think is a growing tend-
ency in research programs to indicate that different modes of treat-
ment are necessary.
Mr. Perito. And you believe that the propensity toward methadone
distribution in a clinical setting causes you, as a prosecutor, problems?
Mr. Horan. Yes ; I think so.
Mr. Perito. And those problems come from diversion ?
Mr. Horan. They come from diversion. They also come from '^he
psychological attitude, if you will, that methadone is the cure, and vou
find an awful lot of addicts, who discover it really isn't the cure, it is
just another drug for those addicts. It just continues to be a difficult
criminal problem.
260
Mr. Pertto. Based upon your experience, have you found diver-
sion on a manufacturing level in Fairfax County ?
Mr. HoRAN. No ; we have not.
Mr. Perito. I assume that based upon your experience your diver-
sion is found on the low levels of dispensing, say from private
physicians?
Mr. HoRAN. Almost entirely private practitioners.
Mr. Perito. Have you found any evidence of diversion on the drug-
store level?
Mr. HoRAx. There is a recent report by the Virginia Board of Phar-
macy. An investigator who did a report for the Virginia Board of
Pharmacy found virtually no diversion anywhere in the State.
Mr. Perito. So it is fair to say that ordinarily, and based on your
experience, the diversion which causes you problems, as a prosecutor,
comes from private physicians ?
Mr. HoRAN. Yes ; it does.
Mr. Perito. Based upon your experience, how do you think that
diversion problem can best be handled ?
Mr. HoRAN. I feel at this point in time a private practitioner simply
should not be in the business. He should not be in the business of
methadone maintenance. My feeling is that I have never seen a prac-
tioner in the metropolitan area of Washington who I feel has the
pi'opcr supportive services to go along with his program so that he
is an effective rehabilitation mode. I think that with the average physi-
cian we have run into in the metropolitan area of Washington, all he
is is another drug seller. I would hate to think that organized crime
ever wants to move in under the guise of a medical license. Organized
crime might move into the dispensing of methadone, because it is a
high-profit drug as it is being dispensed privately.
Mr. Perito. You presently have operating in Fairfax County thera-
peutic communities ?
Mr. HoRAN. Yes ; we do.
Mr. Perito. I assume by that you mean a drug-free community ?
Mr. HoRAX. Yes.
Mr. Perito. And they only use methadone as a detoxification drug?
Mr. HoRAN. Actually the treatment center, itself, does not use metha-
done at all in treatment. We use methadone in the jail facilities as a
withdrawal drug to detoxify an addict.
Mr. Perito. How long has the therapeutic facility been in operation
in Fairfax County ?
Mr. HoRAiSr. Since September of 1969.
Mr. Perito. Do you have any statistics from that facility as to the
efficacy of their approach insofar as the reduction of crime or incidence
of antisocial behavior is concerned ?
Mr. HoRAN. I don't have any specific statistics that could prove it
one way or the other. I do know that of those in the treatment pro-
gram wc have had very few that we later see in the court scene as a
criminal statistic.
Ml-. Perito. Do you know, as a genei-al matter, whether therapeutic
communities have been successful in reducing the crime rate of addicts
under treatment ?
Mr. Horan. I think probably they have been.
261
Mr. Perito. Is your thinking based upon studies that you have
seen?
Mr. HoRAN. Mostly the reading that I have done in the area, from
other parts of the country.
Mr. Perito. If you have any of those studies, I would appreciate
you making them available to the chairman of the committee.
Mr. IIORAX. I certainly will.
(As of the time of printing of this record, the committee had not
received the studies or statistical evaluations from Mr. Horan of the
efRcacy of drug-free clinics insofar as the reduction of crime or anti-
social behavior is concerned. )
Mr. Pepper. Mr. Blommer.
Mr. Blommer. Mr. Horan, would you say that in Fairfax County
(here are very many drug takers that you would call addicts, as op-
posed to drug experimenters or drug users ?
Mr. Horan. The head of ou]- Fairfax-Falls Church Mental Health
Center, a psychiatrist, refers to our population of drug abusers as
1)eing garbage collectors. By that he means they will take anything,
regardless of what it is, or what form it is in.
I would suspect an overwhelming percentage of our kids are in
that boat. They will use anything. They aren't committed strongly
to any one drug, by and large.
We tried to figure out the other day, sitting down, tried to put
together a list of those we thought were anyv>^here near 4 years in
the vein, and we couldn't come up with 10, and most of them were
addicts that we had dealt with, 7, 8 years ago, coming out of the city
of Alexandria, mostly. They are the only ones we could come up with.
Most of our kids are diversified drug users. They have tried heroin
a few times here and there, along with a number of other things, and
they aren't in the vein that heavily.
As a matter of fact, I can recall no case of a jail prisoner who
took much longer than 20 hours to be completely detoxified. Most
show absolutely no withdrawal symptoms after the 20-hour mark.
As a matter of fact, we have had kids come in, who supposedly
had big drug habits, who never show any withdrawal symptoms the
whole time they were in the jail.
Mr. Blommer. Mr. Horan, do you have what you would call a black
market in drugs in Fairfax County and if so, what drugs are available.
Mr. Horan. I think they are all available, unfortunately. I think
our drugs essentially come from about three major sources.
First, I would be in the hard narcotics field, heroin and maybe some
morpliine on rare occasions. That almost invariably is coming out of
the wholesalers in the District of Columbia. I know of only one whole-
saler that we have ever dealt with in Fairfax County in the heroin
area. That is one source.
The second source is the methadone source which appears to be
private practitioners in the District.
The third source is the ximerican free enterprise system at its best,
and that has to do with marihauna, LSD, and hashish, and there it is
a very amateur, nonprofessional, somewhat noncommercial market
where kids are using a tremendous amount of ingenuity to come up
with drugs.
262
A a'reat case in point was a conple of years airo I had a phone call
from th<? ]>r;)secutor in Lincoln County, >7ebr., Foit PJafte, Kebr. Pie
wanted to know if we had a kid in our coinmunit}', for want of a better
name, Joe Blow, and I said yes, we did. As a matter of fact, we were
prc^eciitinir him for a drn^ oifense at that time. They had just picked
him up in ISTebraska with liis trusty sickle in hand, he was cuttinj^
down a field of marilmuna in Lincoln County, Xebr., and had 17-
pouuds in the trunk of his car when the Lincoln County, Nebr., police
arr-psted him.
H? is th.e free enterpri'-e type who would come back with a tremen-
dou'^ amount of marihauna for sale.
Ml-. Blommer. You liave said tliat you find that methadone in your
black market comes from physicians in the District of Columbia that
are jirescribinjT; it. Are there any physicians in Fairfax County that
are prescribing methadone that you feel is entering in that black
ma rket ?
Ml". HoRAisr. No; we can't show any physician in northern Virginia
add'ug to the black market. We have a couple of cases that involve
aboi!^ eiirht persons who are receivino; metliadone maintenance from
Virginia physicians, but we find no indication of diversion.
Mr. Blommer. If you found a doctor in your county that you felt
was more of a peddler than a healer, is there any statute in the State
of V' rcinia that you could use to prosecute that doctor ?
Ml-. IToRAN. Yes; I think we could prosecute him under our Drug
Coutrol Act.
Mr. Bf o^FMER. You have heard Dr. JafTe refer to his law. Then the
Stat.'^ of Virginia has a comparable law?
M:-. HoRAN. It is comparable law. In my opinion as a prosecutor it
would be very, very difficult to get a conviction because I think you
run into the basic ]>i-oblem that tlie physician sitting there before a
jury, he can lay it all off on the medical considerations, I made a medi-
cal judgment and this w^as my mode of treatment.
I think you would have trouble convicting him imder the statute.
I think, in Virginia, a far better vehicle would be to go through
the State board of medical examiners to revoke his license, or in the
case of pharmacists, the State board of pharmacy to revoke his license.
I think that would be a far better method of getting at the corrupt
practitioners than would be a criminal prosecution under the Drug
Control Act.
Mr. Blommer. Would you favor Federal legislation in this area?
Mr. HoRAN. I am totally in favor of Federal legislation that sets
up strict controls on methadone availability. One of the reasons I feel
so strongly about it is that I know that for a year we banged our
heads against a brick wall to try to cut down the availability of this
drug that was coming out of the District of Columbia.
We have been totally unsuccessful. We have got three deaths to
prove it. It seems to me only Federal legislation is going to control
that situation, at least as far as Virginia is concerned.
Mr. Blommer. Thank you, JVIr. Horan,
That is all the questions I have, Mr. Chairman.
Chairman I^epper. Mr. Mann ?
Mr. ]Mann. No questions.
263
Chairman Pepper. Mr. Steiger ?
Mr. Steiger. Thank you, jMr. Chairman.
Mr. Horan, to your knowledge, has any physician ever been charged
in the State of Virginia under the statute to which you just referred?
Mr. HoRAx. Yes ; I think there have been charges under that statute.
Mr. Steiger. To what degree of success ?
IMr. HoRAX. The net effect was that the physician just turned in his
license and the prosecution ended there. They didn't pursue it.
IMr. Steiger. He didn't continue the practice of medicine?
Mr. HoRAx. He lost his right to practice medicine.
Mr. Steiger. You mentioned in several instances of private physi-
cians in the District of Columbia who are the source of diverted
methadone. How many are we talking about ?
Mr. HoRAX. At least four.
Mr. Steiger. At least four.
And you know who they are ?
Mr. HoRAX. Yes ; I think we have a good idea.
Mr. Steiger. What kind of volume are we talking about. I ^uess the
thing that would really interest us would be not only that which finds
its way into Fairfax, but that which is being diverted in the District,
also.
Mr. HoRAx. One example that I can give you is in the case of one
specific physician. We have had him under surveillance a number
of times over in the District because we feel that at least two of the
drug deaths we have are related to his supply.
In the course of surveillance of this physician there was never a
time when the physician had less than 10 patients an hour in his office
at $15 a throw. If you give him a six-hour day and a 5-day week, he
has about $325,000 gross minimum in just his dispensing habits.
Mr. Steiger. Excuse me. All of these patients, based on your observ-
ance, were receiving methadone ?
Mr. HoKAX. Yes ; everybody that was in there. That is what he is
there for.
Mr. Steiger. He didn't do much else ?
Mr. HoRAX. He is supposedly a general practitioner, but I think
his main business is methadone. In his case, he is dispensing in a form
that is probably costing him $0.25. In my opinion, the whole treatment,
at least as we know it, has to do with dispensing methadone and
nothing more.
Mr. Steiger. Right.
Mr. HoRAx. There are no rehabilitative or vocational services.
Mr. Steiger. Do you know the form, the physical form ?
Mr. HoRAx. Methadone mixed in Tang.
Mr. Steiger. It was the same form in which it is given at the clinic
as you described ?
Mr. HoRAX. That is right.
Mr. Sreiger. It has been your experience, which you stated in your
statement, that contrary to some of the medical opinion we had that at
least one victim apparently did shoot the mixture in the Tang ?
Mr. HoRAX. Every one of our dead ones was in the vein with metha-
done; in one case it was the methadone mixed in Tang. Every one
of them was shooting but only one of them, to my knowledge, had
Tang.
264
Mr. Steiger. Did you discuss with the District of Columbia author-
ities this particular physician ?
Mr. HoRAN. Yes ; I did.
Mr. Steiger. Did they corroborate your observance?
Mr. HoRAx. As a matter of fact, the District of Columbia Police
indicated to me that on four occasions they had detectives who went
to this doctor's office and got methadone.
Mr. Steiger. Do you know what action they took against him ?
Mr. IIoran. There was a grand jury proceeding, and the grand jury
did not indict. I am only basing this on hearsay, as to what the grand
jury proceeding was. There has never been a prosecution for illegal
dispensing against that physician.
Mr. Steiger. Is there an AMA organization in the District?
Mr. HoRAN. I believe there is.
Mr. Steiger. Do you know if anybody has called this matter to their
attention ?
Mr. IIoiLVx. I think it has been. I think it has been brought to the
attention of the D.C. Medical Society.
Mr. Steiger. As far as you know — this fellow — there was no action
taken to limit this activity ?
Mr. HoRAN. No ; there was not.
Mr. Steiger. Now, these other three that you are aware of, are they
conducting as extensive an operation as this gentleman?
Mr. HoRAN. One of them may be bigger.
Mr. Steiger. Is it possible that there are other physicians that you
aren't aware of?
Mr. HoRAN. Oh, yes; I am sure of that. "What happens to you. I
think, is that certain physicians develop a name in drug circles, that
name is mentioned, and it is kind of a public relations program to be-
come known and then you become the source.
I think that is what happens. Maybe the kids in ^Montgomery
County are going to someone else; I don't know.
]Mr. Steiger. Have you ever checked with the FDA to find out if
any of these four have a so-called IND number issued by the FDA ?
Mr. HoRAN. I have checked with them on two of them and they do.
Mr. Steiger. They do ?
Mr. HoRAN. Two of them do.
Mr. Steiger. What was the response of the FDA when you advised
them of your observance ?
Mr. HoRAN. We never had an awful lot of success with FDA. I
guess we had about as much success as the Bureau of Narcotics and
Dangerous Drugs. There seem to be some loggerheads between the two
of them as to what the policy should be. I final Iv brought it to the
attention of Virginia's two U.S. Senators and "at least, based on
the speech that Senator Byrd gave on the floor of the Senate, he didn't
have an awful lot of success with FDA, either.
Mr. Steiger. I think loggerheads is a very general philosophy.
I take it, then, as recited both bv the chairman and INTr. ^Nlann.'and T
guess everybody else, that you do favor very specific Fodornl statutes
which obviously would be applicable in the District of Columbia «
Mr. HoRAN. Yes, sir ; I do.
265
Mr. Steiger. Limiting the dispensing of methadone ?
Mr. HoRAN. At this time I don't think private practitioners should
be in the business.
Mr. Steiger. Based on your testimony, at an estimated cost of 25
cents, this man is making a profit of $14.75 a patient, less the overhead
for rent and lights and heat, and at the rate of 10 patients an hour,
he is there for somewhere in the neighborhood of $150 an hour ?
Mr. HoRAN. At least.
Mr. Steiger. Mr. Chairman, I won't pursue this any further, but I
would like to compliment the staff and Mr. Horan for spelling this out
so specifically. I think one of our basic problems has always been the
tendency to accept the medical profession as being incapable of the
kind of action you described, and I, for one, have never subscribed to
that, the sanctity of any profession. They are just people, and I would
hope that we would be able to do something, Mr. Chairman.
Chairman Pepper. I am sure the committee will give very serious
consideration to that problem.
Mr. Horan. I would suggest, Mr. Chairman, if I might, I think one
of the difficulties that you run into is that by and large medicine as a
group has never paid much attention to this subject because it was just
beyond normal medical needs. I think what has happened is that you
do have a very small percentage in the clinical end, and of course they
are some of the great minds on the subject, Jaffe, Wyland. and Dole.
Those are the people who have the most experience with it. Medicine
generally has never dealt with it.
It is not taught in medical schools. When the private practitioner
gets into this business he is dealing with a very difficult situation be-
cause he is not really in a knowledgeable position.
Chairman Pepper. If I may corroborate what you said, my wife and
I have been identified for a long time with the Parkinson Foundation
and Institute, and we have come in contact with some of the outstand-
ing authorities who have developed and discovered methods for the
practical application of L-Dopa in the treatment of Parkinson's dis-
ease, and these authorities say very strongly that the average practi-
tioners should not be permitted to give L-Dopa because they don't
know that much about it.
I know a Senator here in the Congress right now who was being
given, by certain medical authorities, large quantities of L-Dopa. One
of the outstanding authorities in the country visited the Senator and
reduced his dosage very much and he improved, because it is a spe-
cialized subject and you have to know a lot about it before you can
wisely dispense it.
JNIr. HoRAN. Yes, sir.
Chairman Pepper. Have you finished ?
Mr. Steiger. Yes, sir.
Chairman Pepper. Mr. Rangel.
Mr. Rangel. Yes.
Mr. Horan, you support the efforts being made b}^ the District of
Columbia and New York City in the area of treating addicts with the
use of methadone ?
Mr. Horan. Yes ; in a certain class of cases.
]Mr, Rangel. And you also support its use in the jails of Fairfax
County ?
60-296— 71— pt. 1 18
266
Mr. HoRAN. We don't support it as a matter of maintenance, only as
a matter of withdrawal.
Mr. Kangel. For detoxification ?
Mr. HoRAN. Right ; bring them down, and we bring them down in-
side of 48 hours.
Mr. Rangel. What is the ethnic composition of the drug addicts in
Fairfax County?
Mr. HoRAN. That is a good question. INIy county is about 5 percent
black. Using the normal phrase "minority group," I don't think there
is a high percentage of any other minority group in my county. Yet
in the year 1970, of 322 prosecutions only 10 of the 322 were blacks.
In our black community, by and large, we never really had a drug
problem until the fall of last year when one major dealer — and this is
the only real wholesaler I have ever dealt with in the heroin field —
moved into our black community, began a selling operation, and un-
fortunately about the time we got into the act there were a number of
15- and 16-year-old blacks in the vein, pretty serious heroin habits.
Of course, Ave never would have cracked it, except for a District of
Columbia policeman. He is really the one who cracked it for us.
Mr. Raxgel. So your overwhelming population in Fairfax County
is white ?
Mr. HoRAN. That is right.
Mr. Rangel. If you had to give a general classification, what would
they be, middle income ?
Mr. HoRA>r. High-middle income. In median income we are about
the third or fourth county in the count r3% I think.
Mr. Rangel. Were you here earlier when I asked Dr. Jaffe whether
he thought that the medical profession had established a different
standard in taking care of the problems, medical problems of poor peo-
ple as opposed to the medical problems of middle income people ?
Mr. HoRAN. Yes; I heard that question, and I thought about that.
Mr. Rangel. Aren't you really supporting that type of thing in
your testimony today ?
Mr. HoRAN. No. I feel this wa^-, and I feel pretty strongly about it :
You look at the statistics, the statistics still indicate that one-half of
all heroin addicts in the country live in the city of New York. Of those
in the city of New York, let's face it, most of tliem come from Harlem
or Spanish Harlem. As long as there Avas a problem in the city of New
York in those communities, nobody really cared, who cared outside the
city authorities ?
The rest of the countrs^ didn't worry about it, it wasn't their prob-
lem. I think, by and large, because it was the low-income groups in the
city of New York, no one cared.
That is a tragedy. I think we should have been learning something
from New York's 30 years of experience and we didn't.
On the other hand, I think that medicine by and large now sees it
on a large scale, all over the country. ]\Iedicine is looking at it, and
I think medicine, like everybody else, is scrambling for an answer. I
would not impute to medicine the motive that they are willing to take
the easy way out and just consign these low-income groups to
addiction.
Mr. Rangel. Let's look at it in view of your testimony. What you
are basically saying is that you would like 'to see medical science pro-
267
vide otlier ways to take care of your addict population rather than
relying on methadone 'i
Mr. HoRAN. Yes ; I would.
Mr. Raj^-gel. And you also say if the situation gets so bad in your
community that there is no way out except methadone, then, and
only then, will you consider this ?
Mr. HoRAx. Absolutely.
Mr. Rangel. I am asking you, would you not give the sam.e con-
sideration to the District of Columbia and the population of New
York City, that is, until you can evaluate that our addict population
has reached that point then you would have this same reservation about
the distribution of methadone for any community ?
Mr. HoRAx. I sure would.
Mr. Rangel. I am only hoping that the medical profession will
share your ideas.
Mr. H0R.VX. Of course, Mr, Rangel, my difficulty is in evaluating
New York. I, necessarily, have to rely on what Dr. Dole is saying,
Dr. Gollance is saying, what New Yorli's experts are saying about their
population, and they tell me in their writings that what they are
essentially aiming at is the guy who has been in the vein for many,
many years, the guy who is just fully, totally, and completely hooked
on heroin.
They are saying to me the only way we can treat them is with meth-
adone. My answer is, I don't know.
But I do know this, that I don't think methadone is the answer
if you have got a guy only 2 years in the vein and if they are com-
mitting New York addicts with 2 years in the vein to methadone,
I think they are wrong.
I think they should be going some other route of treatment,
]\Ir. Raxgel. So if my breed of addict, or a part of my breed of
addict, is similar to what you described as similar to Fairfax County's
breed of addict, we would share the same ideas ?
Mr. lioRAx. Yes ; I don't think the addict, the IT-, 18-, 19-year old,
I don't think he should be committed to a methadone mamtenance
program at that age or with that short a term of addiction. When I
ttilk of breed of addict, really what I am talking about is in New
York where you have a lot of people who have been in the vein 10
years, I don't have any of those. But I think that those that are in
the same position as mine, the 18-year old who has been in the vein
for a year, I don't agree with New York putting him on methadone
any more than I agree with Fairfax County putting him on
methadone.
Mr. Raxgel. Mr. Chairman, I want to join in with my colleagues
and thank the staff for bringing Mr. Horan before us. I think it sub-
stantiates the fact that not everyone has just accepted methadone as
a solution to our present problem.
Thank you, Mr. Horan.
Chairman Pepper. We all will profit very much from your testi-
mony.
We have some more questions.
Mr. Winn.
Mr. Wixx. Thank you, Mr. Chairman.
268
Mr. Horan, let's back up a little bit. Over in Fairfax County, those
that are on drugs, the kids that are on drugs, a high percentage of
the users are on marihuana ; right ?
Mr. HoRAx. Well, a less high percentage all the time. In 1967 one
case out of every 10 would be a stronger drug than marihuana. By
last year it was one case out of every four. I think there has been a
real graduation of marihuana users.
Mr. Winn. The percentage of those who were on marihuana have
switched and gone to the harder drugs in the percentage of one out
of four now ; right ?
Mr. HoRAN. Yes.
Mr. Winn. All right. Physicians prescribe all kinds of drugs for
different things, which is within their realm. It is a little hard for
me to comprehend that all the bad guys are in the District of Columbia,
physicianwise, and all the good guys are in Fairfax County.
Mr. Horan. I wouldn't want to create that impression although,
you know
Mr. Winn. I think maybe we have.
Mr. Horan. In fairness to our medical society, I would say abso-
lutely that one of our real sources of help out there has been the medi-
cal profession. I think they police themselves.
Mr. Winn. That leads me into the next question : Do you think it
is because of the strength of the Fairfax County medical society that
they are keeping a stronger and tighter rein on the doctors and physi-
cians over there that might be prescribing, say free lancing, methadone
compared to the District of Columbia ?
Mr. HoRAN. Yes, sir. I think that is probably part of it. I think
another ])art of it is the fact that when the drug phenomena hit us in
1966, medicine got in the act early, and medicine began taking a look
at this subject that they knew nothing about.
Let's face it, the average physician, if he is below age 25, he never
had a course in medical school that involved the three main abuse
drugs in society today, LSD, marihauna, and heroin. They aren't
taught in medical school because they have no therapeutic value.
Mr. Winn. They are still not being taught now ?
Mr. Horan. Well, Georgetown
Mr. Winn. But not nationwide ?
Mr. Horan. No ; it is not.
So medicine, first of all, in a community such as mine, has got to
get into the act to understand it to begin with, because they are in a
foreiirii field, just like every layman out on the street.
Our medical society did that. Our medical society took a good hard
look at prescribing practices, which I think is really the key.
I think medicine has got to look at themselves and say what are we
doing.
Mr. Winn. Right. That clarifies that, because I don't think you
really made that clear, at least I didn't get it that way in the earlier
testimony.
Now, the Drug Control Act is basically controlled again by each
State. That would go right along with the same vein of thinking,
depending on which State is really going to clamp down and wliich
ones are going to close their eyes to some of the acts ; right ?
269
Mr. HoRAN. That is right.
Mr. Winn. Which would come into effect possibly again because
of the control and the District of Columbia control might be lighter
than in Virginia.
Mr. HoRAN. I think that is right.
Mr. Winn. Okay.
Well, I don't know about Baltimore — how about Baltimore?
Mr. HoiLVN. I never had all that much experience with Baltimore.
Mr. _ Winn. All right. You mentioned several times the history of
the jail cases, and I understood you to say that you have a system, I
believe you referred to some hours and you said 24 hours as an aver-
age for getting them detoxified ?
Mr. HoRAN. Most of the time, they are detoxified in 24 hours.
Mr. Winn. Twenty-four hours ?
Mr. HoRAN. That is without any
Mr. Winn. Yes ; right.
Mr. HoRAN. "\^^ierever it is felt that they need help to come down,
it is all over in 48 hours.
Mr. WixN. Then you use methadone ; right?
Mr. HoRAN. Jail physicians prescribe Dolophine in a certain amount
and that is what the prisoner gets and it never goes over 48 hours.
Mr. Winn. What is their reaction to the methadone within that
48-hour period ?
Mr. HoRAN. It all depends on what kind of addict they are.
Mr. Winn. Give us the worst example and give us — and the lightest
one obviously would have no reaction, probably. The heaviest
Mr. HoRAN. One of the things you constantly have to watch for is
the kid who comes in there and the first thing he is saying when that
jail door closes is, get me the methadone, because the word is out
among that breed that you can get this stuff if you qualify and you
may have a rruy coming in there that isn't really any addict at all, and
he wants methadone because he is going to get high.
Two davs in jail high beats 2 days in jail any other way. So he wants
it. ■ ^ _
Mr. Winn. How does he get hisfh on oral methadone that is taken
with Tang?
Mr. HoRAN. Anybody who says you don't get a high on methadone
is dreaming. I am talking about you and I. The problem is — and I see
the newspapers constantly use this term — a "noneuphoric substitute
for heroin" — it is not a noneuphoric substitute.
If you are talking about a guy who has been in the vein 5 years,
yes; but you know, you could do anything to that guy and it is going
to be noneuphoric compared to heroin. With most other people we
get a high.
Many women today in hospitals after a very difficult delivery, the
prime druff used the following day after the delivery, if the woman
is in pain and having problems, is what they call in the hospital Dolo-
phine, and that is methadone, same drug. They give her Dolophine.
You talk to anv woman who has ever hpd Dolophine and ask her if
it is euphoric. She says, "You bet your life. That is the reason they
gave it to me. it lifted my spirits and killed the pain. That is why
they gave it to me." It does have a definite euphoria on the scale.
270
It is not up to heroin or morphine, but it is probably on the level
with Demerol ; anybody who has ever had Demerol will agree it has
a good euphoria.
li a guy comes into jail and is really not an addict, he is going to
get a high.
Mr. Winn. Wait just a minute. I want to point out strongly, Mr.
Chairman, that this is in direct conflict with testimony we have heard
in the past from several of these other experts. I want to point it out
because it is completely different.
Chairman Pepper. Apropos of what my colleague said, the way I
believe it was stated by Dr. Jaife this morning was that with the first
little bit of taking of methadone you do get a high, but then if the doc-
tor giving it keeps on experimenting with the individual and gets to a
point where that person is stabilized and he doesn't get a high,
Wasn'tthat the gist?
Mr. Winn. I believe that was Dr. Jaffe's ptatem.ent, Mr. Chairman,
but I believe one of the other experts said that there was no euphoric
sensation from orally taken methadone.
Mr. HoRAN. I say that is flat out untrue.
I think the problem is that they are constantly asking a true addict
is there any euphoria, and he is telling the truth, for him there is
none, but he is comparing it to heroin. It is like the Irishman and the
Englishman seeing the guy la3'ing in the ditch. The Englishman said,
"Look, that guy is drunk." The Irishman said, "No, he isn't, he
moved."
It is about the same ball park, really.
There is medical research that will substantiate the fact tliat if
you get to a certain level of heroin use, say the guy who is maybe a
hundred dollars a day in the vein, he gets to a certain level where the
heroin itself is noneuphoric because he has gotten too high on the
scale, there is no euphoria left in the drug for him.
In fact, there are some in research who sav you could create the
same blockage M-ith high doses of heroin as you do with high doses
of methadone, because you reach the point where the drug itself
reaches the block.
Mr. Winn, Let me ask you one more question.
Of the drug deaths that you referred to, could the drug deaths be
from an overdose of oral methadone ?
Mr, HoRAN. That is a very good question. In two of the cases it
appears that the dead boy was taking it both orally and intravenously.
It could have been the combination, although our pathologist
suspects that because of the massive infusion when you go in through
the vein, that is what causes the quick respiratory system depression.
Mr. Winn. We have had some statements made here and the facts
presented to us, that some of the deaths not in Fairfax County, but
some of the deaths from methadone really proved out to be not deaths
from methadone at all, but a combination of lots of other things; is
that possible ?
jNIr. HoRAN. Sure it is.
Chairman Pepper. The committee has to go to the floor to vote.
We will take a brief recess. We will be back in a few minutes.
(A brief recess was taken.)
271
Chairman Pepper. The committee will come to order, please.
Mr. Keatinsr, ttouIcI you like to examine ?
]Mr. IvEATixG. ^Ir. Horan, I was not here for your entire testimony.
However, the portions that I heard in the question and answer por-
tion of vour statement I found to be excellent.
I think ]Mr. Ranp:el had indicated, and I agfree, that the goal we want
to achieve is rehabilitation and not total maintenance for the life-
time of the addict. So I don't have any specific question, but I wanted
to make those comments.
Chairman Pepper. Thank you.
]Mr. Horan, your testimony about the drug problem in Fairfax
County is of particular interest to those of us who are on this com-
mittee now who were members of the committee in the last Congress,
because either in the latter part of 1969 or the early part of 1970 we
held a hearing in Fairfax Countv, vou recall, in the courthouse?
]Mr. HoRAxrYes, sir : the fall of 1969.
Chairman Pepper. What interested us was that here was a very fine
county, composed of very fine citizens, high level of income, primarily
residential in character, that had a heroin problem.
I recall very well that we had some students from one of your high
schools who testified at our hearing and told about the prevalence of
drugs in the schools, the high schools.
So, you, as the Commonwealth's attorney of Fairfax, are telling us
that in 1969 the drug problem in Fairfax County became serious and
continues to be, I imagine, a very serious problem.
Mr. HoRAx. Yes, sir ; is it.
Chairman Pepper. Do you find that drugs, either in one way or an-
other, are related to the crime problem in your county ?
Mr. Horan. Mr. Chairman, we have seen in the last 2 years, anyway,
a veiy high percentage of drug-related crime. They aren't actually
coming into the court as a drug case, a drug prosecution, but in the
area of burglary or robbery. We had two murders last year where the
defense to the murder was that it was committed under the influence
of LSD. So we have seen a very high percentage of drug- related crime.
Chairman Pepper. So you are concerned about the drug problem in
relationship to crime primarily as the Commonwealth's attorney.
You have observed, as a prosecuting attorney, certain reactions to
the use of methadone which have also concerned you and which you
have been very ably telling us about here today. You are speaking, of
course, out of your experience as a prosecuting attorney, not as a medi-
cal doctor, I assume ?
Mr. HoRAN. That is right.
Chairman Pepper. I suppose we all agree that somehow or another
we must find a way of dealing adequately with the drug problem, par-
ticularly heroin problem, and we don't want to create another problem
in tryinsf to get rid of the first,
Mr. HoRAX. Exactly.
Chairman Pepper. You have raised a very serious question as to
whether or not a private physician, unskilled in respect to this sub-
stance of methadone and others of similar character, should have au-
tliority to distribute it. dispense it. There is always a possibility of
abuse. We are very much concerned about that very thinp-. We had "wit-
272
nesses yesterday who brought out the very question you talked about
here today, the danger of allowing private physicians to prescribe
methadone at will.
If it were to be distributed by a private doctor, would you consider
it desirable, if not imperative, that there be a registry so that every
doctor who did prescribe methadone would have to report it to a cen-
tral force or data bank so that any other doctor who wanted to protect
the public interest would have easy access to that information to know
what other doctors were prescribing, maybe in the same day for the
same patient, and also it would give an opportunity for somebody
looking at that data bank to see how much methadone, for example,
was being prescribed by any one doctor, whether he was making a pri-
mary business of that ; would you favor such a data bank ?
Mr. HoT^Ax. I would feel that, if the private practitioner is going
to be in the business, the data bank is absolutely imperative. I think
that is part of our problem here.
Second, I think ovce. a data bank was established, it should be moni-
tored by someone outside those who are in the business.
Chairman Pepper. Well, the last question is: Would you think it
desirable for the Federal Government to give very serious considera-
tion to trying to find something better and less objectionable than meth-
adone in dealing with this matter of breaking heroin addiction ?
Mr. HoRAN. Yes, I do, Mr. Chairman. INIy concern is with the ques-
tion of leaving a drug personality when you are finished with your
methadone program.
It would seem to me Federal money would be well spent in th_e
area of trying to come up with a different tool, a different ]>harma-
cological tool.
As a criminal prosecutor I sit there and when somebodv shows me
reduced crime rates I have got to be impressed ; that means something
to me. Maybe I am selfish. Maybe I don't like as much business as
I have.
1 would like to see a reduced crime rate. But I always have in mv
mind — what is the price? You know, we could reduf^e the rate of rnnp
by providing every rapist with a wom.an, for example, and you could
go to your handy service clinic and get a woman and then we cut rape
in half, or worse, and what is the price? I feel the snme wav about
methadone. What is going to be the price of having this many drug
personalities, and that's what we have when the drug is out in socie^v.
I think the Federal dollar would be well spent, coming up with a
deto-^ifi^ntion nnd ab'-tinence notential in another drnier.
T think the chairman mentioned before the possibility of coming up
with a drug that would make it revolting to have one narcotic.
With the American pharmaceutical mind we ought to be able to
come up with something like that.
Chairman Pept^er. We have discovered from onr A^arious hearings
that about half of the crime is related to drug use, and, therefore, if
we could cnt down drug use we would reduce crime.
That is the reason the House of Pepresentatives is concei^ned about
drugs. So we are dealing with something directly related to crime, are
we not ? T ask you as a prosecuting attorney.
Mr. HoRAN^. There is no question about that.
Chairman Pepper. Thank you very much.
273
Any other questions, gentlemen ?
Thank you, Mr. Horan. We appreciate your coming here today.
The committee's next witness is Dr. Daniel H. Casriel, a New York
psychiatrist who has long been interested in drug addict rehabilitation
programs.
Dr. Casriel received his medical training at the University of Cin-
cinnati, and served as a captain in the U.S. Army Medical Corps.
Dr. Casriel has served as court psychiatrist in the New York City
Court of Special Sessions; psychiatric consultant to the S^'nanon
Foundation ; clinical assistant professor of psychiatry at Temple Uni-
versity Medical School, and cofounder and medical-psychiatric direc-
tor of Daytop Village, a therapeutic community for addicts.
Dr. Casriel, in addition to the private practice of psychiatry, is the
director of AKEBA, an addict treatment program in New York.
He is the author of "So Fair A House," the story of Synanon, as
well as the author of several articles.
Out of your wide experience. Doctor, we are very much pleased to
have you here today. I am advised that you are accompanied by Dr.
Walter Rosen and Rev. Raymond Massy, who will supplement your
statement and respond to questions.
Mr. Perito, would you inquire ?
Mr. Perito. Thank you, Mr. Chairman.
Dr. Casriel, as you have been kind enough to provide us with some
written material and a statement by Dr. Revici ; is that correct ?
STATEMENT OF DE. DANIEL H. CASEIEL, DIEECTOE, ACCELEEATED
EEEDUCATION OF EMOTIONS. BEHAVIOE, AND ATTITUDES
( AEEBA) ; ACCOMPANIED BY EEV. EAYMOND MASSE Y. INSTITUTE
OF APPLIED BIOLOGY, INC. ; AND DE. WALTEE EOSEN
Dr. Casreel. Yes; I have given you some of the written material
and my remarks after Dr. Revici's initial lecture on his new drug called
Perse. I didn't give you the article that Dr. Revici has written, but I
assume you have that.
Mr. Perito. Yes ; we do.
Mr. Chairman, at this point I respectfully request that the materials
which have been furnished to us by Dr. Casriel be incorporated into
the record.
Chairman Pepper. Without objection, they will be received and will
appear following Dr. Casriel's testimony.
Mr. Perito. Dr. Casriel, you have worked with the addiction prob-
lem in a substantial portion of your professional life; is that correct?
Dr. Casriel. That is correct. Almost 20 years.
Mr. Perito. Is it fair to say that your therapeutic approach is an
amalgamation of your learning from Synanon and Daytop, plus
some innovative thinking of your own ?
Dr. Casriel. Also my training in Columbia Psychoanalytic Insti-
tute, my experience in Synanon, my establishment of Daytop, my ex-
perience in Daytop and my own private practice.
I have a new amalgam of treatment now which is different from all
of these and I find it clinically very effective.
274
;Mr. Perito. It is my understanding, Doctor, that in your treat-
ment ajiproach you have been using- a new experimental drug; is that
correct ?
Dr. Casrtel. Yes ; it is, Mr. Perito.
Mr. Perito. And that experimental drug can be properly referred
to as a rapid-acting detoxification drug?
Dr. Casriel. Yes ; it can.
Mr. Perito. That drug is nonaddictive ?
Dr. Casriel. It is nonaddictive.
Mr. Perito. Could you kindly explain to the chairman and members
of this committee what your experience has been with the use of this
drug ?
Dr. Casriel. Yes.
Chairman Pepper. You are talking about the drug Perse, P-e-r-s-e?
Dr. Casriel. Right.
I met Dr. Revici, the developer of this drug, a year ago last Febru-
ary, and I guess like most of you who might have seen it for the first
time, I didn't believe my clinical eyes, but in the past 14 months I am
convinced that this is a major breakthrough, on a chemical basis, of
the addictive phenomena of addiction.
I personally have given it to about a 100 addicts, about 30 of
whom have remained in my therapeutic community, called AREBA,
which stands for the Accelerated Reeducation of Emotions, Be-
havior, and Attitude.
I have never found any hai'mful side effects from Perse per se. It
has removed not only the addicting quality, but it gives the individual
a sense of well-being, the type of well-being he had before he was
addicted.
However, I would like to make sure that the committee realizes
there is a difference between an addict who is addicted, and an addict
who is not addicted.
After you remove the addiction you still have to treat the individual.
My work in the past 20 years has been with people. I have rehabil-
itated tlie addicted and it really doesn't make mucli difference what
they are addicted to, whether it is heroin, or morphine, or alcohol, or
homosexuality, or delinquency, or whatever.
The basic underlying personality structure has to be changed.
Perse has made my job much easier with those character disorders
called the addict.
Chairman Pepper. With what?
Dr. C ASPJEL. With those people, the psychiatrists call the addicted
personality.
Chairman Pepper. I see.
Mr. Pfrito. Doctor, is it fair to sav that you are drawinij a distinc-
tion between physical addiction and ps3^chic addiction ?
Dr. Casrtel. Yes ; there is a tremendous distinction. Perse removes
the physical addiction, the phA'siological addiction. It takes the type of
psychotherapy that I am doing, whicli is much different than classical
psychotherapy, to restructure the addict.
'■I think in terms of the physiological addiction, the physical ad-
diction, it is interesting that the several people I heard before me
Avho spoke about methadone and methadone blockade really have not
mentioned what do they mean by blockade, where does the location of
the blockading effect, what is the j^hysiological cause of addiction,
how does addiction work, what is addiction, how does it Vvork, v\'hy
does m.ethadone blockade, what does it blockade, et cetera, et cetera, et
cetera.
These answers have never been mentioned. I am aghast, really, that
this whole concept of methadone maintenance started with the re-
search, clinical research of six highly addicted heroin addicts by Dr.
Dole, who then transferred them to methadone and maintained them
on methadone.
Tliere is no theory, no pharmacological theory to substantiate meth-
adone addiction or methadone maintenance.
I met Dr. Eevici. He is a fine old gentleman. He speaks in such a
quiet voice and he is so esoteric it took me about a year to really un-
derstand his understanding of the nature of addiction, and if I may,
in the next few minutes, I would like to give this committee my inter-
pretation of his understanding of the nature of addiction.
He developed Perse with a pencil and paper. He theorized the
nature of addiction from his knowledge of intercellular physiology,
biochemistry, and pharmacology. With this theoretical approach he
then theorized the type of pharmacological type of drug that was
needed to solve it.
Chairman Pepper. That is the way Dr. Einstein developed the
Einstein tlieory, with a pencil and paper.
Dr. Casriel. On a piece of paper, a pencil and piece of paper, and
you might have said he never had enough money to do it any other
way.
He took this chemical and applied it successfully to thousands of
laboratory animals and then finally applied it to several thousand
patients that he has detoxicized from heroin without any harmful
effects.
I have detoxicized about 100 without any harmful effects whatso-
ever. I have personally taken some Perse, myself, to see the effect that
it would have in preventing — it also prevents alcohol addiction, alco-
hol intoxication — to see what it would do to me in preventing alcoholic
intoxication. Normally 2 ounces of alcohol taken by me will give me a
drunk and I fall asleep. One big cocktail will get me sleepy on an
empty stomach.
I took two of his capsules of Perse and proceeded to drink 8 ounces
of scotch without any side effects of dysarthria or intoxication. It is
true my belly felt a little bloated and my wife told me I smelled like
a kangaroo, but I was not drunk. I had no harmful effects.
I have no hesitation, if necessary, to inject this whole bottle of Perse
into me. I am that sure of its safety.
This is_a 100 cubic centimeter bottle. The addict only takes 5-10
cubic centimeters.
("hairman Pepper. Orally?
Dr. Casriel. Injectable, because we know how much is going in that
way. The first day about four times, the second about three times, the
third day twice and the_ fourth day one injection, and this is supple-
mented with the pills which are continued for the week.
276
So that at the end of the week this person is detoxicized from his
addiction.
Chairman Pepped. You mean if anybody had been taking heroin for
a protracted period of time and had that course of injections which
you just described, all in 1 week, that at the end of that week that
person would not have any further craving for heroin ?
Dr. Casriel. Wliile he is on Perse, no further physiological craving,
but if he stops taking Perse and takes heroin, he will get his old habit
back, his old euphoria.
The first injection of Perse immediately cuts down the amount of
heroin they need to sustain their addiction. I have seen people go from
iiO bags a day to one bag until they came to me the next clay and got
another shot of Perse.
Now, how does Perse work? Dr. Revici stated that heroin is an
alkaloid. iVn alkaloid is a building block of protein. Those chemicals
which are addictive are basically alkaloids building blocks of proteins.
Now, if you put a specific protein into your body like milk, you will
get a specific reaction to that milk, you will get a marked inflammed
area and you will develop certain antibodies to counteract the proteins
in the milk.
But an alkaloid is only a small portion of a protein and it doesn't
develop a specific antibody when it is injected. Instead, the body devel-
lops a generalized defensive substance which is a steroid, which com-
bines with the alkaloid, be it heroin, or methadone, or morphine. But
because it is not specific there is an overproduction of this steroid.
For instance, if one unit of heroin got into the body, the body miglit
manufacture in an analogous two units of steroids, one which combines
with the heroin and neutralizes the effect of the heroin.
The other one is free in the body. It is this free steroid which is not
attached to the heroin which causes the addictive phenomena, it causes
the craving phenomenon.
Now, when a person who has never used a narcotic injects a small
portion of narcotics into his body or takes it orally, the body's defense
system is activated. The injectable route is the quickest route. If you
digest it, it take a little longer to get into the bloodstream. The eftects
of the narcotics will be felt by the body, it goes to the brain centers.
It diminished the body's awareness of pain and it is a basic depressant.
One dies of an overdose because one's respiration stops and then the
individual stops breathing. That is how one dies of an overdose.
One of the lifesaving measures is to give artificial respiration imtil
the effect of the narcotic is passed out of the body.
Now, the body removes heroin in about 4 to 6 hours. It takes the body
about 36 hours to remove methadone. That is why one injection or
one pill of methadone can last at least 24 hours, Avhereas one injection
or one pill of heroin would only last 4 to 6 hours.
But when this heroin is detoxicized it is removed by the body, the
steroid whicli the body has developed previously to defend itself
against the hei-oin is free and it gradually develops an attraction to the
body tissue, sotting up a type of ])ulling or craving sensation. It sets up
in tile body what Dr. Eevici calls an anoxicbiosis, which when ti-ans-
lated into English means a negative oxygen metabolism. It is ver}'
similar to the type of pain and feelings you would get if a tourniquet
277
were tied around your hand. You get a negative oxygen metabolism
Avith an increase of lactic acid. The oxygen isn't present to break down
the carbohydrates in the body.
"Wliat we have then, after the injection of heroin after 4 hours, the
heroin goes through the body, we have this steroid which turns upon
the body which produced it, causing an anoxicbiosis. This is perceived
by the addict as a craving, as a yearning. As this anoxicbiosis builds
up greatei- and greater, depending on the amount of steroids, there is
localized acidosis that develops in the body and the body attempts to
compensate for this localized acidosis by a generalized alkaline reac-
tion. This is manifest clinically as the so-called cold turkey phenom-
enon. It is very uncomfortable for the addict to experience. It is seen
with high amounts of steroid — not high amounts of heroin — but a
high amount of steroid developed over a long period of addiction or
due to methadone maintenance. The blockading effect of methadone,
by the way, is just the overwhelming of the body's ability to produce
more steroids and the body then develops a tolerance for methadone,
just as some people who start to become heavy alcoholic drinkers can
show heavy tolerance for alcohol before they become drunk. I have
seen people drink 10 ounces of alcohol and look like they are sober.
But tlie steroid which has been produced in response to this foreign
alkaloid, remains in the body about 7 days. It takes about 7 days for
this steroid to break down. This is why it takes 7 days to detoxify some-
body from addiction. It takes 7 days to maintain a state of oxygena-
tion in the body while the steroid is being broken down.
Dr. Revici has developed other pharmacological tools to go along
with this basic tool called Perse. For instance, when a person has been
on methadone maintenance, for instance, he has so much steroid in him
that all the Perse that you give him still causes some side effects, you
just can't get enough of this oxygenizing substance into the tissue and
that is all that Perse is.
Mr. Perito. Doctor, excuse me.
Are you saying it is more difficult to detoxify a methadone addict
than a heroin addict ?
Dr. Casriel. Yes, because a person on methadone maintenance, has
tremendous quantities of defensive substance built up in them. Dr.
Revici has developed a substance which will temporarily combine and
neutralize the steroid in the blood and this is called trichlorbutinol.
It is an alcohol, but the interesting thing about this alcohol, it doesn't
develop more steroid.
For instance, if I have given a person who is really under tremen-
dous craving, and you know he has a large steroid component because
he has been on, say, methadone maintenance, I would give him, to-
gether with the Perse, some trichlorbutinol. Within 7 to 15 seconds he
feels better because that alcohol combines with the steroids in the
bloodstream. It takes about 7 to 15 minutes for the Perse to get into
the tissue to counteract the anoxiobiosis. If the person is already in
secondary stages of withdrawal, the cold turkey phenomenon, you can
give him a little hydrochloric acid to counteract the generalized alka-
line condition that he has.
If we know the degree of his steroid developed, we can detoxify a
person without any side effects. If we don't know the amount of
278
steroid he lias in him we might get some ^vithd^a\Tal effects after using
Perse because we havn't given him enough Perse or we don't give it
often enough. It is true we do get some side effects, residual side effects
of their detoxifying process.
Mr. Perito. Doctor, are you concerned about the possible toxic effects
of the selenium in that solution ?
Dr. Casriel. Not at all. I never knew what selenium was. Dr. Revici
told me there are four types of selenium. Three are highly fatal in
minute dosages. One is completely inert. Of course, he uses the one
that is completely inert. It has no effect on the body. It acts apparently
as a catalytic agent to the peroxide in Perse, and hydrogen peroxide is
an ox3^genizing agent. Perse has a fatty acid base. Dr. Revici's research
for the last 50 years concerned itself with these fatty acids. This allows
this material to get within the cell. '
For instance, water doesn't permeate the skin. Fats don't permeate
the skin, but he has developed substances that can permeate the skin
and get right into the tissue so that other things such as muscular
aches and cramps and arthritis can be relieved directly because he can
add an oxygenizing substance directly to the tissue, wherever he wants
to apply it.
So what happens is that when the Perse gets into the cell, the bind-
ing of the selenium to the peroxide is free. The peroxide that was
bound to the selenium is free. The peroxide is then used as an oxy-
genizing agent, removing the negative oxygen balance and giving the
person a sense of well-being and very frequently the addict will say,
"My God, what did you give me? I feel as if I got a fix, my stomach
feels warm and good, my head feels clear, my head feels clear.'*
"What kind of drug are you giving me because suddenly I feel as
if I got a fix, except my head stays clear and I didn't get any high
and I didn't go on the high, but my stomach feels good and I feel
as if I had a iix, except I don't have any side effects of having a fix."
Mr. Perito. It is a feeling of normality ?
Dr. Casriel. Yes ; Feeling of normality ; saying, "I haven't felt like
this since before I shot dope," is normal.
Now, the interesting thing with the physicological addiction is that
the body responds in a nonspecific way to several things, so that not
only will the body develop a steroid in defense of the" alkaloid that
you inject, but frequently a hot bath or hot shower will cause a steroid
development.
I remember when I was medical superintendent of Daytop, on Satur-
day night the residents would take a hot bath or hot shower, get
dressed, and would split out the door, I never could figure out why
they used to leave on Saturday night after they were all cleaned and
dressed up. I figured some of them were afraid of the visitors, or since
they are dressed up, they might as well leave, or it is Saturday night
and they remember how it used to be on Saturday night. I ani begin-
ning to realize one of the reasons they would split is because that is
when they took their hot baths or hot showers. A person who has been
physiologically clean by cold turkey procedures can, under certain
circumstances such as a hot bath, develop a craving again as if he had
need of addiction.
Mr. Perito. Doctor, I would like you to clarify something: The
committee has heard some testimony in the past that there are primary
279
and secondary withdrawal syndromes. Would you care to comment
on this phenomena, if such syndromes are, in fact, recognized by
clinicians treating: addicts ?
Dr. Casriel. That is probably 99 percent psychological. However,
it is theoretically possible that he might have had a hot bath, or it
is theoretically joossible he is under tension. When I get tense my
"fix" is to go to the Caribbean for a week. Other people's fix is to have
a scotch and soda. Other people play a good game of golf or tennis.
The addict, with his psychological memory, says, "'V\nien I feel
like this I want a good shot of dope." Perse is not going to cure the
addict, it is going to resolve his addiction and keep it, certainly,
within manageable results, because on a psychological theoretical level,
every addict w^ould rather get high on a $5 bag than remain addicted,
spending $100 a day. He would not have to be addicted, therefore the
amount of crime that he has to commit will be tremendously reduced
because he worit need $100 to get a reaction to his heroin.
So certainly this can remove the crime tremendously. However, I
Avish to go on record as very strongly suggesting to the committee
that the person who had been addicted is in tremendous need of psycho-
logical retraining and retreatment.
I also want to tell you as a psychiatrist that our classical means of
treating are completely ineffectual when it comes to the treatment of
a psychological addict, or as a matter of fact, the psychological delin-
quent, the criminal, and so forth and so on.
In the past 10 years we have developed a new process which has
gotten tremendously favorable results. In AEEBA nine out of 10
people that come in stay. I expect that those that stay will be well,
psychologically well; emotionally, behaviorally, and attitudinally re-
educated, and if necessary reeducated morally, educationally, and
socially.
The treatment process is a reeducation of that human being in af-
fairs of his thinking, feeling, and behavior. This takes time, and the
medical profession is not yet geared to this type of treatment. But
v\'e can buy the time with Perse to train and retrain the professional
army of psychologists and psychiatrists and social workers to truly
rehabilitate the human being, because heroin or methadone is only
one chemical. These kids that are on methadone maintenance, I have
seen them on cocaine maintenance, barbituate maintenance, and delin-
quency maintenance.
If you think giving them methadone is going to remove the prob-
lem, it is going to give you an additional problem.
One of the big problems you are going to get is amphetamine and
cocaine. Cocaine especially because methadone doesn't stop them from
enjoying cocaine, and cocaine is a much more dangerous drug than
heroin is. So are amphetamines and, of course, so is LSD.
But at least we now have a chemical that is nonaddicting, that is
nontoxic in any way, that will remove the addictive phenomena. Also,
by the way, work for barbiturate addiction and alcoholic addiction.
It can sober up the alcoholic as it does the narcotics addict and also
sober up the barbiturate or a person in a barbiturate coma the same
wav.
I, for the life of me, can't understand why they have been dragging
their feet on this chemical.
280
Mr. Perito. You are referriii"' to the FDA now?
Dr. Casriel. Yes. Over 2,000 people have taken it. I would be will-
ing to take this whole bottle by injection or orally. I am not a hero — it
is a perfectly safe drug. It is a perfectly safe drug.
Chairman Pepper. How long has it Ijeen now since Perse was sub-
mitted to the Food and Drug Administration?
Keverend Massey. About two and a half months.
Mr. R angel. That is the second time?
Reverend Massey. That is the second time.
Dr. Casriel. To me this is lifesaving.
Cliairman Pepper. You personally treated how many patients when
you first started ?
Dr. Casriel. Approximately 100.
Chairman Pepper. And you personally observed those patients?
Dr. Casriel. I personally observed those patients and I have per-
sonally observed my reaction with Perse in me with alcohol.
Chairman Pepper. And you have had no injurious effects in your
patients ?
Dr. Casriel. No.
Chairman Pepper. That has achieved the effect you have described,
to detoxify ?
Dr. Casriel. Yes. I have been able to detoxify three people who were
on methadone maintenance with this, who have come to me. One was
on 140 milligrams of methadone maintenance, one was on 160 milli-
grams of methadone maintenance, and one was on 240 milligrams of
methadone maintenance.
In addition, the person on 140-milligram methadone maintenance
was also taking about 60-100 milligrams of barbiturates a day and was
also taking anything he could take, anything he could get, which in-
cluded cocaine, and so forth.
Chairman Pepper. Doctor, how would that interesting, and certainly
challenging, drug be properly adapted for general use into a drug ad-
diction treatment program ?
Dr. Casriel. Under methadone — and I agree with the previous
speaker that methadone should not be in the hands of the general physi-
cian— it shouldn't be used, but if it has got to be used, don't put it in
the hands of general physicians. I think it is chaos under clinical con-
ditions.
But Perse can be given to every physician in the country. This is
not addictive. You only need to use this at most for a week.
Chairman Pepper. You mean Perse could safely be used and pre-
scribed by a private physician.
Dr. Casriel. Every physician in the country. It is not a narcotic.
He doesn't need a special narcotic control, it is not dangerous, it is not
addictive.
It will also detoxify alcoholism and barbiturate addiction. It is a
lifesaving drug. It is a major breakthrough in treatment. It has given
me the opportunity to treat the addict as I would treat the aA'erage
character disorder, because we don't have to treat them against their
physiological craving. We remove that right away. They are imme-
diately able to get into treatment. I don't have to wait for a period
of detoxification of a month or 2 weeks, or whatever.
281
They are immediately psychologically capable of being engaged
psychologically. .
i wouldn't think of trying to psychologically treat a person on meth-'
adone any more than I wonld try to wash a person who has a raincoat
around them. You just can't get through that protective rubberized
skin.
Mr. Pekito. Knowing what you do, Doctor, about Perse, would you
use methadone to detoxify an addict, rather than rely on Perse ?
Dr. Casriel. No ; this is much easier, much simpler, much cheaper,
much quicker, much everything.
Chairman Pepper. By the way, what is the cost of Perse ?
Dr. Casriel. Reverend ISIassey, you are the administrator to Dr.
Eevici.
Reverend Massey. I can't recall the exact cost, but I understand it
should be less than $1, or less than $1.25 or something like this.
Chairman Pepper. Less than $1 a bottle ?
Dr. Casriel. About 5 cents a shot.
Chairman Pepper. How long would that bottle that you said cost
less than a $1, how long would that treat a heroin addict?
Dr. Casriel. An average addict needs about 6 shots, that is about
20-40 cubic centimeters. You could treat two-and-a-half or three ad-
dicts with this.
Chairma]! Pepper. Treat two-and-a-half addicts. That is phenom-
enal. Doctor.
Dr. Casriel. Yes, it is, Mr. Pepper. It is a major brealdhrough. I
didn't believe it when I fir^^t saw it because I have been treating drug
addicts for a long time. But I have been with this now for 14-15
months, and it works. "\'\niat can I tell you ?
Mr. Perito. Do you think your AREBA approach would work with-r
out Perse ?
Dr. Casriel. Yes ; but not as well. We don't have any problem hold-
ing them. These kids stay. We suck them in psychologically. We don't
have to work against the physiological craving.
Mr. Perito. If that precludes the physiological craving it is pos-
sible for a person to detoxify on Perse but relapse soon after the effects
of Perse wear off ?
Dr. Casriel. Yes. You are not going to cure the psychological prob-
lem with this. You will cure the physiological addiction with it. Those
people still need to be treated.
Mr. Steiger. Would counsel yield on that point ?
I wondered. Doctor, the person who repeats the process several times,
does he require additional Perse each time ?
Dr. Casriel. No.
Mr. Steiger. In other words, there is no cumulative resistance to
Perse ?
Dr. Casriel. Not at all.
Mr. Steiger. Thank you, Mr. Perito.
Mr. Perito. As far as you know, the 1,900 patients that have been
treated by Dr. Revici are drug free ?
Dr. Casriel. I don't know. I haven't followed Dr. Revici's patients.
I have enough trouble following my own.
Reverend Massey. May I answer that question for you? Approxi-
mately 1,900 patients treated with Perse, I can say that these 1,900 are
60-296— 71— pt. 1 19
282
not drug free. I can say approximately 7.5-8 percent, that I know of
and follow up, are drug free.
What does that give us? Approximately 143-145 individuals that
I know of that are free of drugs.
The other remaining amount are either individuals whom I could
not keep up with because of no addi-ess, or moved, no contact, out of
town, because we get them from Boston, we get them from California,
as well, coming for this treatment. So, therefore, I can say I can put
my hand on approximately 145 individuals who are drug free from
this medication here.
Dr. Casriel. I would like to say one other thing, and I think it is
imporatnt in passing.
Dr. Revici does not charge anyone an3^thing for his treatment. I have
gotten medication now for 15 months without cost to me, and I pass
that on to my patients. In other words, I don't charge them for this
drug.
Dr. Revici is the head of the Institute of Applied Biology which
which is a nonprofit corporation, and I have seen him treat literally
scores while I have visited him, scores of indigents. There has never
been a question of fee. I have seen him treat people who come in who
are extremely wealthy, and there has never been a question of a fee.
This is a man who is one of the true humanitarians that I have met,
one of the very, very few.
Chairman Pepper. Doctor, in a treatment program, in the use of
Perse, would there need to be clinics set up over the country to get it, in
addition to the doctors?
Dr. Casriel. No ; the Perse, itself, could be given through medical
channels because it is not addicting, it is not habit-forming. You
just take it for a week. It is like penicillin. If you got pneumonia
you take penicillin for a week and it cures pneumonia. If you are ad-
dicted and 3^ou take this for a week it cures your physiological
addiction.
As Reverend Massey said, a certain small percentage, once they got
free of the monkey on their back, will stay clean. A much larger per-
centage, because they are psychologically mixed up, will revert back
to addiction.
However, they don't like a larce habit. They get no fun out of a large
habit. Once they found out this can at least remove the habit, thev
won't need $100 a day to maintain their habit. One shot of heroin will
give them a much better high than $100 worth before.
However, these people now can bo engaged in psvchological treat-
ment. You have to treat the individual psychologically. It really does
not make any difference if they are addicted to morphine or bar-
biturates, or liSD, or anything else, you have to treat them
psychologically.
I also again wish to reiterate that the current classical psycholoiricnl
treatment is not effective, but we have developed an effective process.
This will give us time to tool up. Currently, right now, Phoenix
ITonse, which is the largest rehabilitation center in the country,
which is over 1,000 people, have sent to my institute 15 of their top
clinical people who are actively involved in the rehabilitation of th^ir
addicts, and I am retooling them in my current knowledge, the psy-
chological knowledge of what I have learned.
283
Drug addiction can be cured. This doesn't mean just a remova\ of
drugs. It means changing the underlying structure of the personahty.
We have to do this. We cannot settle for anything less because there
are just too many people who are addictive prone, certainly over half
the country.
Chairman Pepper. Doctor, I hate to interrupt you.
Members of the committee, we will take a short recess.
( A brief recess was taken. )
Chairman Pepper. The committee will come to order. We will con-
tinue with the questioning of Drs. Casriel and Rosen and Reverend
Massey.
Mr. Mann, any questions.
Mr. Mann. Doctor, you have been using Perse and the followup for
about 14 months ?
Dr. Casriel. Yes.
IMr. Mann. What dropout rate have you had in your experience?
Dr. Casriel. Well, I am a psychiatrist and I treat the total spectrum
of problems. I have developed a private therapeutic community called
AREBA, which certainly about 00 percent are there because of the
use of heroin and similar destructive drugs, a couple LSD. We have
only lost five. About 95 percent have stayed. We are now graduating
our first members.
The program is geared for 9-month rehabilitation courses. We
sent our first member back to your home State, Miami, Fla., about 2
weeks ago. He is a beautiful boy. I helped establish Self -Help and the
Concept House in the Miami area. He is now in Self-Help, helping
scores of others.
Chairman Pepper. Have vou fijiished, Mr. Mann?
Mr. Mann. Yes.
Chairman Pepper. Mr. Rangel. w^ho has been very much interested
in Per?e. has asked to speak to a question out of order because he wants
to clear up some possible confusion.
Mr. Rangel. Yes.
Reverend Massey, you gave a very small percentage of Dr. Revici's
that are drug free.
Reverend Massey. Yes, sir ; correct.
Mr. Rangel. But these are persons you can identify as beins: druar
free? i ^ j b 6
Reverend Massey. Correct.
]\Ir. Rangel. This does not imply that the other patients with the
doctors are not drug free?
Reverend Massey. True.
Let me state here that I know of individuals going through this
ti-eatment, and I want you to understand that I have been with Dr.
Revici right from the beginning when he started the use of Perse.
Every day, 7 days a week for the past 17 months. Individuals moti-
vated somehow, self-motivation or through motivation of the court,
have come to Dr. Revici for treatment for the detoxification from the
use ot hepom, alcoholism, or some type of drug, have been treated and
detoxified. But once they have left, some go immediately back to the
use of drugs.
Now, why? Because probably their habits were very high 40 50
bags a day, which totals about $100 a day. To get it back down to a
28
A
$2-a-day habit these individuals who return directly to the use of
druo:s after detoxification have no real intent of really staying drug
free.
Then we have those who are really motivated within themselves to
really leave the drug scene. These individuals, some that I can account
for, like I stated, still others who are still drug free, I am sure, but
cannot be reached.
]\Ir. Raxgel. Reverend INIassey, this drug only brings the addict back
to where he was before he became an addict ; is that correct ?
Reverend Massey. True.
]Mr. Raxgel. And the patients that you have been dealing with
mainly have come from the Central Harlem community; is that
coi-rect ?
Reverend Massey. Correct.
!Mr. Raxgee. So no matter what this drug does, it sends them back
to the same addict environment from which they became addictive in
the first place ?
Reverend Massey. Correct.
^Lr. Rax^gel. So I believe that Dr. Casriel was sayinof this does not
take care of the psychological problem which may exist before the
person became an addict ?
Reverend ISIassey. It on! v takes care of the physical.
Dr. RosEX. The concept has to be, in anything such as this, that there
is a totality of treatment. You can't deal with drug addiction, with
alcoholism, with any of those problems, unelss you have a totality of
treatment. That totality' must encompass both psychological and
physiological. It must encompass rehabilitation, vocational rehabilita-
tion, counseling, changing the patterns of their economic existence,
changing the patterns of where they live and how they live.
If you are going to have any kind of program that is worth a darn
you will have to have a program that encompasses all of that.
What Dr. Casriel was saying, Perse is great, you can give it and have
an addict withdrawn without any problems and then you must ap-
proach the other aspects of the situation that need attention. It ran be
done immediately with the totalitv being added as you go along.
But it is never going to work without funds because Dr. Revici just
started with this 14 months ago. Of course, he has many addicts com-
ing in and goino; out the old revolving doors, but no money to do the
total program. It is not going to work to that effect until you have a
totality of program in anything, either the drug addiction or the
alcoholism.
]Mr. Raxgee. I would like to state for the record that it was this
drug and Dr. Revici I was speaking about when I first had tlie oppor-
tunity to join this committee and liavinff been born and raised and still
live in this community, I don't suppose anybody was more cynical
when it came to drug rehabilitation than mvself.
I just want the record to state that my first impressions. I felt the
need to bring with me the administrator of the Harlem hospitals drug
rehabilitation program. That is how cynical I was before I had the
opportunity to meet Reverend IMassey and talk with Di-. Re\nci. The
results and what we witnessed with patients was so unbelievable that
the doctor from Municipal Hospital has now gone back on a daily
285
basis in order to continue with this chance to see the miraculous re-
sults that have taken place. I personally have gone back on several
occasions to the clinic. I have talked with patients, talked with young-
sters that have given up on being decent human beings, given up and
have talked with their parents and grandparents, many times in the
presence of responsible State officials that have subscribed publicly
to the methadone program and yet vigorously support the efforts
that have been made by Dr. Revici.
I just want that stated for the record. I only regret that the illness
of Dr. Revici prevented him from more eloguently being present.
But I hope that in the near future, whether we have further hearings
or not, that each one of you will have the opportunity to really meet
this very decent human being who I believe has made an outstanding
contribution in this area.
Chairman Pefpek. I want to say for the record that Mr. Rangel has
been impressing upon the consideration of the committee this remarka-
ble work and Dr. Eevici's remarkable work and your splendid coop-
eration for some time. He has entertained, as he has expressed here to-
day, high hopes for it. That is one of the bases on which we initiated
these hearings, to see if we can't get the Federal Government to have
a part in the development of some of the brilliant leads that we have
alread}" learned about. This is one of them.
Now, anything that offers a hope, even the hope that you have
testified about here today, should receive the strongest approbation
of the Government of the United States as soon as the Government
is satisfied that it is safe and will do substantially what you claim
for it. Because this would, to a large degree, enable us to combat the
drug problems in this comitry.
Seventy percent of the people in prisons in this country are there
for alcohol abuse. We have got to spend billions of dollars if we are
going to use the current methods of dealing with drug addiction. If
we could develop something like this it would make the whole prob-
lem immeasurably more easy and cheaper and effective.
Dr. Casriel. I asked Dr. Rosen to come with me. He is a general
practitioner in Harlem. He has been spending a considerable amount
of his time with alcoholism and the problems of that.
Chairman Pepper. You find it effective with respect to alcoholism ?
Dr. RosEX. Let me give you a little bit of background that might be
of interest.
I started practice in Harlem 21 years ago, and I agree with what
Mr. Horan said about the training that a doctor gets in terms of drug
addiction and alcoholism. It is practically nil.
I had an excellent residency in internal medicine and I came into
practice and thought I was pretty well equipped to handle anything
that came along. All of a sudden I am operating a practice in Harlem,
I see alcoholics, drug abuse, and I don't know what to do about it.
The only thing to do when a drug addict came into my office would
be to suggest Lexington, Ky. It has a facility and that is about where
3'OU can go, and they would laugh in my face.
This was a period of frustration for many, many j^ears and at pe-
riods of time I would knock my brains out, calling social workers, try-
ing to find something to do for them, somehow to handle the situation.
286
I got to the point once in terms of the methadone we are talking about
in the private practitioner's hands, there were a number of houses at
one point, about 4 or 5 years ago, who were dealing with drug addic-
tion : Exodus House, Phoenix House. These drug addicts are pretty
shrewd. They come in with, "Doc, I am drug addict, I want to kick the
habit and if you give me something to help it. I swear I am going to
kick it. I have a job, a family, I can't go into a program."
Most of the time, of course, this was something I wouldn't accept
from them. I thought at this point maybe if you get a drug addict or
any kind of addict who has some motivation, maybe you can use that
motivation and direct it.
So I contacted Exodus House and we got together on a program
where as somebody came to my office under those circumstances I
would say, "Look, if you are really sincere and you want to do some-
thing I will give you enough Dolophine, methadone, to withdraw but
not yet, you first have to go to Exodus House, you have to get involved
with a meeting there, get a letter from them and come back here.
"I will give you enough for 2 days, until the next meeting, and 2 days
more, and 1 day more, until you are withdrawn."
• As Mr. Horan said, public relations in the drug addict community
is so great that they were falling all over themselves in my office wait-
ing for prescriptions for methadone.
Sure, they hit the first meeting, the second meeting, but I think out
of the whole group, maybe I did about 30 in a month's period of time,
there wasn't one that really made it.
Eeally what they were doing, if the habit is getting to be so high
that they can't afford that kind of habit, the methadone cuts it so that
they can go and start back down again on one bag instead of five or
three instead of 10, or if things are tight on the street and they can't
get it, methadone is a good thing.
I don't know their names, but there are a lot of practitioners I know
of who will give you a prescription any time you walk in. They are
not involved in drug-addiction programs. They are selling methadone
prescriptions.
Chairman Pepper. Mr. Steiger, any questions?
Mr. Steiger. Yes, Mr. Chairman.
Let me understand. Dr. Casriel, this Perse will detoxify an5^body
who is addicted chemically, I use that advisedly, recognizmg that an
opiate is a natural derivative, including alcohol ; is that correct ?
Dr. Casriel. That is correct.
Mr. Steiger. When you say detoxify an alcoholic, are you saying
that works when a gaiy is hungover, v.ill this cure the hangover feel-
ing, because this is something I understand ?
Dr. Rosen. No; hungover is not a criteria of alcoholism. Wliat we
are dealing Avith is somebody who has passed over the line from social
drinking to compulsive.
"What the Perse will do, and it is very interesting, because of this
stuff Dr. Casriel came up with, because I didn't know some of these
concepts — some of the concepts up at Columbia about the development
of alkaloids — what happens in anybody's body when they take a drink,
what is the physiological mechanism. They have come up with some
studies that have shown there are actually alkaloids produced in the
brain that are similar to the alkaloids of hallucino<renic substances.
287
Just to get back to your question of what Perse does, in the same
sense it wiU detoxify a drug addict, in the disease of an alcoholic there
is a physiological mechanism that creates the compulsion and Perse
will destroy the physical compulsion of that disease. So that they will
go through withdrawal like a dream.
Alcohol is more frightening than narcotics. They die from alcohol
withdrawal, but not from narcotics.
Mr. Steiger. Assume they have a man in a state of alcoholic in-
toxication. Have you had any experience — or you. Dr. Kosen, or you —
or perhaps Reverend ISIassey has observed this — we give Perse to the
man in the state of alcoholic intoxication or under the influence of al-
cohol or LSD ; what is the result?
Dr. Casriel. With alcohol he is sober. With LSD, it doesn't help.
Mr. Steiger. He gets sober with one shot ?
Dr. Casriel. Weil, I have only had about half a dozen acute alco-
holics come into my institute, but with one shot they get sober ; yes.
Dr. Rosen. It varies, and just how darned drunk they are. I have
had them falling down drunk and it doesn't always sober them up,
but where a second shot
Mr. Steiger. In what period of time would it sober up a person
reasonably drunk?
Dr. Rosen. About 5 or 10 minutes; 5 or 10 minutes after the injec-
tion you will have someone just weaving a bit, sober.
Mr. Steiger. A^Hiat would happen if an addict, whether it is in
speed, freak or whatever, if he were to take Perse, or Per-se, which
pronunciation do you prefer?
Dr. Casriel. You name it. Perse.
Reverend ISIassey. I think Dr. Revici's pronunciation is Per-se, being
French, it is Per-se.
Mr. Steiger. "Wliat would occur, or have you considered the possi-
bility of the individual who, anticipating a breakdown of his char-
acter, would take Perse in advance of either amphetamines or alcohol?
Dr. Casriel. I already mentioned this. I did this to myself.
Mr. Steiger. You took that prior to your
Dr. Casriel. Prior to the 8 ounces, and I didn't get drunk, and 2
ounces will get me drunk.
Reverend ISIasset. May I state here, also, with the addict himself, if
he takes this prior to an injection of heroin he will get high.
Mr. Steiger. He will get high ?
Reverend Massey. He will get high.
Mr. Steiger. How about amphetamines ?
Dr. Carsiel. Not amphetamines. It works on barbiturates, alcohol,
and narcotics. These are all alkaloids.
Mr. Steiger. All right. In the production of this substance obviously
it is inexpensive to produce. Is Dr. Revici producing it himself?
Dr. Casriel. Yes.
Reverend Massey. In his laboratories.
Mr. Steiger. Has he approached a pharmaceutical house or have
they approached him ?
Reverend Massey. They have approached him.
Mr. Steiger. And he is not interested ?
Reverend ]Massey. Yes, he is; but he wants to get Federal Drug
Administration approval.
288
Mr. Steiger. You mentioned anoxicbiosis. Is that a characteristic
symptom of all of the withdrawals, of either alcoholism or narcotic
withdrawal ?
Eeverend JMassey. I can't answer that with authority, because I
am not, you know, I am not Dr. Kevici. I think the anoxia, the negative
oxygen metabolism is the criteria.
^ii-. Steiger. All right. Again using the same anticipatory vision,
do you know if Dr. Revici has measured the oxygen deficit effect ?
Reverend Massey. Yes ; he has.
Mr. Steiger. Giving this prior to say just exertion because, you
know, we develop anoxia if we climb the stairs.
Reverend Massey. I saw his book that was sent to the Food and
Drug Administration with all the tests with the oxygen differentia-
tion, with Perse, without Perse, and so forth and so on. He has all
that documented.
Mr. Steiger. That is a measurable situation ?
Reverend Massey. Yes ; he has that measured.
Chairman Pepper. Would you let me interrupt you just a minute?
We have this as a matter of committee business. I have had a note
passed to me by Mr. Wiggins, the ranking Republican, advising me
that five members of our committee have other commitments and can-
not be here tomorrow, and since all of us would like to hear the testi-
mony for tomorrow, we will defer tomorrow's hearing until a later
date.
Mr. Steiger, you may continue.
Mr. Steiger. Doctor, both of you are, I assume, aware of no con-
sistent ill effects in the use of this. On the other hand, you don't know
of any prolonged use. By prolonged — is there anybody. Reverend
Massey, perhaps you could help us — is there anything in the 7 months'
period of your exposure to Dr. Revici's treatment, do you know of
anybody who has been treated, say at least twice a month, or once a
month ?
Reverend Massey. No, Mr. Steiger, no ; in reference to that I know
Dr. Revici has given this over a long period, to laboratory animals,
without any harmful side effects.
He has also told me the amount he has given mice and rats that is if
similar amounts were given to human beings in terms of weight, about
6 liters have to be injected before a toxic response. That is less fatal
than the water. I couldn't inject 6 liters into the body.
Mr. Steiger. All right. All the substances that make up this mate-
rial are available?
Dr. Casriel. Inexpensive and available.
Mr. Steiger. Inexpensive and available, and you say you can give it
orally but it simply takes longer to achieve the same effect, in a larger
dosage ?
Dr. Casriel. Right, a little larger dosage ; yes.
Mr. Steiger. In your experience with your community with
APEBA, do vou find yourself oombatiTiir the ol-)vions ro^^nonso of the
dedicated addict who says, "You found this wonderful thinir and I
am now able to get high for little or nothing and there is really no
reason for me to stay straight because I can s^ei: "
289
Dr. Casriel. No; that hasn't been my experience. AREBA is for
an upper-middle-class youngster and we seek them in psychologically
and they don't even think about drugs after a few days of AREBA.
Dr. Rosen. Most of them in my group, which is entirely different
from the AREBA group, come and eventually agree to go through this
treatment because they have some motivation, so they go and have it.
But what happens to many of them is that they get thrown back into
the same environment and same friends and it is not a question of
using this and Imowing they are going to go back to it. The motive
is there originally, but the same life pressures cause them to relapse.
Mr. Steiger. The guy goes back to his own group and who started
in the first place, he is still better off because he can conceivably hold
a job and do all of these things ?
Dr. Casriel. He doesn't have to be addicted any more.
IMr. Stetger. I understand that, but there is no blockage effect —
yes : there is a blockage effect as far as the narcotic
Reverend Masset. Let's put it this way : This also reduces the mental
desire for the use of the drug, as well.
Mr. Steiger. That is prett}^ hard to measure, isn't it. Reverend?
Reverend Masset. I am telling you.
Let me tell you from what I know, not from what I am guessing at :
I see 75 percent of our patients being treated. "\Anien I say 75 percent,
that is a large percentage, in and out of a hospital.
Now, we have seven male beds and three female beds. Those who go
into the hospital and stay the length for treatment, I see them all.
I am tliere every dav.
Mr. STEiGER.That is 1 week ?
Mr. Perito. Is this Trafalgar Hospital that you are referring to ?
R e veren d Ma sse y. Th at is right .
Mr. SiT^iGER. This is in the hospital for 1 week ?
Reverend Massey. Correct ; for the 1-week period.
There is something amazing about this medication. The individual
who is in the hospital for the 1 week, when he is discharged and comes
back to the office where the doctor talks to him, I talk to'him, he states
he has no desire whatsoever, no desire whatsoever for the use of heroin
or what have you that addicted him previously.
Now, how does he take on this desire after treatment? He returns
to the environmental surroundings. He is first offered by the pusher
in the neighborhood a bag of heroin free. Why? Because he has
detoxified himself, he is not addicted any more, he has no desire. I
get this constantly from most individuals who stay through the period
of treatment. But he falls back into that old environment again, no
job and society constantly turns him away.
When they see he has a record or has been addicted to drugs he is
turned back to his environment because society rejects him, because
he was a previous addict.
Mr. Raxgel. I would lilce to state that while Dr. Casriel and
Reverend Massey have stated that the addict treated says he felt
normal, I think the tragic thing is that after treatment at the clinic
they have merely said they want a job.
Dr. Casriel. Right.
290
Mr. Eangel. I could see then that if I was unable to fill that need
for a job, how easy it would be for them to go right back into the
same population. So I think we are both saying the same thing.
Reverend Massey, in addition to working very closely with Dr. Revici,
has a long reputation of working very closely in the community, so
that he really wears two hats when he is working in the laboratory,
because the other is his very close identification with the addict popu-
lation in my district.
Mr. Stetger. I just have one question. I am about through.
You know, we heard Dr. DuPont previously, and I don't remember
who else, that the "I feel normal" reaction is one that they have heard
from people who are on methadone maintenance. I don't want to make
an equation here, but obviously they feel an improvement, and there is
clearly a chemical improvement because the physiological craving is
answered and there is no high and so they feel relatively iiormal.
Are they getting any kind of a comparable situation out of Perse
and if not, why not ?
Dr. Rosen. Simply because of the fact that they are being normal
on a drug. They are taking the drug to be normal. With Perse, you
give them the drug and detoxify them and the noncravings and the
normal feelings they have are while they are not on medication. You
do that with an alcoholic where the craving lasts 3 months with this
up and down sensation that he needs a drink. I will take them through
withdrawal and they will tell you they have been through drying-out
places before and they know they have got this constant hassle with
needing a drink on Perse without tranquilizers, without any sedative
drug, they will say, I feel normal. But they are not on addictive drugs
while they are saying it. ■,■<.■<
Reverend J^Iassey. Gentlemen, may I say here that with methaaone
—and I was for methadone at one time because I had no other source
of referral. I figured that if methadone was available, shoot, why not,
if it is going to reduce the crime rate in the communities, if it is going
to allow an individual to become employed, why not. But then when
I approached Dr. Revici in coming up with a medication that is not
addictive, whereas an individual does not have to depend on a drug to
survive, to work every day and to lead a normal life, then I felt that if
Dr. Revici can fulfill these desires of coming out with a medication
that will detoxify an individual 100 percent, that is, taking the drug
out of the body and leaving it normal like myself, I am under no addic-
tion at all — then I feel that an individual who speaks normal from the
use of detoxification with Perse, then he actually speaks the truth.
Now, how can an individual who is taking methadone in place of
heroin, even if he is maintained, say he feels normal ? The body has
drugs in it. If he has used — if methadone is used as a treatment for a
number of days, he still has drugs in the blood cell. He is not normal.
He will have reactions. He will have a desire, because the body is
calling for more drugs at certain times.
It is impossible for an individual who is on methadone. I have taken
methadone, myself, and I think I heard a gentleman ask whether or
not an individual can get a high off of methadone orallj\ I was never
on any dr-ugs at the time, and I have experimented with drugs for
the main reason I wanted to be able to converse with the addict, and
291
I am out in the street at 3 and 4 o'clock in the morning with the addict
trying to help him, and to be able to communicate with the addict I
have to understand him.
I have tried — not LSD, I am sorry — I have tried heroin, cocaine;
marihuana is out of the picture because that is not a drug. I have tried
some barbituates, Seconol, you name it, I have tried it, except LSD
and speed. I know what I am talking about.
INIr. Steiger. AVliat happened when you took methadone ?
Reverend Massey. I got high off of 10 milligrams — I got high.
Chairman Pepper. Is that all ?
Mr. Steiger. Yes, sir.
Chairman Pepper. Mr. Winn, would you yield ?
Mr. Wixx. I will be glad to yield.
Chairman Pepper. Thank you very much. ]SIr. Keating, you may
inquire.
Mr. Keatixg. I am interested in a couple of points. Maybe you said
and maybe I didn't hear it, but I assume that you implied there are
no withdrawal sjmiptoms with the use of Perse.
Dr. Casriel. If it is used correctly there is absolutely no withdrawal
symptoms.
Mr. Keating. They don't go through the suffering that is associated
with withdrawal ?
Reverend Massey. May I answer that question ?
I don't like to, like I say — I noticed with the addict who is going
through treatment in the hospital — and let me say Dr. Casriel is in
one location and I am in another — there may be some symptoms as
far as where I am. There may be some symptoms of withdrawal, and
when I say "symptoms" they are very mild, running eyes, running
nose, yawning, some crampiness of the stomach.
With the use of Perse they may have some aches, but they are
so minor they are variable.
Dr. Casriel. I agree. When I say no symptoms I mean ■
Mr. Keating. No comparison. Everj^thing is relative ?
Dr. Casriel. Veiy moderate.
Mr. Keating. The gentleman mentioned something before about the
high numbers confined in jail because of public intoxication. I used
to sit on the bench for a number of years. We have had them in court
and the idea was to put them in jail for a few days and send them
home or else keep them a night in jail.
Would Perse be, or could it be used in this situation where they
are arrested and it is not safe to leave them on the street because they
can be physically harmed and they have to be brought in ? They could
be treated with Perse and then go home ?
Dr. Casriel. In 15 minutes they are sober.
Mr. Steiger. Winos, too ?
Dr. Casriel. In 15 minutes they are sober.
If a wino has no brains left because he has drenched his brain, that
is something else.
Mr. Keating. The population of our city jails — and I can speak
from experience — are occupied mostly by people who have been ar-
rested for public intoxication.
292
Dr. Casriel. Mr. Keating, I have been thinking about this for
many months now. I can see the use of Perse like peanuts in a bar and
before you leave to drive home take one or two peanuts called Perse
and drive home sober.
Mr. Keatino. We have been through Antibuse. The governments are
spending thousands and hundreds of thousands of dollars on alco-
holism.
We have councils all across the country. If this works as effectively
as you say, in my area where we arc fighting for a new workhouse
facility or correctional institute for misdemeanants, we could reduce
the size of the facility substantially by simply having this form of
medication to treat the alcoholics.
Dr. Rosen. There is no comparable medication. Antibuse doesn't
]Mr. Keatixg. I understand that. I am speaking generally of all
these programs and all this money being spent in all these areas.
If this is as effective as you say
Dr. Casriel. Mr. Keating, I think this is revolutionary. I can say
you are going to have a lot of inquiries because I am going to get busy
on that letter and a lot of councils I have worked with through so
manv years, contacting you, that people on probational — I am getting
off the field of druofs, but not really
IMr. Keatixg. That is the point, it is the same thing, alcohol and
barbiturates and Seconals and heroin and LSD. You have got the
problem of the person. This will resolve the physiological problem
of alcoholism, narcotics, and barbiturates.
]Mr. SA>:r>:\rAx. Is this addictive ?
Dr. Casrtel. No: not at all. It is not nn alkaloid.
Mr. Keating. How long does it take for an alcoholic, the man who
has been drinking for years and there is no way for you to reach him.
he still, I understand, has psychlogical problems, but how long does
it take him to phvsiologically recover ?
Dr. Casriel. From acute — 5 minutes.
IMr. Keating. So that vou are talking about, in the case of metha-
doTie or heroin, it takes about a week or mavbe I misunderstood.
Dr. Rosen. Withdrawal from alco^^ol is about the same time, about
5 dn vs in the chronic alcoholic to withdraw him.
Dr. Casriel. But the acute symptoms-
IMr. Keating. But he needs about a week to destroy
Dr. Casriel. The steroids.
Dr. Rosen. Let's not go cutting down moneys for alcoholism. The
thing is it is not a panacea that we cnn have peanuts on the bar and
there will be no alcoholism, because the alcoholism is going to be there.
You can have somebody withdraw and take this and go back to drink-
mp- for the same emotional reasons as bof orehnnd.
Mr. Keating. If this is as successful as indicated, you eliminate
one of the obstncles of treatment.
ATr. Rosen. Tha<- is the main impact.
Mr. Keating. '\"^niich is the mnior thrnst of what we are all talkinfir
abont and driving at, which makes the psychological problem easier
to cope with.
Dr. Rosen. Right.
Mr. Keating. Mr. Chairmnn, I find this extremelv remarkable and
verv fascinating, and obviously it has a number of other possibilities.
293
You have been kind to take me out of order and Congressman Wiim
has allowed me to go out of order.
Mr. WixN. I have no questions. Go right ahead.
Chairman Pepper. Go I'iglit ahead. Mr. Keating.
Mr. Keating. I can just see at the misdemeanor level, as I indicated^
that this destroys the whole concept under which we have been operat-
ing. We talk about putting in a whole detoxification center. Well, you
wouldn't even need it at all. really.
Dr. Casriel. As I think I have mentioned in my paper that followed
Dr. Revici's paper on this, it is going to revolutionize the problem of
addiction : alcohol, narcotics, and barbiturates.
Mr. Keating. How long has it been before the Food and Drug
Administration ?
ISTr. Rangel. About 21/4 months. It was there before and rejected for
additional tests. We had scheduled a meeting with Dr. Revici before
the FDA. The FDA has not really rejected it in terms of saying tliat
it doesn't do everything Dr. Revici claims it does, but in their opinion
there are certain clinical tests that ha,ve not been made, and Dr. Revici
was supposed to have come down.
Tills committee has had doctors available to go with him. We thought
we would be able to come back with some lav knowledge of what the
FDA was reallv demandinsf. Unfortunatelv, because of the sudden ill-
ness of Dr. Revici, this meeting has been postponed.
But T have talked with people in the l^Hiito House that have been
in touch with the FDA, as well as the FDA itself, and they have made
it abundantly clear that we are not rejecting any of the testimony that
we have heard today, but merely indicated that we have certain
standards that have to be met. T think Mr. Perito will be able to report
back soon.
Mr. Keating. "Wliat limitations are there, at this sta^e, from the use
of Perse by hospitals, physicians, and the fact that it has not been
approved by the FDA ?
Dr. Casrtee. Well, right now it is only a research drug usable in the
State of New York by experts.
:Mr. Keating. Could, for example, a physician in my district use it?
Dr. Casriel. What is your district ?
Mr. Keating. Cincinnati, Ohio.
Dr. Casrtel. That is where I went to medical school.
Reverend Masset. Only in New York State may it be used.
Mr. Rangel. Transportation could be arranged for him to come to
New York.
Dr. Casriel. xis soon as we get FDA approval you will be able to
use this on a research basis throughout the country. That is what we
have been waiting for and waiting for, and every time there is an
automobile death, every time there^is a death from addiction I feel
there is something wrong with bureaucracy.
^ Mr. Keating. We all know 50 percent of the deaths, as someone men-
tioned, automobiles, come from drivers under the influence. I am talk-
ing in terms of 20,000, 30,000 people a year. We are not going to have
100 percent. We are talking about a lot of people whose lives may very
well have been saved. '
Mr. Steiger. Bill, would you yield on that?
j 294
What period of time are ^ve talking about for the oral
Dr. Casriel. About 15 minutes, 20 minutes; depends upon a person's
capacity to absorb.
Mr. fciTEiGER. I can see just before closing time everybody have a
Perse.
Dr. Casriel. Right, everybody sober up, party's over, sober up.
Mr. IvJEATiNG. I have no more questions.
Chairman Pepper. Mr. Winn.
Mr. Winn. No questions, Mr. Chairman.
Chairman Pepper. Mr. Blommer.
Mr. Blommer. One question, Dr. Casriel.
You said that you treated three people who had been maintained
on methadone, and 1 am sure that you talked to them about their
experiences on methadone.
Now, when they said, as I assume they said to the doctor that was
maintaining them on methadone, *'I feel normal," were they speaking
the truth?
Dr. Casriel. They are lying out of their heads, for God's sake. They
weren't just on methadone, they were taking everything they could
o-et their hands on. They told the doctor this is good. They were tak-
ing cocaine, barbiturates, getting drunk, taking anything. It is ridicu-
lous. They don't know the psychology of an addict. He will lie through
his teeth. He will steal his mother's teeth, and you expect him to tell
the person who gives him methadone, or if he is taking anything
else, of course, he won't say that. He will say. This is a wonder-
ful drug and I have been looking for a job, et cetera, et cetera, et
cetera. You are dealing with a pathological infantile character dis-
order.
How can you treat them as if they are adult people, adult, respon-
sible people ? They are all liars, all liars.
Mr. Blommer. My next question was what you think the people on
methadone maintenance think of the program. I think you have an-
swered that.
Chairman Pepper. Doctor, just one or two questions.
We had testimony before our committee from the commissioner of
corrections of New York City. He testified that thousands of people
who come into the correctional system with heroin addiction simply
have to go through agonies of withdrawal, without any treatment at
all, because they don't have any treatment.
Dr. Casriel. Mr. Pepper, let me answer that.
I was a court psychiatrist and I saw them kicking the Tombs, and
I was a ward psychiatrist at Metropolitan Hospital and I saw them
kick at Metropolitan Hospital, and I have also, of course, been in
Synanon, Daytop, and I have seen them kick this. The same kid, with
the same habit, with the same length of time, reacts completely differ-
ent in the Tombs, in Metropolitan Hospital, and in Daytop.
In the Tombs he will figure the least he will get is to be known as a
junky with a large habit. He gets status. The more he complains and
climbs the walls, he figures maybe if he screams enough they will send
Jiim to the hospital and he will get some methadone.
.In the methadone unit they yelled bloody murder and climbed the
wa2lB because they got methadone. The same kid, and I saw them, the
295
same kid literally, the same kid in the jail with methadone and Day-
top, the same kid would finally tell me what he was doing. He figured
the more he screamed, the more drugs he would get, or at least have the
reputation of a junky with a big habit.
In Daytop they have a cold, runny nose, upset, sick, in a day or two,
and then get over it. It is not a physiological thing.
Now, methadone maintenance is another thing. That is a lot of dope
and the kid you have to withdraw from the methadone maintenance
can really get pretty damned sick.
Chairman Pepper. This would be a simple and relatively inexpensive
way of treating those with withdrawal symptoms ?
Dr. Casriel. Yes ; you just give them a shot or a pill.
Chairman Pepper. Well, Doctor, I think all of us are excited about
this testimony you have given today. We have heard about Dr. Revici's
work and we certainly do hope, and I know my colleagues hope, it can
be a satisfactory drug and come into general use.
It has been my belief for a long time that that is one of the reasons
this committee committed itself to hold these hearings.
Dr. Casriel. If you can speed up this drug to public use you will
save lives. Every day that is wasted is killing people, and costing bil-
lions of dollars.
I think, if I may suggest, if you can use your influence to speed up
the investigational use of this drug so that it can get out on the market,
I know it is going to work. I know it works.
Chairman Pepper. Mr. Sandman, would you like to inquire?
Mr. Sandman. How many cases have you tried this on ?
Dr. Casriel. About 100.
Mr. Sandman. I wasn't here when you apparently testified.
What were your results ?
Dr. Casriel. They were detoxified.
Mr. Sandman. Detoxified. Does this satisfy their desire ?
Dr. Casriel. Satisfies their desire.
Mr. Sandman. You can take a hardened heroin addict
Dr. Casriel. I can take a person on methadone maintenance — to
me that is the hardest — and get them off.
Mr. Sandman. Now, he has to continue taking this, he never really
is cured ?
Dr. Casriel. Oh, no ; a week and you are finished. This isn't a main-
tenance drug.
Mr. Sandman. Oh, you only do this for 1 week ?
Dr. Casriel. One week at the most.
Eeverend Massey. May I also say here that some can take it for a
week, some for just 2 to 3 days. If an individual is shooting 50 bags
a day he may take it for 3 days only with approximately three or four
injections per day.
Mr. Sandman. But he is going to go right back to heroin ?
Reverend Mabsey. No ; I beg your pardon.
Mr. Sandman. He is not ?
Reverend Massey. Also, he takes oral medication in between the
injections. He is given oral medication.
Mr. Sandman. This is injected ?
Reverend Massey. This is injectable. I have a brother who was on
heroin, shooting approximately 50, 60 bags a day. A year ago — no, it
296
was March of 1970 — he was admitted into Trafalgar Hospital, de-
toxified, received this injection for 3 days. The remainder of his stay
in the hospital — he stayed 8 days — he received oral medication, and
I must say he is back to the use of drugs but it is not because he
stopped.
Mr. Sandman. This doesn't cure the habit ?
Reverend Massey. This detoxifies him physically.
Mr. Sandman. It just detoxifies him ?
Reverend Massey. Correct.
Mr. Sandman. I got it.
I have no more questions.
Chairman Pepper. Well, thank you very much, Dr. Casriel, Dr.
Rosen, and Reverend Massey. We have very much appreciated your
testimony and we are obliged to you for coming here today and giving
us this very exciting testimony. We appreciate it.
For the record. Dr. Rosen, please give us your name and address.
Dr. Rosen. Walter Rosen, 102 Eastll6th Street, New York City.
Chairman Pepper. And you are a medical doctor ?
Dr. Rosen. Yes, sir.
Chairman Pepper. Under the laws of New York ?
Dr. Rosen. Yes, sir.
Mr. Pepper. How long in practice ?
Dr. Rosen. Since 1949.
Chairman Pepper. Since 1949.
Reverend Massey, your full name ?
Reverend Massey. Rev. Raymond Massev ; my address is 144 East
90th Street, Institute of Applied Biology, In New York City 10026.
Chairman Pepper. You are a member of the clergy ?
Reverend Massey. Yes ; I am.
Chairman Pepper. What is your church ?
Reverend Massey. Bethel Baptist Church, Jamaica, Long Island.
Chairman Pepper. You have been associated with Dr. Revici for
about IT months ?
Reverend JNIassey. Correct.
Chairman Pepper. Thank you very much.
(The material received for the record follows:)
[Exhibit No. 14(a)]
The Case Against Methadone
Daniel Casriel, M.D., past president, American Society of Psychoanalytic
Physicians, and medical psychiatric superintendent, Day top Village, Inc.
The current proposition before the city council to supply drug addicts with
methadone is, in my opinion, malpractice. To substitute one narcotic for another
is not the answer nor the solution to drug addiction. When a narcotic is made
free and available by Government agencies, it can only increase and encourage
the further use of drugs.
Is it planned to make methadone legal and keep heroin illegal? Is a person
using heroin a criminal and an addict using methadone a patient? Is a person
selling heroin a criminal pusher — a person selling methadone a businessman?
Is a man selling scotch a criminal but a man selling bourbon a law-abiding
citizen?
How about the pot (marihuana) smoker — should he continue to go to jail for
possession while his cousin the junkie goes to work — as the proponents of metha-
done maintenance propose? The fact is that a large proportion of pot smokers
are law abiding and functioning citizens.
297
What will the other 50,000 addicts in this country do when they hear the boys
in New York are getting their stuff free and legal? New York will have 50,000
new citizens to add to our welfare rolls. "What will we do with the deluge V Will
they have to be a citizen of New York to obtain free or low-cost methadone?
They will not have to be a citizen of New York to steal from the citizens of New
York. What will prevent the have-nots from buying and stealing some methadone
from the haves? Do the proponents of maintenance really believe that a new
underworld market in methadone will not be established?
The millions of addictive prone — how many of these people will become addicts
because another narcotic is legal or at least easy to obtain? Have we forgotten
the reasons for the original narcotic laws? Are we prepared to treat 6-8 million
addicts?
Proponents of methadone maintenance therapy say the glamour will be taken
out of addiction when the addict drinks his opiate rather than injects it into his
arm. First, addiction to the addict is as glamourous as terminal cancer. Those
that need to inject something into their vein (very few for a symbolic need —
they use a vein because it gives them the quickest and strongest kick) and will
continue to inject something, and many would-be addicts who have fear of
injection now would have a new source of oral narcotic to start them on the
road to heroin.
In this country there are three groups — three philosophies — one might call
them three armies, fighting the common enemy of drug addiction.
The first army, of course, are the traditionalists. I myself was once an ad-
herent of this group. In 1962, the New York Tribune contained a quote relative
to the treatment of the drug addict. It was :
"Put him away either in a hopsital or jails for the rest of his life — or give
him all the heroin he wants."
I was the author of that statement. I had all but thrown up my hands in help-
lessness. After using the traditional approach in a great number of cases, I
knew I had cured no one and that any help I had given was transitory, inef-
fectual, and not worth the time and the effort. The schools, the courts, and the
hospitals had no better results. Doctors in private practice refused to treat a
drug addict. No force, intimidation, jail term.s — even the threat of death — bad
any impact on the addict. The traditionalists admitted failure, and just did all
they could to keep the problem under control. But it does not stay under control.
It became worse all the time in terms of numbers of addicts and the degree of
chronicity and tenacity of their habit. The traditionalists were and are losing
the battle.
Recently a second army has arisen. A new philosophy has re-emerged — on the
basis of, "If we can't lick them, let's join them," we now have, "If we we can't cure
them, let's try to control them. We'll stop them from stealing to get money for
drugs. We'll give them all the drugs they need." These are the adherents of the
methadone system. This was basically the philosophy of the "British System."
I personally feel that this approach is absolutely wrong not only philosophically,
but also medically. As a scientist I can accept any program which ha« a re-
search design and is limited in its scope, but I am utterly and completely op-
posed to the indiscriminate use of methadone as a treatment for drug addiction
in the city. I feel we are opening Pandora's box. We shall develop not only a
heroin underworld traffic, but a methadone underworld trafllc. The British
found they had a problem of illicit heroin trafl3c developed from supplies given
to the addict legally, and the British have had, until now, only a very minor
problem with what I call secondary addicts. Our problem in this country is
entirely different, as a majority of our addicts are what I call primary ad-
dicts— that is, drug addiction is a way of life for them. They withdraw from all
of life's constructive functionings and their entire lives are centered around the
obtaining of narcotics — raising the "bread" (cash) and finding the "connection."
They live to shoot dope.
Dole and Nyswander reported in 1965 ^ on the results of their preliminary
studies in the use of methadone to block heroin addiction. At that time much
hope was placed in this method as a result of their findings. However, Dr. Victor
H. Vogel, chairman of the Narcotic Addict Evaluation Authority of the State of
California, wrote on September 3, 1965 to the Journal of the American Medical
Association :
.j'i'K't'Vf 'l^y
1 Journal of the American Medical Association.
60-296— 71— pt. 1 20
298
"The paper by Dole and Nyswander on the treatment of heroin afldiction by
methadone does not come np to expectations pjenerated by prior publicity in the
public press and two feature articles in the New Yorker.
"The authors seem to be unaware of the tragic consequences of the introduc-
tion of heroin as a cure for morphine addiction at the turn of the century and
the later introduction of Demerol as a harmless narcotic. Although the authors
state at the beginning of the paper that it is only a progress report, an unwar-
ranted conclusion is made, 'Maintenance of patients with methadone is no more
difficult than maintaining diabetics with oral hypoglycemic agents, and in most
cases the patient should be able to live a normal life' : The authors are silent on
the problem of treating methadone addiction.
"Although 22 cases are presented as evidence of success of the treatment, two
had been followed less than 1 month and 10 cases for less than 2 months : Perusal
of the paper shows that four of the cases were still in the hospital, four others
had used 'Unscheduled' narcotics, two others had been discharged after toler-
ance tests only, and one left the program against advice.
"A common pitfall for investigators studying new cures for narcotic addiction
is the difficulty of determining the degree of addiction at the beginning of the
experiment. liimmelsbach and others have shown that narcotic dependence
can be determined only by objective observations during withdrawal, after
which the subject may be restabilized and experimental testing with the new
drug begin.
"The evidence presented in this paper that the substitution of the narcotic
methadone for the narcotic heroin is superior to withdrawal from all narcotics,
is not impressive. In spite of what the authors say. successful treatment by
withdrawal is not rare, particularly over a period of less than 2 months which
is the time reported by Dole and Nyswander in 10 of the 22 cases."
The following statements might be useful in counteracting some of the mis-
leading reports that are becoming more numerous daily.
Victor H. Vogel, Harris Isbell and Kenneth W. Chapman, wrote in the Journal
of the American Medical Association. December 4, 1948, in an article called The
Present Status of Narcotic Addiction: "The total addiction liability to metha-
done is almost equal to that of morphine, although its physical liability is less.
The euphoric effect of methadone on the addict (and undoubtedly in the addic-
tion prone person) is equal to that of morphine, so that its habituation liability
is high."
Harris Isbell wrote in his article "Methods and Results of Studying Experi-
mental Human Addiction to the Newer Synthetic Analgesics," published in the
annals of the New York Academy of Science, October 1, 1948: "The behavior
of men addicted to methadone was similar to the behavior seen during morphine
addiction. The patients ceased all productive activity, neglected their persons
and their quarters, and spent most of their time in bed in a semi-somnolent
state which they regarded as very pleasurable. Psychological changes seen dur-
ing addiction to methadone were similar to those seen during morphine addiction.
During addiction to methadone patients continually requested increases in
dosage."
Harris Isbell, Abraham "Wikler, Anna J. Eiseman, Mary Daingerfield and Karl
Frank, in their article "Liability of Addiction to 6-dimethylamino-4-diphenyl-?.-
heptanone (methadone amidone or 10820) in Man: Experimental Addiction to
methadone" published in the Archives of Internal Medicine, October 1948:
"When the dosage was increased to 40-60 mg. daily in the second week of addic-
tion, definite evidence of sedation appeared after the third or fourth iniection,
and the men began to express satisfatcion with the effects of the drug. Their be-
havior became strikingly similar to that seen during addiction to morphine. . . .
The degree of somnolence and lack of activity was greater than that seen dur-
ing morphine addiction. The men complained about this, and said that while
addicted to methadone they could do little but stay in bed. They stated that
methadone lacked a peculiar quality possessed by morphine, which was termed
'drive' and which they described as a sense of ambition to work and play games.
When it was pointed out that their behavior while addicted to moriihine was
inconsistent with these observations, the patients were puzzled and stated that
when they were receiving morphine at least they thought they were ambitious,
but when they were taking methadone they knew that they were lazy."
Last December Dole and Nyswander wirh Alan Warner reported on further,
and more extensive, studies (750 cases) in the Journal of the American Medical
299
Association, December 16, 1968, Vol. 206, No. 12, and it is presumably on the
basis of these studies that New York City has established a pilot program
for the treatment of addicts by this method.
However, Dole and Nyswander themselves state in their report :
"We have not, however, considered it desirable to withdraw medication from
patients who are to remain in the program, since those who have been dis-
charged have experienced a return of narcotic drug hunger after removal of the
blockade, and most of them have promptly reverted to the use of heroin. It is
possible that a very gradual removal of methadone from patients with several
years of stable living in phase 3 might succeed, but this procedure has not yet
been adequately tested."
In the same report, Dole and Nyswander also write :
"Since blockade with methadone makes heroin relatively ineffective, a pa-
tient cannot use heroin for the usual euphoria. * * * He can, however, remain
drug-oriented in his thinking, and be tempted to return to heroin."
"The greatest surprise has been the high rate of social productivity, as de-
fined by stable employment and responsible behavior. This, of course, cannot
be attributed to the medication, which merely blocks drug hunger and narcotic
drug effects. The fact that the majority of patients have become productive
citizens testified to the devotion of the staff of the methadone program — phy-
sicians, nurses, older patients, counselors and social workers."
In the Progress Report of Evaluation of Methadone Maintenance Treatment
Program as of March 31, 1968 by the Methadone Maintenance Evaluation Com-
mittee, Chairman Henry Brill, published in the same issue of the Journal of the
American Medical Association the authors mention : "None of the patients
who have continued under care has become readdicted to heroin, although 11
percent demonstrate repeated use of amphetamines or barbiturates, and about
a percent have chronic problems with alcohol."
Now I come to another point I should like to make against methadone main-
teuance therapy, which is an ethical, or perhaps I should say philosophical one.
Can we, as physicians, in all good co^iscience, prescribe medication which is not
curative, which may prove to be very destructive, when there is a growing
school of thought, backed by ever-increasing proof, that there is a cure for the
disease? Do we not, as physicians, owe the patient the opportunity of at least
having a chance of being cured, before we condemn the individual to a fate,
at best, of a zombied state of existence, and at worst to a reinforced highway
to destruction and death? Should a physician prescribe aspirin for pneumonia
and avoid the use of iJenicillin? Methadone at best treats only the symptom and
not the disease. At worst, methodone reinforces the disease. Methadone also
does something else. It reduces the motivation to get well. "Why try and get
well," says the addict. "Why suffer the stresses and strains of what amounts
to psychological rebirth in a therapeutic community such as Daytop? Why learn
to function and grow up when I can get all the methadone I need to avoid all
the pain of addiction, and I can spend my time raising money for a little
heroin that will give me pleasure. Why pay for dinner when I can get a free
lunch?"
Methadone does something else too. It re-inforces the addict's sense of futility
and hopelessness. He is now able to say to himself "you see? There is no cure * * *
so why try? Even the medical profession has admitted there is no cure. My friends
in the street, my fellow junkies are right. Once a junkie always a junkie."
It is planned to make methadone legal and keep heroin illegal. Is a person
using heroin a criminal and an addict using methadone a patient? Is a junkie
selling some of his heroin a criminal pusher — a junkie selling (or trading) some
of his methadone a businessman? Is a person drinking or selling scotch a criminal
but a person drinking or selling bourbon a law abiding citizen? Even during the
illogical years of prohibition we did not become that illogical.
And how about the "pot" (marijuana) smoker — should he continue to go to
jail for possession while his cousin the junkie goes to a hospital — or (more
ridiculously) as the proponents of methadone maintenance suggest — goes to
work? A large proportion of "pot" smokers are otherwise law abiding and
functioning.
Also, what will the other 50,000 addicts in this country do when they hear
the "boys" in New York are getting their "stuff" free and legal? What will pre-
300
vent them from coming to New York to get their "free lunch?'' What will we do
with the deluge? Will they have to be a citizen of New York to obtain free or low
cost methadone? They will not have to be a citizen of New York to steal from
the citizens of New York. What will prevent the have nots from buying and
stealing some methadone from the haves? Do the proponents of maintenance
really believe that a new underworld market in methadone will not be estab-
lished?
How about the millions of addictive prone — how many of these people will
become addicts because it is legal or at least so much easier to obtain? Have we
forgotten the reasons for the original narcotic laws? Are we prepared to treat
6-8 million addicts in addition to the 6-8 million alcoholics we already have?
Some proponents of methadone maintenance therapy state the glamour will be
taken out of addiction when the addict drinks his opiate rather than injects it
into his arm. First, addiction to the addict is about as glamorous as terminal
cancer. Secondly, those that need to inject something into their vein (very few
have a symbolic need * * * they use a vein because it gives them the quickest-
strongest kick) will continue to inject something. And thirdly, many would-be
addicts who have a fear of injection, now could have an additional large steady
source of oral supply to start them on their road to heroin.
FINANCIAL
The proponents of methadone maintenance introduce a point that appeals to
the taxpayer, i.e., methadone is the cheapest treatment, about 13 cents a day.
A closer look at the figures yields these facts :
$85 a day for early phase inpatient care (6 weeks approximately).
$5 a day for outpatient service.
Against the normal term of 18 months for rehabilitation in the therapeutic
communities, such as Daytop Village, the comparison cost of methadone care is
higher :
Methadone (18 months inpatient (6 weeks) and outpatient) (16% months).
$5,887.
Therapeutic community (e.g., Daytop) (18 months), $5,748.
And when you consider the fact that after the 18 months, the therapeutic
community (Daytop) produces a drug-free, resiwnsive recovered individual
while methadone maintenance produces a dependent addicted individual, the
comparison becomes clearer. Over a period of 10 years the Daytop graduate
will have 8Vi years of autonomous, productive (tax-paying) performance with
additional cost to Government while methadone maintenance will produced a
full 10 years of drug dependence at a total 10 years of $25,470 per individual.
And the final point against methadone. Diseases, like this are unethical and
immoral. They do not play the game according to the conditions set forth. When
will we learn that you cannot do business with disease? If we do not destroy
disease, disease will destroy us. There is no compromise. There can be no main-
tenance.
And now for the third army in the field fighting the enemy addictive disease,
a growing army in which I am proud to be among the leaders. An army com-
posed not only of professionals, but of doctors, psychologists, sociologists, social
workers, clerical workers, enforcement oflScers, judges, officials from the Depart-
ment of the Treasury, customs oflicials, but now we have in our ranks the re-
habilitated victims that were in the enemy organization. We have a new breed
of men, the ex-addict, who by his training has been a paraprofessional, ready,
willing, and able to assist us and one other in depleting the enemy's forces:
addicts, * * * bound in slavery to their addiction, and in destroying once and
for all the enemy * * * sometimes called addiction, sometimes called criminality,
sometimes called pothead, sometimes called alcoholism, sometimes called homo-
sexuality, sometimes called school dropouts, sometimes called the inadequate
personality, * * * always called the character disorder.
For over 7 years I have observed and taken part in the fight against addic-
tion by a new tactic, a new philosophy, which on one hand is very difficult, yet
on the other hand whose tactics are so obvious as to sometimes be oversimpli-
fied and called common sense. After working intensively learning the process of
treatment of the drug addict specifically and the character disorder in general,
I was finally able to trace it back and evolve a psychodynamic theory which to
301
me adequately explains why the process works. This theory is now being put into
practice by Daytop and some other therapeutic communities where ex-arldicts
work together to help themselves and each other grow into mature, responsible
human beings. It is a process which involves 18 months of intense confronta-
tion and challenge to growth within the addict/ex-addict peer group. Hard work
is the name of this game of recovery. There is no magic in winning back human
lives. To attest to its success, we have an ever-increasing army of Daytop resi-
dents and graduates who today bear witness to the fact that the addict can
recover his life — that man is not fragile and need not be sedated — that he can
be challenged to grow !
To effectuate treatment one must first remove the shell of heroin and prevent
the individual from acquiring or running into any other kind of shell. And then,
once exposed to the light of reality, without his fortress of the shell of with-
drawal, he is in a position to be taught how to grow up emotionally, socially,
culturally, morally, ethicall.v, vocationally, and educationally. This is no small
undertaking, but nothing less will suffice * * *and this is what is done at Daytop.
Which brings me to the treatment techniques. Empirical observation and re-
search at Daytop has found that there are only two prescriptions and two pre-
scriptions needed for complete treatment. They are simple. The prescriptions
are: 1) No physical violence, 2) No narcotics or other chemicals, and by infer-
ence no other shells under which to hide. By these two simple prohibitions we
have successfull.v eliminated two of the three ways an individual copes with
pain or danger. There is only one reaction open to him. only one method which
he can utilize, and that is by reacting to real and imagined stresses and strains,
real and imagined pains and dangers ... by fear. Motivated by fear he can
do one of two things. He can stay and attempt to cope with his fears, or he can
run out of the door, sometimes never to return, frequently to return again at
some later date. We have found that at least 80 percent of those who enter Day-
top will sooner or later remain to get well. We do not know what happens to the
other 20 percent who will never return. Perhaps they are dead, perhaps they
are in jails, perhaps they are in hospitals, perhaps they are still attempting to be
drug addicts, perhaps they have stopped taking drugs, perhaps they are on
methadone.
Daytop now has three facilities housing approximately 300 members, and a
rehabilitation rate of 92 percent C103 graduates). If allowed to grow it could
make a real impact not only on the drug addiction problem in the city, but also
on crime, delinquency, and, not least, on our tax dollars. If given support, it
could save the people of New York hundreds of millions of dollars now stolen by
addicts or wasted by ineffectual treatment processes.
Efren Ramirez, in his article, "City and Community Resources for Drug Addic-
tion." published in New York Medicine, Col. XXIV. No. 9. Sept. 19GS. writes:
"Addicts . . . almost without exception, show clear and definite manifesta-
tions of a wide variety of character malformation."
"They are poorly motivated toward long-range treatment and rehabilita-
tion . . . There are few professionals who can motivate addicts . . . By and
large the way to break through the apathy and lack of committment in the addict
is to use the simple expedient of employing a trained, rehabilitated ex-addict,
who can show by his own example, the feasibility of rehabilitation."
"For the serious addict rehabilitation requires a stay of some length in a
therapeutic community . . ."
"Addiction is one of the outstanding problems of the city of New York. And,
as such. It must be dealth with in an unusual, imited, really coordinated way."
And I think I can do not better to close these remarks by ouoting from the
article Medical Aspects of Drug Abuse by Michael M. Baden, in the same issue of
New York IMedicine :
"There is professional sterility when a physician marvels at a cirrhotic liver
and does not apnreciate or concern himself with the severe psychiatric and social
factors that led to it. Even if the alcohol consumption were stopped, as with
Antabuse, the underlying primary p.sychiatric pathology must still be treated
if we are to cure the person and not merely the symptom. So it is with drug
addiction: removing the needle does not in itself even begin to deal with the
causes that lead to the use of the needle . . . drug abuse is not a physical disease
but a psychiatric one and must be treated as such if it is to be cured."
302
[Exhibit No. 14(b)]
Casriel Institute of Group Dynamics, New York, N.Y.
I am honored to be the first discussant of this historic paper presented by
Dr. Revici. His paper has opened a new dawn on the treatment of addiction. Be-
cause of the great contribution of his knowledge of cellular physiology and
pathology and his resultant pharacological treatment of disease, I aim sure medi-
cal history will honor him as one of the greatest physicians of this century. I
am proud to be able to sit at his side today.
When I was first introduced to Dr. Kevici. some 15 months ago, to observe
the clinical reaction of several obvious drug addict patients to an injection of
his drug, I felt highly suspicious as to the nature of the drug. The individuals
reacted as if they had just received a "Fix." In 15 months I have given this
drug to over 100 drug addicts. Though their clinical reaction remained the
same as I first observed, after a week's utilization of Perse, the individual is
totally free of all narcotic needs and of Perse too.
Except for four cases early in my use of Perse, there have been no side effects
These four early cases reacted with a toxic "Grippe Like" fever which lasted
about 24 hours. Dr. Revici stated that it was the sulfur in the particular
preparation that caused this effect. After he lowered the sulfur concentration,
no other generalized side effects attributed to this drug was ever observed!
Clinically it seems to be perfectly safe. On one occasion, I personally took two
pills, to evaluate its effectiveness in preventing drunkeness due to alcohol.
Two tablets allowed me to drink 8 ounces of 86 percent T & B Scotch without
any side effects as to dysarthria, dizzyness. drowsiness, sleepiness, euphoria,
or any of the side effects T usually obtain from more than 2 ounces of alcohol
The clinical reaction of Perse is exactly as Dr. Revici describes.
I have had the occasion to detoxifize three people who were on methadone
maintenance ; one using 140 mg., one using 150 mg., and one using 240 mg. daily.
In all cases, the people were detoxified successfully and effectively. All of
the residents given Perse in my therapeutic community, called AREBA, were
able to maintain themselves and remain in the community, needing only addi-
tional rest. The clinical effectiveness I have observed from Perse is exactly
that which Dr. Revici described in his 1,000 cases. Rather than to review the
clinical reactions which Dr. Revici has already adequately reviewed, and for
which he has much more documentation than I. I shall formidate some of the
chnnges that I anticipate will take effect in the wake of the utilization of Perse.
The use of Perse will force a total review of the entire abuse and treatment
not only of narcotics, but also of alcohol and barbituate addiction. Perse will
eliminate the addictive probabilities of all these drugs, as well as remove the
effect of the drug if Perse is taken. However it will not remove the psychological
dependence, only the physiological addiction.
1. Methadone is contra-indicated and will stop being given for both mainte-
nance and withdrawal.
2. The simple, inexpensive (fraction of a centi diagnostic test for immediate
detection of Alkaloids in the urine also developed by Dr. Revici means that
though individuals may still take drugs, they will not become addicted. At
the first sign (i.e.: positive urine test) of the use of any alcohol, narcotic, or
barbituate: Perse could be given, eliminating the addictive cycle.
.^. The restructuring of most 24-hour therapeutic communities into large day
centers. This will reduce the cost by almost half. The average cost of the
therapeutic community like Daytop Village is ,$11 a day. Methadone mainte-
nance in the Dole Set-up costs S.'i..50 a day. A day center such as was structured
by myself in Hialeah. Fa., in Operation Self Help, operating 10 a.m. to 10 p.m..
7 days a week should cost closer to the $5..50 a day per person level. Unlike
methadone maintenance which could last forever, the average length of a time
of treatment in day renter will probably be in the area of a year. With the new
advances in the psycholoa:ical treatment of the addict, the actual time in a day
center conld be shortened.
4. Since the person is not addicted, he will be much more readily treatable,
psychologically.
5. Since hospitalization is not necessary (i.e.: the period of time normally
needed for detoxification of addiction) pyschological treatment can be prescribed
and instituted immediately at the clinic where the test takes place. There will
303
be no loss of applicants due to the need to wait for the end of the detoxification
period.
6. Since people need not become addicted, they are not necessarily weak or
need additional hospitalization for complication due to addiction.
7. Since they do not become addicted, crimes committed to obtain money for
drugs will be markedly reduced. Insurance costs will come down, courts and
police will have a markedly lesser business. Jails will not be as crowded. The
savings could be passed on to the taxpayer.
8. Because of no addiction, many more addicts can be treated on an outpatient
basis, with a great reduction of costs. Hospital beds for addiction can be phased
out.
9. Perse is not only antiaddictive, it tends to remove the psychological effects
of nonspecific "tissue memory"— spontaneous physiological readdiction will be
greatly reduced.
10. Perse will remove acute intoxication. One or two pills and 15 minutes
will remove drivers from "driving under the iufiuence of" — preventing half of
the auto fatalities, lowering insurance costs, etc.
11. Perse is life saving if given in time, no one need die of an overdose of
narcotics or barbituates.
12. Perse cost is extremely low. It can be reproduced relatively easily and
distributed quickly. Perhaps the current addiction programs already set up
can be the institutions which will distribute the Perse, take the urine tests,
and institute the specialized psycotherapy.
13. Money saved could be used to retool the psycotherapy used for the treat-
ment of severe character disorders. This is essential.
The criticism I have heard from professionals in discussing Dr. Revici's paper,
is that he has no scientific reference to the literature in his paper. I refer them
to Dr. Revici's erudite, professional textbook. Christopher Columbus could not
have given a cross-reference on previous work of the New World he discovered.
Dr. Revici has opened the way for the period of new results in the field of
addiction as well as other fields. Dr. Revici should not and cannot be judged
as one may with classical schools of researchers. Perse is revolutionary. It is
but one of many chemicals to spring from the "Pen" of a revolutionary researcher.
Dr. Revici, relying on his own knowledge of biochemistry, physiology, histology,
pharmacology, as well as clinical medicine theoi'ized the problem of addiction.
The cause of addiction. From his theory of cause and effect, he formulated his
chemical treatment, all on pencil and paper. He took his theories to his animal
laboratories and then finally to his human clinical laboratory, his hospital.
Trafalga Hospital. What more is there to question? Thousands of animals and
over a thousand patients have taken Perse without ill effects. So have I. Treat-
ment is not chronic, only for a week or less, therefore, no serious problem of
chronic accumulation of drugs, being build up in the body or other pathological
interreaction being built up in the body. The fact that Dr. Revici could the-
orize by pen, a treatment approach which he could successfully then apply
clinically, awes me.
On the contrary the headlong fatal social plunge into methedone maintenance
is based on a nonvalidated hypothesis, not biochemically validated, not physio-
logically validated, not pharmacologically validated and without even a scientific
theory of how methodone "blockades the effect of Heroin" only a clinical hy-
pothesis. Dr. Revici's theory, of course does explain this phenomenon. It is
not at all a "blockading effect" of methedone on heroin — but rather an exhaus-
tion of the bodies defensive reaction to the overwhelming dosages of methedone.
As an expert in the clinical treatment of addiction, I am totally convinced as
to the merit of Perse. Dr. Revici you are a blessing to all of humanity, I salute
you.
Research in Drug Addiction
(By Em. Revici, M.D.)
In the past years the tremendous growth in the number of people addicted to
drugs, has made of addiction a main national problem. The limited ability to
cope with the first basic aspect of the problem, the medical one, has conse-
quently limited the eflBciency of the psychological and social approaches. This
explains why the problem of addiction is still practically uncontrolled. The fact
that no real progress has been made in the medical control of addiction appears
304
to result from the insuflScient understanding of basic processes involved in addic-
tion and especially in the withdrawal syndrome.
The study of the pathogenic aspect of addiction and of the withdrawal sjti-
drome from a new angle has led us to certain conclusions concerning the nature
of the processes involved. As corrolary, a new approach aimed at controlling
addiction itself, without subjecting the person to the distressing withdrawal
syndrome, has been developed. It has resulted in an effective short-term therapy,
simple to administer, nontoxic, and inexpensive.
THEORETICAL CONSIDEBATION
In the study of addiction and of the withdrawal syndrome we have applied
our previous research concerning the mechanism involved in the pathogenesis
of abnormal conditions in general, and of the intrinsic role played by lipids in
these apthogeneses. In this research we have shown that symptoms, clinical and
analytical signs of any abnormal condition can be integrated into one of three
basic biological offbalances. Each one is characterized by its proper pathogenic
metabolic processes, clinical manisfestations and analytical changes. In one
of these offbalances we found that the metabolic processes have a prevalent
anoxybiotic character. The metabolism of glucose, limited to the fermentative
phase, leads to the appearance of acid substances, mainly lactir acid. The re-
sulting local acidosis is one of the main characters of this offbalance. It is the
further utilization of excess hydrogen liberated in these processes that gives
the occurring metabolism an anabolic character. In the second offbalance the
abnormal processes concern mainly the sodium chloride metabolism. The chloride
ions of sodium chloride are irreversibly fixed, while sodium ions which remain
free, bind carbonic ions. This results in the appearance of alkaline substances.
A local alkalosis characterizes this offbalance. The occurring dyschlorohiotic off-
balance has a catabolic character. In the third offbalance, the dy.soxybiotic. the
abnormal metabolism lends to an intensive fixation of oxygen, with the appear-
ance of peroxides.
The study of these three offbalances has also furnished characteristic Hinical
and analytical data. This permits not only to define but also to recognize the
offl^alanfe present. The study of the relationship between these offlialances has
shown fundamental antagonistic characters between them: that is, between the
biological processes involved, and the resulting clinical manifestations and
analytical changes.
Further study of these offbalances has shown the importance of the level of
the organization where the abnormal processes are taking place. Clinical mani-
festations and analytical data were seen to differ widely if a subnuclear. cellu-
lar, tissue, organic or systemic level of the body organization is affected. When
a condition is studied, this organizational aspect has to be considered.
Moreover, these offbalances were connected with the pathogenic intervention
of lipids. In the anoxybiotic offbalance, a predominance of lipids with positive
polar groups, mainly sterols, was found.
The dyschlorohiotic offbalance was seen to result from the intervention of a
spocific grouo of lipids with negative polar groups. These are separated as
"abnormal" fatty acids: namely, those having trienic conjugated double bond
formations in their molecules. The irreversible fixation of chloride ions, which
charactprizes this offbalance takes place at the conjugated double bonds of
these fatty adds.
In the dysoxybiotic offhnlanr-e. free unsaturated fatty acids with nonconju-
gated double bonds were seen to intervene. The physicochemiral antagonism was
seen to exist between the respective linids which intervene in the pathogenesis
of the offlialances. It could be related to the clinical and pathogenic antagonisms
seen between the offbalances. as well as between the processes involved and the
resu^fins: mnnifest'itions
Stn^'ting from tb's point, the i-.li.irmacologirnl a.sin'"t of ''T^ids aiid otbi^r agent's
was inve.stigated. losing each one of these three groups of lipids, it was nossiWe
to induoe the respectivo offbalan<^e. Various other agents were studied for their
relationship to thp lipids and their capacity to induce an offlialance. Their
spenfic as well as their nonspecific actions could be integrated in the defined
offlifilnnnes. This extilains many of the pharmacodynamic properties of these
agents. FJnsed on the offlmlnnces thes« agents induce they can be separated into
three groups which manifest the antagonism between the offbalances. Their
305
general character to induce an anoxybiotic, dysoxybiotic or dyschlorobiotic off-
balance, is associated to a specific capacity to act mainly at a certain level of the
organization.
The therapeutic approach was thus developed by relating these basic concepts
of offbaiances with the pathogenesis of the different conditions and the phar-
macopdynamy of different agents. In this guided therapy the nature of the agents
and their doses are determined by the ofEbalance present in the condition to be
treated. This is revealed by the clinical and analytical data obtained.
In practice, analysis of a condition under this specific aspect permits to rec-
ognize which offbalance is present and which level is affected. Consequently,
it suggests which agent has to be used in order to corret the condition. The clin-
ical and analytical changes induced by these agents are indicative of the neces-
sary changes in dosage.
ADDICTION AND WITHDRAWAL SYNDROMES
It is from this specific point of view that v>'e have approached the problem of
drug addiction and withdrawal syndrome. From the interpretation of the ana-
lytical data and clinical manifestations it appears that the addiction itself cor-
responds to an anoxybiotic type of offbalance. This offbalance was seen to be
induced in part directly by addicting drugs.
When administered experimentally in animals, addicting drugs were seen to
induce an anoxybiotic offbalance. For instance, rats with standai'd wound made
on their back, were given drugs of the narcotic group. They induced changes
toward more acid values in the pH of the crust of the wound measured on the
second day. This corresponds to an anoxybiotic off"balance.
A similar anoxybiotic offbalance was seen to result also from another mecha-
nism. When an addicting drug is introduced in the body it acts as an antigen
and the body tries to defend itself against it, as it does against any antigen.
However, in the specific case of the addicting drugs, the body appears unable
to produce the entire progressive series of defense substances, up to the spe-
cific globulins which would fully neutralize the antigen. Consequently the body's
I'esponse remains at a lower step of this defense mechanism, with a low degree
of specificity. This corresponds to release of lipids with a positive polar group.
As this defense is qualitatively insufficient the body produces an excess of these
defense substances. Their lipid nature with positive polar groups induces an
anoxybiotic offbalance. Addiction, therefore, corresponds to nn anabolic aroxy-
biotic offbalance which is induced directly by the addicting drug, and mainly by
the excessive production of these low specific defense lipidic substances.
In general the organism attempts to correct the abnormal situation created
by the presence of an offbalance. This is attempted by the intervention of nroc-
e««es corresponding to an opposite offbalance. For the anoxybiotic offbalance
these "correcting" processes are mainly brought about by the appearance of
dyschlorobiotic processes, through the intervention of conjugated fatty acids.
This dyschlorobiosis, whir-h in the case of drug addiction occurs mainly at the
systemic level of the body, is recognized through the appearance of a systemic
alkalosis. We have shown that the main analytical change which corresponds
to the withdrawal syndrome is the appearance of alkaline urines, resulting from
the systemic alkalosis. Manifestations such as abdominal cramps, di'-rrhea.
vomiting, lacrimation and muscular pains appear to result mostly directly from
the intensive dyschlorobiotic offbalance with systemic alkalosis. The addict may
control this noxious dyschlorobiotic offbalance. by intake of an addictinar drug.
By inducing anoxybiotic changes the addicting drug acts directly upon the
antagonistic dyschlorobiotic offbalance present in the withdrawal condition.
When a systemic acidosis replaces the previous alkalosis, the dyschlorobiotic
offbalance is temporarily controlled. Urines then change from alkaline to acid.
However, as a consequence of the repeated intake of drus:s. the amount of defense
anoxybiotic substances, as well as the intensity of correcting dyschlorobiotic
processes, is progressively increased. This results in an increasing need, an urge,
for more addicting drugs. Withdrawal of the addicting dru;? leaves the bodv of
the addict under the full infiuence of the progressively more intensive noxious
correctins: processes. The dyschlorobiotic offbalance which results, with it« in-
tensive alkalosis and the withdrawal symptoms which it induces, is thus progres-
sively increased.
306
It is this role of the intervention of "correcting" process in the withdrawal
•condition which explains why all withdrawal syndromes are more intensive for
the first 3 to 4 days after the discontinuance of the drug, and why they decrease
in intensity in the following days. This is due to the fact that although noxious,
the correcting processes acting upon the anoxybiotic offbalance of the addiction
itself, succeeds to reduce its intensity with time. As a corrolary, the correcting
processes also decrease.
THEEAPETJTIO ATTEMPTS
These considerations concerning the pathogenesis of addiction and of the with-
drawal syndrome led us to a therapeutic approach. As mentioned nbove, an off-
balance can be induced by administration of the lipids respon.sible for the off-
balance. This is also obtained with synthetic agents which have the same ba.sie
lipoidic-physico-chemical characters.
Our studies have shown that each offbalance is opposite to the two other off-
balances. Likewi.se, when one offbalonce is induced it will control any one of two
others. An induced dysoxybiosis may thus act against an anoxybiosis as well as
upon a dyschlorobiosis. These basic considerations were used in the search for
a guided therapy for drug addiction, .since the addiction itself is an anoxybiosis
and the withdrawal pyndronie corresponds to a dyschlorobiosis. Theoretically,
both should be controlled by agents able to induce a dysoxybiosis. Consequently
in the therapeutic attempts we u.sed agents which we knew from previous studies
to be able of inducing a dysoxybiotic offbalance.
We have found these properties in the members of the sixth series of the
periodic elements : that is, for oxygen, sulfur, selenium and tellurium. Adminis-
tration of agents able to furnish oxygen in a highly reactive form temporarily
influenced the withdrawal symptom.s. but were unable to control addiction
itself. This led us to use the second member of the series : sulfur. Inorganic
bivalent sulfur compounds as well as magnesium and ammonium thiosulfates
were \ised. We discontinued their use, for, despite effectiveness, we could not
administer sufficient amounts to fully control the condition. However the clinical
results obtained with these agents showed that we were on the right path. Con-
f^eqnently, we used bivalent negative sulfur but as organic lipidic compounds.
They were mainly hydropersulfides and persulfides of unsaturated fatty acids.
These compoiuids. although active, were however seen still not suffif^iently
effective to control withdrawal symntoms such as muscular cramps and vomiting.
This led us to consider selenium, the third member of the series. In view of the
high toxicity of most of the selenium compounds this became the main problem
in therapeutic use. Previous experience with selenium preparations has shown
that active selenium preparations with a very low toxicity could be obtained.
These are compounds of bivalent negative selenium, with lipidic properties. We
selef'ted an organic lipidic compound of bivalent negative selenium, with the
selenium bound as perselenides to unsaturated fatty acids.
In experimental studies in animals this preparation induced a dysoxybiotic
offbalance. It Is this strong activity which seems to indu<^e debydrogenation
whif^h in turn changes sterols into inactive substances siich as Diet's hydro-
carbon, (the ^ methyl, 1, 2 cyclopentanophenanthrene). By inactivating the ster-
ols they intervene in the pathogenesis of the anoxybiotic offbalance.
The same processes act upon the abnormal fatty acids with conjugated double
bonds, leading to their inactivation. This influences the dyschlorobiotic off-
balance. We have been using these preparations in order to act unon the two
offbnlances present In drug addiction and in withdrawal symntoms. These
nrena rations are used as oily iniectables and orally. The clinical results obtained
have confirmed their tbei-aneutical value.
The important role nlaved by the svstemic alkalosis in withdrawal symptoms
has led us to the use as adjuvants which have a strongly acidifving and oxidising
action. Hydrochloric acid and to a lesser extent its ammonium salt, effectively
net upon the svndrome. A preparation containing acidifying and oxidizing acrents
is used f's "adiiivant." This preparaiion for control of the withdrawal syndrome
is administered orally.
TOXTCITT
Toxicity studies in animals have shown that the orcranic lipidic selenium prep-
arations we use have an extremely low toxicity. In order to detprmine in acute
toxicity the LD50 in mioe and rats, we used couf^entrated solutions of the pr<^para-
tion having more than 10 times the content in selenium than the preparations
307
used in humans. In intraperitoneal and subcutaneous injections, doses up to 2 mg.
selenium per 100 g. of animal were tolerated without ill effects. The LD50 for
mice for intraperitoneal injection was 40 mg. Se/Kg, and for rats, 53 mg. Se/Kg.
The LD50 for subcutaneous injections are GO mg. Se/Kg in mice, and 72 mg. Se/Kg
in rats. In a 60 Kg man this would correspond to 1,000 ml. injected all at once. The
usual therapeutic dose for humans is a maximum of 50 ml./day for 2 days and 20
ml. for the 3d day— This is a total of 120 ml. for 3 days of treatment. Therefore,
the safety index for the drug is sufficiently high. There is a very low toxicity for
subacute administrations. The only limitation is the amount of oily material to be
injected. Infections of 0.05 mg. Se per 100 g. mice and rats daily, 5 days a week, for
6 \Yeeks, was seen to be without ill effects. Similar doses injected in dogs for 6
weeks were also seen to be well tolerated.
In chronic toxicity studies, doses for mice of 0.1 mg. Se per 100 g. body weight,
were injected for 3 months, without ill effects. The animals were not losing weight
and behaved normally. Pathological studies showed no lesions in any of the
organs. Administered to pregnant mice in doses of 10 mg. Se/per mouse, for 3
consecutive days, the preparation did not interfere with continuation of the
pregnancy, nor with the condition of the offsprings. Administered to mating
female and male mice, no teratogenic effects were seen.
The same lack of toxic effects was observed when preparations containing 35
mg. Se per ml. were administered to mice and rats through a catheter introduced
directly into the stomach. Administered orally to weanlings, it did not interfere
with normal development.
There were no changes in blood (CBC, hematocrit, electrolytes, enzymes — GOT,
GPT, LDH — albumin, globulin, CO- combining power, thymol turbidity, choleste-
rol) and urine analyses (glucose, albumin, acetone, blood, pH, surface tension,
chlorides, sediments) of experimental animals (mice, rats, guinea pigs, dogs, and
rabbits) kept on selenium preparations. There ^pve no ahnarmaiitjps e^thpr in
the gross and microscopic examination of the organs of animals sacrificed in
acute, subacute, and chronic toxicity studies.
In humans preparations containing up to 10 mg of selenium per ml have been
well tolerated without any local or systemic reactions in repeated I.M. injections
of 10 ml. In some subjects in concentrations at or above 10 mg of selenium per
ml the compound tended to induce a local reaction at the site of the injection,
which was still stronger with repetition of the injections. We are using in pref-
erence preparfitions having up to 10 mg selenium per mil. They were well toler-
ated locally. Capsules for oral administration containing up to 35 mg of selenium
each were also seen to be well tolerated in doses up to 10 a day.
We have used the same preparations in humans for other conditions and have
administered them continuously for several months, without producing any
toxic effects. Blood and urine analyses (the same as those mentioned for animal
studies) as well as clinical data have shown no toxic changes.
From these studies we have concluded that the selenium preparations we are
using are safe in doses much higher than those necessary to induce therapeutic
effects.
Acidifying and oxidizing adjuvants, pharmaceutically accepted, which act
upon withdrawal manifestations were added to the treatment with selenium.
Their concomitant administration with selenium preparations did not influence
the very low toxicity of both preparations.
TREATMENT
The selenium preparation containing 0.35 mg Se per ml is administered in in-
tramuscular injections in doses from 5-10 ml. These injections are repeated four
times in the first 24 hours, two or three times for the 2d day, and one or two times
for the 3rl day. Additional injections are given if withdrawal symptoms are still
present. Not more than six injections in 24 hours are given. From the adjuvant
acidifying solution, doses of one ounce are added as often as any withdrawal
symptoms appear without other limitation. After the 3d day of treatment
with selenium the subject continues only on the adjuvant solution. He may re-
ceive however, additional injections of the selenium preparation, only if the
withdrawal symptoms appear and are not fully controlled by the adjuvant
solution.
308
EESULTS
Studies concerning tlie pathogenesis of addiction and withdrawal syndrome
and of the ditl'erent therapeutic attempts were made in over 1,000 patients. They
were young and old addicts, ranging from 14 to 48 years of age. Most were ad-
dicted to heroin and cocaine, a few to morphine and barbiturates. Some were
newly started on the habit, while others were using the drug for years, some
even for more than 20 years.
Almost all patients wlien submitted to adequate treatment responded with the
same promptness. Administration of selenium preparations by injection to an
addict is generally followed within minutes by a favorable subjective change.
Most of the subjects use the same terms to describe the sensation they feel. They
say: "I am normal" to indicate that the effect is fundamentally different from
that obtained with the addicting drug. And this sensation persists usually from
2 to 12 hours. Their manifestation of an immediate loss of the urge, namely the
need for the addicting drug is a very important effect. Concoraitant]y, the pa-
tient Is started on the adjuvant acidifying solution, which is repeated as often as
any symptom of withdrawal appears. With these medications (the selenium
preparation and the adjuvant) addiction and withdrawal symptoms are eon-
trolled without being replaced by euplioria. There is no sensation of being ''high"
like that induced by the addicting drug, but rather an old sensation of feeling
"normal."
With the treatment used as indicated above, most of the patients remain free
of symptoms during and after the treatment.
Against insomnia we give barbiturates only if the usual doses of chloral hy-
drate appear insufficient : and this only for the first days of treatment.
Although there is no pain or any local or general reaction after the injections,
many patients even after first few injections indicate the desire to discontinue
these injections. They say : "I do not need any injections anymore, I have no
urge or any trouble, I am normal now." We then continue the treatment with the
adjuvant solution orally, recurring to injections only if the withdrawal symp-
toms are not fully controlled by this oral medication.
In a variant of the treatment, the injections of selenium are replaced by the
oral administration of the oily concentrated solution of the same px'eparations
with capsules containing up to 3-5 mg. Se. They are administered together with
the adjuvant solution, and in some cases the clinical results are similar to those
obtained with the injections.
In order to evaluate objectively the effects of the different medications upon
withdrawal symptonv'^- we have used a ouantitation of the syndrome according
to the method of Hi-^'melsliaeh, which we have expanded by adding other symp-
toms and signs. Each of the withdrawal symptoms or signs such as vomiting,
diarrhea, lacrimation etc. are given a numerical value. This eva^i^ation of the
condition is made either once or sevei-al times a day, and at the end of each ob-
servation the points obtained are added up. The curves drawn represent the
cour.se of withdrawal. For untreated siibjects the curves have a steep rising
abruptly and remaining elevated for a number of days. For patients receiving the
treatment, the curves barely rise and remain very low. for duration of the treat-
ment and thereafter.
CONTROT,R
In order to assess the real effectiveness of this treatment, we have carried out
control .studies. Some patients were given only a very small amount of the sele-
nium preparation to calm the withdrawal symptoms for a short time. When the
patient felt a return of the symptoms or an urge for the addicting drug, he was
given an injection of sterile sesame oil or of a preparation known as being inef-
fici^'nt. In every instance the incipient withdrawal symi^foms became mngnified
and the patient often became uncontrollable. A number of these patients became
so agitated that they signed themselves out of the program. An adequate treat-
ment with injections of the selenium rtreparation find adjuvant solution cnlmed
the wltlidrn-^'nl pviiiptoms within minntos. Ti.is! pi-T^eduro wns '•r'nen**':! on n
number of diffei-ent pntients, as v,-ell ns cm the same patient at different times,
and was alwavs followed bv the same effect.
Double blind studies will have to be carried out next in an institution better
equipped to Implement such an aspect of the program.
309
COMPAKISOX
The subjects who had undergone previous detoxification treatments, remarked
on the difference between this and other earlier treatments. They particularly-
pointed out that with our treatment they no longer felt the need for the addicting
drug. With methadone, for example, they claimed to have remained with pains
in the legs and e.specially with the urge for the addicting rlrug during, and even
after, treatment. In contrast, the urge for the drug disapiieared practically with
the first injection of our treatment, and then did not recur.
FOLLOWUP
After the first injection with the selenium preparation almost no patient has
voiced the desire the drug. UpoH leaving the hospital after 5 to 8 days, they
all manifest emphatically this lack of need for the drug. On followup visits
many subjects were seen to have remained free of narcotics weeks and even
months after treatment.
Others, however, resumed taking drugs. It is nevertheless important to point
out that not a single patient who has resumed taking the drugs and who has come
back for help, has said that he did it because of a return of the "urge." A few
resumed using drugs because of unresolved psychological problems. Many be-
cause they were "forced" by friends, and have been using addicting drugs without
any need or desire for the drug. Most of the patients after treatment return to
their old problems and their unchanged environment. They do not receive psycho-
logical or social help. Yet, inspite of this, of about 1.50 patients referred to us
by Rev. Raymond Massey of the Neighborhood Board No. 5, Inc., 22 percent
have returned to steady jobs without additional medication, and without the
help of psychological or social services. Of those receiving outside help, another
17 percent have returned to steady jobs.
VArXJE OF THIS APPROACH
In this important problem of addiction, we must evaluate as objectively as
possible the contribution which every new approach may bring to the solution of
the problem. Based on the the results we obtained, our treatment seems to repre-
sent a working solution of the medical problem of addiction. In a few days the
addict becomes free from the craving for the drug, without having to undergo
the torture of the withdrawal syndrome. This then opens the door for the second
and third approaches, namely the psychological and social ones.
Without the physical need for the drug, many of the patients become aware
of the important part played by their psychological condition and ask for psy-
chiatric and social help.
The efficacy of the treatment gives back to the patient the hope he had lost,
namely the possibility of a total recovery. By no longer facing the medical prob-
lem, the psychiatrist can treat a subject who is no longer hopeless or even hostile,
but one who is looking for help, like a nonaddict in his situation would do. And
this is the important contribution of our treatment to the psychological problem
of addiction. The experience of psychiatrists — in particular that of Dr. D. Casriel,
New York City — in the field of addiction has confirmed the importance of the
relationship between our medical approach and the indispensable psychological
treatment of addiction.
While the treatment contributes to the solution of the medical problem of
addiction, we must emphasize the need to integrate it into the more general
problem with its psychological and economical aspects. The medical treatment
will show its full value as part of such a complete program.
(Based on a lecture given at the Trafalgar Hospital medical staff meeting.
May 23, 1970)
Emanuel Revici, M.D., Scientific Director, Institute of Applied Biology, Inc.
TREATMENT OF DRUG ADDICTION
It is unnecessary to emphasize the importance of a simple, safe, efficient, and
inexpensive method for the control of the medical a.spect of drug addiction. This
represents the key for the completion of the treatment through an efiicient
psychological approach — and further social adjustments.
310
The method derives from a special concept concerning the pathogenesis of the
drug addiction itself. The addiction corresponds thus to a peculiar abnormality
of the defense mechanism of the body toward the influence exerted by external
agents, when introduced into the organism. In this special case of an addictive
drug the progressive series of defense substances evaluated is stopped at a rela-
tively low level. The incapacity of the body to manufacture higher more specific
defense substances against the addicting drug results in a quantitatively exag-
gerated aspect of less specific lower means. The excess itself of these defense
substances constitutes an abnormal condition. The apport of the drug, with the
capacity to neutralize the defense substances in excess, suppresses temporarily
the existing anomaly. At the same time it enhances however the production of
more defense substances, increasing thus the addiction itself. The low specificity
of the intervening defense substances explains the possibility to substitute one
addicting drug by another, in order to temporarily neutralize them.
If the addicting drug is not taken, the organism tries by itself to resolve the
existing abnormal condition of the excess of low defense substances. This is done
through the intervention especially of the parasympathic system. It is this inter-
vention which constitutes the withdrawal manifestations. The apport of the
drug, with the consequent neutralization of the defense substances, stops the
intervention of the nervous system and of the withdrawal symptoms.
It is the concept of the pathogenesis of the addiction and of the withdrawal
manifestations which has led to the therapeutic intervention. The agents of the
preparation Perse were chosen to act upon the processes involved in addiction.
The preparation Perse is in a sterile injectable form, readily absorbable.
Toxicity studies have shown practically the absence of toxicity. Doses of 6 or.
of Perse per 100 g. of animal in mice and rats were seen to be well supported.
Reported to human beings they would correspond to an injection of 6,000 ml.
The same, the preparntion introdu'-ed by catheter into the stomach of mice.
were seen to be without toxicity. Similar values were obtained in subacute tox-
icity studies, followed over 10 days with 1 ml. by injection or orally. No gross
or microscopic pathology was found in the animals sacrificed after this period.
No toxicity was seen in the study of chronic toxicity followed over .3 months.
No toxic effects were seen in humans treated with these preparations, as re-
vealed by clinical and analytical studies.
SCHEME OF TREATMENT
The treatment aims to control drug addictions, preventing at the same time
the withdrawal syndrome.
Afjents Used. — Preparation Perse. An organic compound of negative bivalent
selenium, sterile for injections.
To.r/mf?/.— Doses of 2 ml. injected I.P. or S.C. to 28-30 g. mice or of 20 ml.
injected I.P. or S.C. to 150 g. rats were not toxic.
Similarly no toxicity was seen in subacute and chronic toxicity. No local or
systemic side effects were seen in humans with repeated 10 ml. doses injected
I.M.
Conduct of Treatments.— ThQ first day doses of 10 ml. of Perse are injected to
the subject three times a day— that is at S hours interval and at least as fre-
quently as he would usually take his drug. If the subject was taking high doses
of narcotics, this interval is reduced to 6. 4 or even 3 hours. It is the same if
any withdrawal symptoms appear before the schedule time for the next injec-
tion. An injection is then given immediately and the time between the next in-
jections is reduced to a value below the interval.
This form of treatment is followed for the first 24 to 48 hours, after which
the .'subject receives only one injection every 12 hours the next day and one
infection the following 24 hours.
With this form of treatment the patient remains free of his addiction within
2 to 3 days without having had any symptoms of withdrawal.
If necessary, especially for psychological reasons, the treatment mav be pro-
longed for a few more days at the rate of one injection a dav or repeated as often
as desired, without any inconvenience.
311
[Exhibit No. 14(c)]
Significant Therapeutic Benefits Based on Peer Treatment in the Casriel
Institute ^ and AREBA ^
(Daniel Casriel, M.D., New York, N.Y.)
Historically, tlie treatment of emotional and behavior disorders has been the
province of authority figures. We have called these authority figures witch doc-
tors, priests, holy men, faith healers, doctors, alienists — psychiatrists. Society
in general, and the individual in particular have delegated to these men not only
the rational authoriiy due them, but also an irrational authority premised upon
the possession by them of magical omnipotence in one form or another.
Two hundred years ago the mainstream of western society ceased ascribing
magical curative pov.ers to its doctors and priests. But the sick or incapacitated,
individual, in his state of helplessness, frequently — at times unconsciously —
attributes magical power to his doctor or other healer.
Occasionally, the doctor or doctor-surrogate can utilize the role of magical
omnipotence, given him by his patient to help him. But the doctor can also use
this role has a cloak to hide his own feelings of therapeutic inadequacy and help-
lessness However, once the contract is made, neither patient nor doctor can, each
for his own reason, admit to the healer's lack of magic.
Therapeutic improvement, limited by the nonverbalized contract of delega-
tion and acceptance of magic on the part of patient-doctor, comes to a halt Treat-
ment, by the very nature of the relationship, cannot be reconstructive, but at best
reparative, more often, just supportive. Very frequently after an initial improve-
ment, the patient becomes worse when doctor-father-God cannot or will not
continue to live up to the role mutually agreed upon. The doctor's magical role
that he accepted, encouraged, or seduced from the patient has now backfired. Th*
patient feels betrayeii and angry. The doctor feels annoyed and would like to rid
himself of the problem patient
Modern psychiatry, stemming from the basic concept of Freudian theory,
attempted via psychoanalysis to use rational authority to reeducate the irra-
tional authority the patient delegates to the doctor. Unfortunately, psychoanalysis
is not only a very long and costly process, but it is also effectively useful only
witii those personality structures that are both basically adult (versus child-
like) and neurotic (versus character disordered) to begin with all the other
categories are, to a greater or lesser extent, unable to utilize psychoanalysis, as
can be seen in the following chart.
BASIC PERSCNALITY TYPES «
Level of
personality
integration Psychotic Neurotic Character disordered
Adult Psychotherapy with Reconstructive analytic Classical forms of treatment
psychcpharmacology. therapy. relatively ineffective.
Adolescent.. Perhaps reconstructive
analytic therapy.
Childlike Reparative therapy
Infantile _ Supportive therapy
• The major difference between character disorder and neurotic has been published by the author in "Physician's
Panorama," October 1966.
Currently, an ever-growing list of self-help groups are being established.
Starting with Alcoholics Anonymous in 1936, we have seen the rise of Gamblers
Anonymous, Weight Watchers, Addicts Anonymous, Neurotics Anonymous and
groups for wives, parents and friends of the afflicted. Self-help therapeutic com-
munities such as Daytop and Synanon, and more recently, scores of lesser known
smaller self-help communities and storefront operations such as Encounter and
SPAN are sprouting and growing.
'^ The Casriel Institute : the treatment and training facility for the new identity group
process and theory. This new theory and process will be published by Coward-McCann in a
booli called A Scream Away From Happiness to be written by the author.
- AREBA : A private therapeutic community for the rehabilitation of middle and upper
class drug addicts and other behavioral bankrupts. AREBA (accelerated reeducation of
emotions, behavior and attitudes).
312
Why is this happening? What need are these organizations fulfilling that tradi-
tional therapies (medical, paramedical, or religious) failed to fulfill? Who are
the people helping and being helped that found no help by professional workers?
How are the incurable and unhelpable being helped by each other? Who are they
able to help, and why are they able to help each other? What is the new "magic"
ingredient? What can trained professionals learn from all this?
Simply stated, we must examine the process involved with words such as peer
relationship, responsibility, concern, involvement, absence of magic, confronta-
tion.^
First and foremost is the concept of equality — peer relationship. Both in
AREBA and at the Casriel Institute the member entering in the groups or into
AREBA is treated as a potential equal, a peer by the group, the group leader
and the AREBA staff. By inference, it is assumed by all the members of the
group and the staff that the new member's potential for healthy functioning is
basically equal to any other in the group, including the group leader or AREBA
staff who make no secret of once having been in the new member spot). The
entering member is quickly told there is no magic, only hard work. We can
teach, but the member must learn ; no one can do the work for him or learn the
lesson of feeling, thinking, and behaving for him. Each must learn for himself.
Each learns that the more he attempts to involve himself in teaching his peers,
the more he learns for himself. To paraphrase Dr. Cressey, if criminal A at-
tempts to help rehabilitate criminal B. criminal B may not be rehabilitated by
A's activity, but A will almost certainly benefit.
The new member soon learns that others around him have no magical gifts.
Some have inherent special attributes that make them better in some areas than
in others — but all have the potential for happiness. He learns that he can be
as mature, secure, adequate, lovable, and affective as all those around him.
Not only is there no "we — they" situation such as we the patients, they the
therapists, but neither is false therapeutic contract able to be established. The
nonverbal, unconscious transfer of magical curative powers cannot be consum-
mated. The patient-member soon learns that he is not only responsible for. but
capable of his own growth and development. The whole concept of who is re-
sponsible for "getting well" or growing up, is clearly defined.
If a patient delegates magic to the therapist or the therapist accepts the
responsibilit.v of getting the individual well, reconstructive treatment of all
but the adult personality (where little if any magic is delegated or accepted)
is doomed to failure. A therapist has no real magic power. All he has. and this
is in no way an underestimation of his role, is empathy, a desire to help another
humnn being, and knowledge which, if learned and applied by the patient, can be
curative. The leader's knowledge to some degree was gained from his own
academic work, but mostly, and most importantly, from his own experience
working first on himself, and then on others.
The peer group process as practiced in both AREBA and the Casriel Institute
by the author, is so constituted that it does not allow the patient to delegate
magic powers to the therapist (s) and prevents anyone, out of concern, from
assuming responsibilities that in realty, he cannot fulfill. One can be responsible
only to the degree one has control of one's thinking, feeling and behavior.
Therapy is frequently misused because of the conflict and confusion of the re-
lationship between patient and therapist described by the words "responsibility"
and "concern." However, human relationships in general are frequently mangled
by the same confusion. Healthy parents are not only fully concerned for their
newborn child but are also fully responsible for his well-being. As the child grows
older, he must accept a greater and greater share in the responsibility for his own
life. By the time he is adult, he has total responsibility. His parents no longer
have any responsibility though their loving concern may be just as great or even
greater than the day he was born.
A good therapeutic process, whether in AREBA or in the Casriel Institute. Is
to assume only the responsibility of teaching the member what he is doing, think-
ing, and feeling; and what he has to do and feel to be mature. Learning is up to
the member's doing, thinking, and feeling.
3 Df'flnitions (a) Troatment — Any nipnsiiro desitriiod to ariK^liorate or euro an aluiorninl or
undesirable condition: (&) Rational authority is based on g-eniiine ability and comi"'tpnfy
and is exemplified by tb.e teacher imparting: knowledge to a pupil ; (c) Peer — It is sittniflcant
to note that this word Is not defined in the psychiatric dictionary ; {cD Therapy — Treatment
of disease: therapeutic; (c) Therapeutic — PertainlnK to or consisting of medical treat-
ment ; healing, curative.
313
The concomitant is the assumption upon the part of other members that the
new member is potentially equal to them and is equally capable of doing for him-
self and growing up.
In AREBA, it is assumed that the new entering member knows nothing, has
learned nothing but self-destructive, maladaptive behavior, thinking, and feel-
ing. The members and staff of AREBA have in their own growth learned to be
truly concerned for the entering member. They enjoy the challenge and will in-
volve themselves with the new member. They know that the more they teach,
the more they learn. They desire to give. They are given the time and knowledge
to teach the newer members everything they need to know to be mature, loving,
adult human beings. An entering member's potential for being a mature individ-
ual is assumed when he arrives.
There is also the assumption that the emotionally and socially bankrupt mem-
ber has learned nothing constructive for himself. The staff and senior residents
of AREBA painstakingly teach the new member minute by minute, hour by hour,
day by day, week by week, and month by month how to do for himself ; how, in
effect, to act like a mature human being. After a few months, the member starts
to learn how to feel like an adult human being — and feels what an adult human
feels.
In the Casriel Institute, the patient is confronted at the stage of his emotional,
vocational, educational, and social maturation at which he enters the group ther-
apy process and is taught from that level upward.
There is a general avoidance of constructive confrontation throughout our
society's social fabric, because most people fear the consequences of challenging
and being challenged. If a child disagrees with his parents, he is scolded, pun-
ished, rejected. If he disagrees with teachers, he is reprimanded, expelled, or
failed. If one disagrees with the boss, he may be fired for insubordina-
tion, recalcitrance or personality incompatibility. If one disagrees with
the social power structure, he may be considered a traitor, criminal, rabble
rouser, coward, anarchist or fascist. Disagreement with any authority within
our culture gives one a stamp of social disapproval. We have grown up with the
attitude that even if we're right, to disapprove of authority will result in pain
or loss of love.
Translated into a peer relationship, the attitude becomes, "I'll mind my
own business." 1. If I try to help, I'll only get hurt (i.e., the murders that in
the sound and sight of others were not interdicted). 2. If I reach out and show
my concern by expressing constructive criticism, I leave myself open and vul-
nerable to other criticism * * * people in glass houses shouldn't throw stones.
This peer indifference and isolation is endemic throughout our social fabric!
human — including therapeutic — relationship if personal growth is to ensue. The
Yet constructive challenge between equals is precisely what is needed in any
therapist, be it friend, doctor, or group member, will, in this open bilateral
interaction, change and grow too. The therapist must not only be willing and
able to change, but to show by example — by his role model position — that the
enjoyed and benefited from the experience, though he too was once frightened
and lost. He was not delivered into adulthood magically well but had to undergo
his own painful therapeutic re-education, which was hard work, and only later
became training for what he is now doing.
The humanistic-peer attitude on the part of the therapeutic teacher-leader
is essential. Peer relationship on the part of the therapist demands a more
personal kind of involvement. It leads to a quicker, more resonant, and fuller
human growth for the patient. It is diametrically opposite to the formal, de-
tached, impersonal, nonfeeling therapeutic relationship demanded in our train-
ing and experience in psychoanalysis.
The effectiveness of humanistic-peer involvement as a therapeutic treatment
process has several significant implications.
First and foremost is a total change of attitude that professionals have to
develop in order to effectively engage in this type of process.
Second, the obvious empirical observation that a feeling human being, who
has learned for himself as a patient-student the process, and has the capacity,
ability, and desire to engage others, can be an extremely effective therapeutic
change agent. Previous academic training is of relatively little use, though pre-
vious life experiences are of great value as are one's own former neuroses
or character-logical problems which have been resolved. In line with this, cured
hysterics are most effective with uncured hysterics; cured alcoholics are most
60-296 — 71 — pt. 1 — — 21
m
effective with uncured alcoholics; cured drug addicts are most effective with
uncured drug addicts; and cured homosexuals are most effective with uncured
homosexuals. However, this does not mean to say or imply that one has to
be an ex-hysteric, alcoholic, drug addict, homosexual, to do effective intervention.
The peer symptoms identification early in treatment is extremely helpful and
in some cases necessary, but within a few weeks all patients, no matter what
the variation of symptoms, realize they have the same problems,* that below
the symptoms, they are all human beings with the same basic needs and desires
and the same basic fears.
Third, psychoanalysis must be returned to the areas where it belongs : as a
highly specialized, very limited fine tool, in the tool chest of psychotherapy.
Fourth, because of the relative ease of treating and training, large numbers
of individuals can be treated and trained at little cost and relatively little time.
This means that large numbers of skilled group leaders can become available to
meet a tidal wave of need. Costs are within realistic ranges."
Fifth, it is logical to see the role of the professionally experientially trained
psychiatrist, psychologist and S.W. as consultant and trainer of the trainers,
as well as being used as the agent of initial interviews, medication, testing or
using traditional ancillary roles.
The significance for society is that the large number of untreatables could
now be treated ; the large numbers who could not afford treatment could now
afford it ; the large numbers who wanted treatment but had no available thera-
pist in the area could now find therapists ; a large number who were unwilling or
unable to commit themselves to many years of therapy could now look forward
to major reparative psychotherapy and reconstructive (major personality change)
therapy being done in a matter of months for most, or 1 to 2 years for some.
Indeed, this process, if fully applied, could make a significant impact relatively
quickly on major portions of our sick society.
[Exhibit Xo. 14 (d)]
AREBA, Inc., A Humanizing Process foe the Family of Man
Introducing AREBA, A New Concept in Rehabilitating Drug Addicts
AND Other Emotionally Disturbed People
A new psychotherapeutic treatment program for middle-class and upper-
class adolescents and adults — designed for severely character dis-
ordered personalities who do not need a sustained 3-year program
to get well
In 9 months — the time it takes to conceive and give birth to a
baby — AREBA can reprogram a person toward in-the-world behav-
ioral and emotional health.
At highly successful Day top Village, 3 years used to be required to rehabilitate
an addict. But, today, new techniques have reduced the time to a year and a
half. Now, Psychiatrist Dan Casriel and Ron Brancato, former director of pro-
gram at Daytop, have utilized their experience to establish a new kind of program
for middle-class emotionally disturbed people.
Frankly, AREBA is a hard-nosed program that isn't easy. (At least, at the
beginning. When people have been in AREBA a few weeks, they usually start to
like it * ♦ ♦ and to develop an esprit de corps about AREBA. )
The program starts by telling newcomers to stop acting out their symptoms.
Immediately. Then, it goes to work on the distorted feelings and defeatistic
attitudes which have caused the symptoms to exist in the first place.
AREBA makes people face the truth about themselves, find out who they are,
and grapple with how they feel inside. At the same time, it trains people to
function in the world in which they must live.
The AREBA program is designed to treat people whose emotional problems pre-
vent them from functioning effectively and responsibly within the boiuuhiries
of normal society. There are no rigid age restrictions. AHERA i.s strui'tiired
* Inability to accept love or express Identity anger. This Is the subject of another paper
submitted for publication by the author.
* "The Use ajid Abuse of Paraprofesslonals" — unpublished paper by the author.
315
fo focus on the problems of both adolescents and adults. AKEBA is based <m
the principle that psychiatric treatment alone is not enough to rehabilitate an
infantile neurotic or character-disordered personality — who, invariably, does
not know how to function. The program is designed to help an individual in two
ways : (1) to provide psychotherapeutic treatment to help him express and under-
stand distorted feelings and self-defeating attitudes ; and ( 2 ) to provide fetep-
by-step guidance about how to function more effectively in the world.
The program has been founded and structured by Psychiatrist Daniel Casriel
and Ron Brancato, former director of po-ogram of Day top Village. It is realistic,
tough minded, and extraordinarily effectively. Study the schedule following and
see for yourself why AREBA is different from other approaches you may have
read about.
The AREBA program lasts 9 months, and consists of three distinctly diffeient
phases of i)ersonal growth.
PlutHO I — First Jf months, 2Jf hours a day, 7 days a week
At the start, a young person is immersed in a 24-hour-a-day structured disci-
pline. For example, he arises at 7 :30 a.m., immediately begins to clean his i-oom.
and eats breakfast. Then, his day continues with meetings, seminars, group
thereapy sessions (held every day), and specific work responsibilities. Eveiy
hour of the individual's time is programed. He ineracts with others during free
time, and is accountable for everything he says and does. Special "probes" ( last-
ing 8 to 12 hours) explore self-defeating attitude patterns. "Marathons" (30-hour
extended group-therapy sessions) are aimed at breaking down emotional de-
fenses, and getting members of AREBA in contact with gut-level feelings.
Phase II — Fifth mmith through seventh month
In the next phase of treatment, a young person starts to attend school a?ain.
Or, if he is through with school, he goes to work outside of the AREBA com-
munity. He is encouraged to apply what he has been learning in phase I train-
ing. Hut he continues to live in the AREBA community, and continues to be
involved in Dr. Casriel's new identity groups, probes, marathons, etc. In thera-
peutic sessions, the emphasis is on helping the individual express his fears and
anxieties, and helping him learn how to function more effectively in the ex-
panded world to which he is now relating.
Phase III — Eighth and ninth months
In the final phase of treatment, an individual both works and lives outside of
the AREBA community. His involvement with AREBA is to attend encounter and
new identity groups three times a week. During these groups, he works on feel-
ings and attitudes which may be preventing him from adjusting healthily to the
nontherapeutic "outside world." He also spends time serving as a role model
for people entering AREBA for the first time.
Parents get training, too
Throughout the 9-month period, special groups and special counseling are
provided for parents of young people who are in the AREBA program. With
parents, the emphasis is on establishing a permanently better relationship Iie-
tween themselves and their offspring.
[Exhibit No. 14(e)]
Therapy of Narcotic Addicts Sparks Psychiatric Theory
[From the Medical Tribune — World Wide Report]
New York. — A psychoanalyst said here that he has evolved a psychodynamic
theory to explain character disorders by observing and working in the successful
rehabilitation of narcotic addicts. The theory is based on the concept that per-
sons whose primary method of defense is withdrawal, not "flight oar fight," "fit
into the pyschiatric classification of character disorder."
Dr. Daniel H. Casriel explained both his theory and the rehabilitation process,
which he called "the Daytop phenomenon," at a meeting of the American Society
of Psychoanalytic Physicians, of which he is president-elect. The term refers to
Daytop Village and Daytop Lodge, addict-reform communities in Staten Island,
N.Y., patterned after the Synanon centers, with some modifications of technique.
"Daytop is the breakthrough in the treatment of the drug addict," said Dr.
316
Casriel, who is medical-psychiatric superintendent of Daytop Village. "For the
first time, an addict upon entering Daytop sees 100 people who were also
addicted but who are living happily and functioning without drugs or the pre-
occupation with the thought of drugs."
Daytop A'illage has been in existence for 6 months. It is an outgrowth of Day-
top Lodge, established under a 5-year National Institutes of Mental Health proj-
ect to compare the results of several alternative probation arrangements for
felons of the Second Judicial District, New York Supreme Court, and initially
limited to 25 probationers. ,
"People live in Daytop in a pleasant, paternalistic, tribelike, family environ-
ment," Dr. Casriel said, paraphrasing his book on Synanon, "So Fair A House."
The members think of Daytop neither as a hospital, a prison, nor a halfway house,
but as a family-type club or home — a fraternity of people living together and
helping each other to get well * * *. The members are neither patients nor in-
mates ; they are free to leave any time they wish."
OXCE BELIEVED THEKE WAS NO HOPE
He said that he himself had once believed there was virtually no hope for
drug addicts : "Ten years of contact through community psychiatry with the
problem of drug addiction had left me deeply pessimistic * * *. My observations
had almost brought me to the conclusion that, once addiction was established in
certain predisposed but undefined personalitie.s. a basic metabolic change or
deficiency was produced in the a,ddict, manifesting itself in" a craving that only
the opiate could relieve." .'n.:-. .■
"That was my position imtil I discovered Synanon 3 years ago," he said, call-
ing Daytop "the amalgamation of the best that was Synanon and the best of the
professional understanding and knowhow."
Citing the relative lack of success of psychiatry in the treatment of character
disorders, he said that "the question I kept asking myself was, 'Why were non-
professionals able to stumble upon a rehabilitation and cure of the drug addict,
whereas professionals, as a general rule, were completely unsuccessful?' At last
I feel I've discovered why.
"After working intensively learning the process of treatment of the drug ad-
dict specifically and the character disorder in general, I was finally able to trace
it back and evolve a psychodynamic theory which to me explains why the proc-
ess works."
The theory, he said, was a modification of the psychocultural views developed
by the Columbia School of Adaptational Psychodynamics.
"A major defect in the adaptational psychodynamic theory," as.serted Dr.
Casriel, "was its lack of awareness that there are three major methods of coping
with pain or stress. * * * They accounted for two of these ways by the mecha-
nisms of defense called flight or fight, using the emotions of fear or rage. What
they failed to bring into focus is that there is a majoi:, perhaps more primary
mechanism in which one avoids danger or pain. * * * it uses neither the emo-
tions of fear nor rage and may be called isolation or encapsulation. * * * Some
people withdraw from the pain of awareness, the pain of reality, what they
experience as the pain of everyday functioning, by withdrawing unto themselves."
It was bis observation, he said, "that those people whose primary mechanism
of defense is withdrawal are those who fit into the psychiatric classification of
character disorder."
Once this "intrapsychic world without tension" has been evolved, he con-
tinued, "the individual will overtly or covertly fight anyone who attempts to
remove him from his prison-fortress. * * * Once the adaptational mechanism of
isolation is evolved and becomes a primary mechanism, the standard psycho-
analytic techniques using introspections and observation are useless. The indi-
vidual patient, though he hears, cannot be reached."
shbh:,!. must be removed
To treat such patients, Dr. Casriel said, "One must first remove the shell and
prevent the individual from acquiring or running into any other kind of shell."
Then he must be taught how to grow uj) emotionally, socially, culturally, sex-
ually, vocationally, and educationally. '•!/,!•.< I
On this basis, addicts entering Daytop are given two simple prescriptions: no
physical violence and no narcotics or other chemicals — "and bv inference no
317
other shells under which to hide." Only one reaction to his stress is left open to
the Daytop member — fear. He can leave Daytop if unable to cope with his fears.
However, said Dr. Casriel, "We anticipate that at least 80 percent of those who
enter Daytop will sooner or later remain to get well."
If he stays, the member is given two prescriptions — go through the motions
and act as if. The first means to abide by the rules and follow instructions, like it
or not. If a member complains that he doesn't linow exactly how to do as he is
told, he is instructed to act as if * * * you knew what to do * * * you had the
experience * * * you are mature * * * it is going to be successful * * * you are
going to grow up and get well * * * you are already well and adult.
"When people go through the motions of acting as if," Dr. Casriel said, "they
start thinking as if and finally feeling as if." At the beginning of this process,
there is a crucial 90-day hump during which painful underlying feelings come to
the surface, he said, but the support of others at Daytop helps the new member.
COMMUNICATION IS TREATMENT
Treatment through communication then helps the member to understand that
the undifferentiated somatic painful feelings that he has experienced on a vis-
ceral and emotional level * * * are nothing more than fear, anger, guilt, and de-
pression, emotions experienced by all humanity * * * are not exclusive to what he
felt was the mystical parahuman called the drug addict.
Tools of communications used at Daytop are a form of group therapy called
the encounter, seminars, public speaking, psychodynamic interviews, lectures,
and community relations. There are also rituals and rites of passage, including
the intake and indoctrination processes, entrance into regular membership after
a month's probation, a birthday after a year, and primitive rituals to maintain
discipline, called the haircut and the general assembly.
[Exhilnt Xo. 14ff)]
The Family Physician and the Narcotics Addict
(By Daniel H. Casriel, M.D.^)
(From the Sandoz Panorama, February 1970)
Because of my work in rehabilitation of drug addicts, I am often called upon
for help by family doctors faced with this problem in their practices. The fol-
lowing is basically a summary of the answers I have given to their questions.
People seeking relief from their emotional problems have always been among
us. Drugs are not a specific maladaptive resolution of an emotional need, but
our present culture is drug oriented. Most of us have not the slightest hesitation
in taking aspirin at the first twinge of a headache or a sleeping pill for a restless
night or two. The underpinnings of this drug orientation are widespread and
culturally accepted. One has only to turn on the nearest radio or television set
to be cajoled, pleaded with, even intimidated into buying any of the medicinal
remedies for a wide variety of common conditions. The easj' availability of
medicines through comercial production, widespread distribution, and multiple
sources of supply, makes the awarweness, acquisition, and use of all kinds of
drugs so easy as hardly to be given a second thought. In this way the ground is
prepared for the specific use of narcotic drugs, and the resulting addiction to
them by the emotionally troubled.
Availability is a prime factor; it is, indeed, a fact that those sections of the
country which are closest to sources of supply have the greatest problem in this
field. One obviously cannot be a heroin addict without access to heroin. A house-
wife in the black ghetto of Harlem, might be (one could even dare to say, would
probably be) addicted to heroin and in close contact with her pusher : whereas a
housewife in Iowa might be habituated, if not addicted to some barbiturate, tran-
quilizer, or stimulant, while maintaining a very close relationship with her
doctor-supplier.
Anyone who is not functioning, or who is under achieving in a responsible task,
is potentially susceptible to drugs, and a certain percentage of these people will
1 Dr. Casriel Is well known for his snccessfiil rehabilitation of narcotics addicts. He has
been medical director of the Daytop therapeutic community, and its affiliates, for many vears.
He also has a private psychiatric practice in New Yorls City.
318
resort to heroin. One must not forget that before the narcotics laws were passed
in the early part of this century, we had anywhere from 2 to 5 million people
addicted to various nostrums containing opium.
DIAGNOSING ADDICTION
The family physician dealing with a great variety of patients can — indeed
should — make a differential diagnosis specifically excluding drug addiction of any
one who is not functioning near his capacity, or of anyone suffering from a great
deal of anxiety or depression (often masked as fatigue). Look for unexplainable
needle marks or scars on the arms. Test the urine for morphine or its variants.
The psysician should be cautioned in two ways. First, prescril)e no narcotics
unless absolutely necessary, and even then only to patients known to you. Second,
anyone coming in for chronic refills of barbiturates, tranquilizers, or ampheta-
mines, should be referred for psychiatric help l)efore they become addicted to
stronger drugs.
There is also a third aspect which should be borne in mind. This is that the
patient who demands a narcotic for continued or intermittent pain (which may
or may not be somatically induced) is addicted. This addiction may have been
iatrogenically induced for valid medical reasons, but it is the responsibility of
the physician who so addicted his patient to ensure safe weaning and detoxifica-
tion as soon as possible. Those physicians who are asked to mantain someone
on narcotics whose history they do not know, may be perpetuating an illegal ad-
diction, and are guility of malpractice, not only in a legal, but also in the
medical sense.
CUBE IS AVAILABLE
A severe conflict faces a family physician in determining what to do witli a
known drug addict who happens to be a friend, closely related to a friend, or any
well-respected member of his community. Many physicians in such circumstances
have perpetuated the individual's addiction, feeling that there is no real help,
or that help is not available. Let me nov*- state quite emphatically that a cure is
available.
For the past 6 years we have been curing drug addicts at Daytop Village. Day-
top is a therapeutic community. At the moment it con.sists of almost 300 ex-
addict«, men and women, with and without their children or their mates, plus a
staff of about 40 (about a third of whom are ex-residents) living together and
helping each other to recover. Physically Daytop at present consists of three
facilities : the original one in Staten Island, a second at Swan Lake, and a third
recently opened on 14th Street, Manhattan.
There is no magic in rehabilitating a drus addict. There is only an understand-
ing of how to do it. a lot of hard work in doing it, and responsible love and con-
cern by all involved. The program consists of : intake procedures ; intensive group
encounters several times a week ; seminar sessions to improve the member's
ability to communicate verbally, to enlarge his interest and knowledge, and to
enal)le him to comprehend ab.stract concepts beyond his daily life experiences;
and then, of course, there is work, all kinds of work and plenty of it. because
the members of Daytop are taught to be self-sufficient.
Da.vtop has a record of 02 percent recovery. That is to say, not only are 92
percent of those who have graduated now free from drugs, but they are living
mature, productive and responsible lives. !\rany have returned to us and now
work with ns in staff positions, supervisintr and participating in all the internal
v,ork. The staff ratio to resident population, incidentally, is 1 to 22, thereby
making Daytop probably the least expen.sive, and certainly the most effective,
of any kind of program so far tried.
DAYTOP HISTORY
T wrote an article for this magazine about 3 years ago (in the vol. 4. No. S,
October 10(>() issue) in which T detailed the manner in which, having found
standard techniques useless, we developed our methods, and I described the
stages we worked throueh with our members in helping them to achieve new.
mature, .secure personalities. Tn the meantime Daytop has srrown and chansjed
and. indeed, is still ijrowinc: and chanjzinc:. Originally the stav that a resident
could expect when he first came in was about 3 years. Today the expectation is
319
down to 20 uioiiths, and we hope, as still newer processes are introduced, to be
able to turn out a healthy human being within 15 months or less.
Our chief tools are (1) the provocative behavioral encounters, which are group
therapy sessions, but of a different degree of intensity from the usual polite and
inconsequential type generally practiced in clinics or in prisons, (2) an introspec-
tive emotional encounter, and (3) the daily seminar, which might be described
as a sort of mental Swedish drill, an exercise in the use of words, thoughts, areas
of knowledge which will help the member overcome his discomfort at expressing
himself, and broaden the scope of his ideas.
Then (4) the work itself, the job assignment, is also a tool of rehabilitation.
The prevailing values are in conformity with the norms of the so-called Prot-
estant ethic : hard work, family responsibility, regard for others, thrift and
cornern for the future. Lower status chores are assigned to newcomers, or as
a form of sanctions for older residents who have infringed some house rule. The
negative values of the addict are replaced largely through the socialiing pres-
sure of the group therapy meetings, the seminars, and the day-in day-out living
together with others working through, or who have worked through, the same
or similar problems.
I shall not go into full details of the Daytop procedures, which I covered
in my previous article. The important point to remember is that there is a re-
habilitation method which is proven. It works. There is a solution, and there
is hope for the addict and hope for society. Not only in Daytop itself, but by
the role model it has formed, other Institutions may see ways to change so
that society as a whole, as well as the individual addict, will benefit.
I understand the problems of family physicians who practice in areas where
therapeutic communities such as Daytop do not exist. This problem can be solved
in two ways. Out-of-State residents can be taken into Daytop on payment of about
$350 a month, or, if you have large numbers of addicts. Daytop personnel can
develop, with your help, a Daytop in your area.
TYPES OF ADDICTS
There are basically four types, or degrees, of addicts. One is the preaddict,
the person who has a potential to be addictive and who, if set in an environment
where there are drugs around, will become addicted. Then, there is the fringe, or
peripheral, addict. He is already "chipping," is already on sonie narcotic drug.
He has a predisposition and, if allowed to continue, will develop an addiction.
The third type is what I call the soft-core addict, who is taking heroin, but has
been taking it for perhaps less than a year. He might have been arrested. He
might have been put in jail. But his whole life doesn't yet center around addic-
tion. Finally there is the hard-core addict, whose life has been totally centered
around drug addiction for at least a year, and in most cases for several years.
Daytop only takes in the hard-core addicts. The preaddict, the peripheral
addict, and the soft-core addict have been successfully treated at the Daytop
clinics called SPAN (Select Panel Attacking Narcotics). These are storefront
facilities which serve several purposes. They enable the local community to
become aware of Daytop therapy ; they exist as a counterepidemic force in areas
where the use of drugs is high ; they offer a helping hand to the local community
wherever the need arises ; they serve as a vehicle for reentry, where the graduate
of Daytop can confront neighborhood pressures and attitudes that helped give
i"'"se to his own use of chemicals. Most importantly, these facilities confront
early and peripheral drug users with an alternative, and try to rehabilitate them
right nt the storefront through group encounters, seminars, and interaction with
rehabilitated Daytop personnel.
,, PRIVATE TREATMENT
Pre- and peripheral addicts can, of course, be treated privately, too. I have
successfully treated, and am currently treating, very many such cases in my own
private practice. Any physician who is so inclined can receive training in this
new process. Shortly, a book about Daytop called "The Concept" will be published
b.v Hill & "Wang. Another book, "A Scream Away From Happiness." on the theoret-
ical and treatment aspects of the process, will be published a few months later.
In the meantime, for more details, I would refer you to the article "New Success
320
in Permanent Cure of Narcotic Addicts" in this magazine (vol. 4, No. 8, October
1966), or to Day top itself, wliicli tias recently prepared a detailed brochure out-
lining its activities.
[Exhibit No. 14(g)]
CtJREICtJLUM VlTAE OF DANIEL H. CaSRIEL, M.D., DiEECTOR, AREBA
TRAINING
Premedical
(1) Rutgers University, four semesters, prelaw and accounting, September
1941 to March 1943.
(2) Iowa State College, two semesters, engineering. Army specialized training
program, September 1943 to March 1944.
(3) Indiana University, three semesters, premed., March 1944 to January 1945.
Medical
(1) University of Cincinnati, September 1945 to June 1949; M.D., June 1949.
Post Graduate Training
(1) Internship: Brooklyn Jewish Hospital, July 1949 to June 1950.
(2) Psychiatric residency: Kingsbridge V.A.R., Bronx, N.Y., July 1950 to
October 1950 ; March 1952 to December 1953 (including Manhattan State Hospital
and Jewish Board of Guardian, for child therapy, Letchworth Village for mental
defectives ) .
(3) One year credit for assistant chief and chief, neuropsychiatric service,
Ryukyus Army Hospital, Okinawa, October 1950 to February 1952 (Captain,
Medical Corps, U.S. Army).
Military Service
(1) Active duty, March 1943 to February 1946, October 1950 to March 1952;
inactive reserve, November 1942 to November 1962.
Analytic Training
(1) Columbia Psychoanalytic Institute for Training and Research, September
1952 to February 1954.
(2) Persoual analysis: Dr. A. Kardiner, December 1952 to June 1960.
LICENSURE, ETC.
(1) Qualified p.sychiatrist. State of New York, 1954.
', ',(2) Diplomate, American Board of Psychiatry and Neurologv in Psvchiatry,
1957.
(3) New York State Board License No. 73985.
(4) License to practice medicine :
(a) Ohio, 1949, by examination:
(b) New Jersey, 1950, by reciprocity ;
(c) New York, 1953. by examination ; and
(d) California, 19G0, by examination and reciprocity.
PROFESSIONAL POSITIONS
(1) Private practice of analytic psychiatry since December in."3 (80-90 per-
cent of working time). Director of Clinical Institute of the Casriel method
(new identity process).
(2) University Consultation Center, Bronx. N.Y., December 1953 to June 1954.
(3) Three schools project of the New York City Youth Board and Board of
Education, December 1953 to June 19.56.
(4) Assistant clinical attending, Hillside Hospital O.P.D.. Mt. Sinai Hospital,
t)eoeni))er 19,")3 to June 19."6.
(.">) Court psychiatrist to New York City Court of Special Sessions. September
1954 to June 1957.
(6) Posthospital resident housing program of Jewish Community Service of
Long Island Hospital, June 1956 to June 1961.
(7) Therapist to the Girls' Club of Brooklvn, N.Y.. September 19.56 to June
1961.
321
(8) Instructor to New York City teachers and guidance counselor, September
1956 to June lOnO.
(0) Lecturer to probation officers, court of special sessions. September 1959 to
September 1961.
(10) Staff drug addiction services, Metropolitan Hospital; associate attending.
Flower Fifth Avenue Hospital ; instructor in psychiatry. New York Medical
College, September 1960 to June 1903.
(11) Psychiatric consultant, NIMH; grant to study drug addiction in the
U.S. Army. July. August 1962.
(12) Psychiatric consultant to the Synanon Foundation, August 1962 to June
1964.
(13) Consultant: Probation Department, Kings County, New York State Su-
preme Court : consultant. Halfway House Daytop Lodge for Drug Addiction,
June 1962 to March 1966.
(14) Psvchiatric consultant to the Girls Service League of New York City,
May 1963. '
(15) Consultant therapist for youth and work project of the YMCA Voca-
tional Service Center in Bedford-Stuyvesant, Brooklyn, February 1965 to Febru-
ary 1966.
(16) Consultant and therapist for the restoration of young through training
program : A program conducted in cooperation with the New York City Depart-
ment of Correction, March 1965 to September 1965.
(17) Cofounder and medical-psychiatric director of Daytop Village, Inc. (a
nonprofit therapeutic community and an extension of Daytop Lodge). By Janu-
ary 1970. 300 people in four physical facilities and four outpatient (SPAN)
facilities.
(18) Consultant BAN/ -BAN/LSD (barbiturates, amphetamines and nar-
cotics). 1965 to 1968. An ODP clinic, supervised by the New York State Supreme
Court. Department of Probation. 2d Judicial District.
( 19 ) Temple Medical School, clinical assistant professor of psychiatry, July
1967 to date.
(20) Group relations Ongoing Workshops, member of board of advisors and
chief, ps.vchiatric services, 1968.
( 21 ) Board of consultants. Country Place, Warren, Conn.
(22) SANE, board of consultants, 1968.
(23) Board of directors. Spruce Institute, Philadelphia, Pa., 1967 to date.
MEMBERSHIPS
(1) New York County and State Medical Association, 1953.
(2) American Medical Association, 1953.
(3) American Psychiatric Association and District Branch, 1952.
(4) Medical Correctional Officers' Association, 1963.
(5) American Society of Psychoanalytic Physicians, 1958 (president, 1966 to
1967).
(6) Association for the Advancement of Psychotherapy, 1962.
(7) Pan-American Medical Association, 1967, member of the council in the
section on psychiatry, January 15. 1969.
(8) ^Member. Royal Society of Health, 1969.
(9) American Public Health Association.
PUBLICATIONS
Book
"So Fair A House." the story of Synanon, Prentice Hall, 225 pages, December
5. 1963.
Articles
(1) "Suicidal Gestures in Occupational Personnel on Okinawa," U.S. Armed
Forces, Medical Journal, vol. Ill, No. 12, December 1962.
(2) "Intramural Psychiatric Service in a Public High School." New York
State Journal of Medicine, vol. 56, No. 12, June 1956.
(3) "A Mental Hygiene Clinic in a High School," the School Review, Summer
1957.
322!
(4) '-Modification of Adaptational Psychod.vnamics Theory in tlie Wake of
Successful Rehabilitation of the Drug Addict at Daytop Village," Physicians
Panorama, October 1966.
.;, (5) "The Marathon and Time .Extended Group Therapy," Current: Psychiatric
Thea-apies, 1968. n MihiaT-.f .;' -(n-t-,,,- i -r,, '--.
(6) 'Advice To The Family Doctor,'* Physicians Panorama, February 1970.
..(XT). 'Therapeutic Significance of Peer Interaction," American Public Health
Bulletin, to be piiblished.
(8) -Federal Probation."
TO BE PUBLISHED
Books
(1) "The Concept." The story of Daytop. Hill & Wang, Spring 1971.
(2) "A Scream Away From Happiness." Psychndynamic theory and process of
my new identity process, an accelerated reeducation of emotion, attitude, and
behavior. Spring 1971.
Chairman Pepper. Our next witness is Dr. Gerald E. Daridso]!. asso-
ciate director. Drug Dependency Clinic of the Boston City Hospital.
Dr. Davidson was Common vrealth fellow in psychiatry at Beth Is-
rael Hospital in Boston and a fellow in psychiatry at Massachusetts
General Hospital.
In addition to his duties at the Drug Dependency Clinic of Boston
City Hospital, Dr. Davidson is an instructor in psychiatry at the Har-
vard Medical School.
Dr. Davidson, thank you for coming here today to share your ex-
periences with us.
Mr. Perito. will you inquire?
Mr. Perito. Thank you, Mr. Chairman.
Dr. Davidson, I understand you have prepared a paper on your ex-
periences with the drug Perse ; is that correct ?
STATEMENT OF DR. GERALD E. DAVIDSON, ASSOCIATE DIRECTOR,
DRUG DEPENDENCY CLINIC OP THE BOSTON CITY HOSPITAL
Dr. Davidson. Yes, I have.
]Mr. Perito. Would you care to submit it for the record and sum-
marize that paper for us ?
Dr. Davidson. I think I gave you a copy.
Chairman Pepper. Yes, without objection the full statement will be
received and will appear after your testimony. You may make such
statement as you like.
Dr. Da\^dson. The problem that Dr. Casriel referred to bugs me,
too. Originally I referred several patients to Dr. Casriel's therapeutic
community. These Avere patients who had been on methadone mainte-
nance, or one of them had.
He told me — I said, Well, I will put them in the hospital to de-
toxify them.
He said, "No, you don't have to do that." He said, "I have got some-
thing that will detoxify them, we can do that down here."
So I went down to see this miracle that sounded too good to be true,
then found that indeed it was true. The patient whom I referred to
him first had been on large doses of methadone and had been using
heroin and barbituates, as well.
At the present time he is with Dr. Casriel and doing very well.
b'23
So then 1 weut to 'see Dr. Revicii'IW^'llevi'ci, as the bthers have told
you, is a iiiost woiiderf ill gentleman, very kind, veiy fine sort of per-
son. He informed me that it was impossible for me to use Perse in
Massachusetts because it couldn't be t£},ken outside of the State of New
York, pending FDA approval. ''\ '^' •
So that what I did then Mas when I had patients vv'ho needed detoxi-
fication I sent them down to New York. Some of the patients were put
in the hospital in New York in Trafalgar Hospital. Some of them
w^ere given medication to treat themselves with and came back to
Massachusetts. I observed them during this period of time.
, At first the trealment only worked equivocally because Dr. Revici
was treating them as if they were on heroin with the Perse treatment,
taking 3 or 4 days. Those on methadone, particularly large doses,
it takes 5, 6, 7, 8 days, sometimes.
But after the treatment was modified. I found that the patients did
well. They had minimal withdrawal symptoms, and what I did was to
prepare a questionnaire.
Now, it is very difficult for me, under the cii'cumstances, junkies
being as iri-esponsible and flighty people as they are, that it is hard
for me to get followup on many of these people. I have so far sent
down I think about 50 patients and I have followup on about 20 of
them.
In preparing the paper that T presented to you today I at that time
had a followup on 12. I have found that this strange medication does
do away with withdrawal symptoms to a large extent, that it depends,
as Dr. Casriel pointed out, on the situation in which the patient is
withdrawing. If he is in with othei- junkies and sitting around talking
with — talking about dope, he will have withdrawal symptoms.
As Dr. Casriel pointed out, you know, I am a bigger junkie than you
are. kiiul of phenomenon occurs. So that that sometimes happens.
But of the patients that I managed to watch closely during the
period of their taking medication, I found that this is a highly suc-
cessful drug.
I do feel that if vou can l)rin2: this to the Food and Druo"
xVdmimstration that we will be able — I am preparing a program to
test this objectively in Boston if and when we can get it loose from
them. I suppose they have their reasons, although they do tend to
move slowly. By law they are supposed to answer within a month^
and I don't know really what the status is at the present time.
But I found this does w^ork and I do feel this is a tremendous break-
through. The problem with addiction is that — let's take an addict in
Boston. I suppose we have about 10,000 or 15,000, If he has a habit of
$80 a day, $100 a day-
Chairman Pepper. How much. Doctor?
Dr. Davidsox. $80 or $100 a day ; it is difficult to steal that much,
and patients who shortchange banks — well, the banks are getting
smart now. So that what you do is you sell drugs, and you self drugs
to your friends and acquaintances. That makes this such an infectious
disease, that is what makes this so difficult, that it spreads like wild-
fire because each one teaches one. This is where we are infecting large
324
sections of the country, all sorts of small towns out of Boston ; out in
Palmer they have heroin and it is becoming more and more available,
whatever the efforts of the Bureau of Narcotics and Dangerous Drugs.
All they have done is to serve to drive the price up, and make it more
profitable. They have also, in large measure, prevented doctors from
treating this disease for a long time.
They in large measure are responsible for this epidemic. We must
do something to remove the addict from the streets, to remove him
from the drug market. Obviously, with all the efforts of the narcotics
acts and the customs ser\ice, and what have you, more and more
heroin has come into this country every day. It is getting cheaper
and better and our efforts must be concentrated on the addict in the
street, getting him out of the market.
This is why I feel tliat methadone is extremely valuable. I don't
have the same feelings about methadone that the previous witnesses
do. But I think of it in terms of removing the addict from the drug
scene. Perse has this possibility, too, and I think it is an extremely
valuable and useful thing.
It also makes possible the study of addiction on the cellular level.
This is the first time that they have a nonnarcotic antitoxin to the
narcotic. There are techniques, for instance, for injecting this material
directly into the brain, and in my hospital in Boston city they can
put whatever they want to in any given area of the brain directly
and this can be studied, and this Perse is a tremendous breakthrough.
I certainly hope we will be able to use it very soon.
Chairnian Pepper. Well, Doctor, you said you sent about how m.any
patients down from Boston to New York?
Dr. Davidsox. Between 45 and 50.
Chairman Pepper, You can testify that about how many of those
seemed to be cured or were detoxified ?
Dr. Davidson. A great many of them do v.liat Reverend Massey
and Dr. Casriel pointed out, that they use it to cut down on their
habits.
I would say of those that I found, about one-third are clean. That
is a tremendous cure.
You know, for instance, there is one patient I did send down who
came back and said, "Doctor," she said, "I don't remember any more
what it is like to be high. My body doesn't remember what it was
like to be higli on heroin.''
Her roommate uses heroin, and her fiance uses heroin, and in about
a month she was using heroin again.
I think that is in microcosm a good picture of the generalization.
But when they told me that she didn't remember what it was like
to be high, that is extremely important because, you know, once you
are hooked and you have the craving, however much will ])ower you
can apply, it just isn't enough, liecause day after day after day it
is practically impossible, ])eo]ile will succumb.
Everybody has a different strength of will, but everybody has
his breaking point, and this is why the cure rate, so-called, in places
like Lexington and any other medical treatment has been in the
neighborhood of 2 percent all these years.
325
Chairman Pepper. "Well, Doctor, once a person, as you say. gets
hooked on heroin, it is almost a livino; death if he can't cret some relief
from it.
In the first place, the fellow has cot to take several shots a day,
and they tell me that yon mi<iht he trying to work and all of a sudden
you have that impulse and you have got to get out to a rest room or
some secret place and prepare yourself and give yourself that injection
and all.
Dr. DAvrosoN. Right.
Chairman Pepper. So that you are practically deprived of the ability
to do any effective and sustaining work ?
Dr. Davidson. Correct.
Chairman Pepper. Unless you happen to be rich enough to afford the
expense of heroin addiction, you have got to steal, to run the risk of ar-
rest, the more you do it the more likelihood you will be arrested, and
then anybody who has been living a decent life in their better mo-
ments must be affronted that they have to keep on robbing and bur-
glarizing and that sort of thing all the time, so they certainly would
become aware of the fact they have become a slave to a terrible master.
Once you have abused, the ordeal of getting out of it without some sort
of chemical help is a terrible ordeal to endure. Once they get out of it
and get freed from it, I would imagine that all of the social pressures
and the desire to accommodate yourself to the good wishes of your
family, to be a responsible person, all those pressures are working to-
ward staying away from it once he has gotten off the hook ; don't those
things enter?
Dr. DAvmsox. No. they don't, not in 98 percent of the people, be-
cause the body — that is called the craving, or whatever it is — operates.
^Miat you just said is true of alcoholics, too. They just don't get
cured by themselves.
Chairman Pepper. By taking this then, you remove the craving of
the body ?
Dr. Davidsox. That is right.
Chairman Pepper. So they get a chance again to start over ?
Dr. Da\idsox. That is right.
Chairman Pepper. Mr. Perito ?
Mr. Perito. Thank you, Mr, Chairman.
Have you had patients. Dr. Davidson, that you have sent to Xew
York for treatment Avith Perse, that Perse was not effective on?
Dr. Davidsox. Yes, I have had several patients who say it didn't do
a thing for them. I have had — let's put it this way: I would say that
about 70 percent of the patients say that it is effective, that it makes —
I think in the paper that you have is a copy of my questionnaire, and
it is about 70 percent that say it is effective— another 20 percent say it
didn't do a thing for them, and about 10 percent say it made it worse.
The one-third of them with whom this seems to be unsuccessful, as
I look back on them, really weren't prepared, really weren't interested
in getting rid of the narcotic habit.
Mr. Perito. At the present time, Dr. Davidson, you are involved in
a clinical operation at the Boston City Hospital ; is that correct ?
Dr. Davidson. Yes.
Mr. Peritq. That is a methadone maintenance program ?
Dr. Davidson, That is a methadone maintenance program.
]\rr. Pkrito. Your patients are primarily ambulatory ?
Dr. Davidsox. Yes.
■ ; Mr. Perito. How large a group of addicts ape you treating in
Boston? . I i^f,./ k,jg ')>'l>l^UUi 1-0 f ,/■,;,! ffOT
n 430 and 450 patients
Dr. Davidsox. We have about between 430 and 450 patients m ou^
group.
Mr. Perito. Is that the largest methadone program in Boston ?
Dr. Davidsox. Yes. There is only one methadone program in Boston.
We have about 430, 450. There are 120 in a subsidiary clinic in East
Boston, and there is a small program at BostoivXJn^ye^sity which treats
maybe a dozen patients, r .>+ ,r-,, rrrRf{ r'o-r ?:f='f ■• J .":tv't
]\Ir. Perito. How is that program financed ?
Dr. Davtosox. Entirely by the city of Boston.
Mr. . Pertto. How . niuch, money do you receive from the city of
Boston?- r ;t',- C'lO-f est T ?5'f r^.''-) + tl
f.Dr. Davidsox. We run that clinic on somewhere near $150,000 a
vear.
Mr. Perito. $150,000 to treat 400 addicts ?
Dr. Davidsox. That is right. We are bursting at the seams. We are
doino- a bad job. We are afraid almost every day of some kind of
catastrophe, but that is the situation ; it is.
Mr Perito. Would vou agree with the conclusions, expressed by
Mr. Horan insofar as the euphoric effect of methadone is concerned?
Dr. Da\t[dsox. Yes and no. I think that Mr. Horan thinks he is a
doctor and he isn't, and I don't think that he really deals with people.
, - T am sorry he is not here to hear me say that.
Addicts take drugs in order to feel normal. They don't take druj^s
in order to be on a joyride all the time. In order to beon a joyride they
take more and more.
But many of the people take drugs in order to feel normal. After
thev have had methadone for a while they don't get a high from it.
There is another thing that I have noticed. There are a number of
patients whom we call borderline psychot.ics who are not psychotic and
not normal, either. These people seem to do'extremely well on metha-
•done. They tend to regularize their lives, to become functional again,
audit seems almost an ideal drug for them. -ov m ,'
One boy that T spoke to, T said, "Bruce, how about quitting? You
know, you have been on methadone for 6 months. 8 months."
He says, "Look, Doc, I spent some time in McLean until my family
run out of money and 2 years in the Massachusetts hospital and they
diagnosed me as a schizophrenic, and I foimd dope and methadone
afterward."
He said, "Since I have been on dope T have finished high school,
scholarship at the Boston Museum School, my work is winning prizes
all over the place, I am a junior faculty status and T am teaching
courses and T will be dammed if T will quit." T have beon working with
Bruce in psychotherapy and he is getting so that he is not quite so
borderline any more and he is beginning to become more in control of
himself and he is talking about quitting. . , , . ,
' - o
Mv feelino- about methadone is that very f recjpently it stabilizes the
situation, eels people off the street, j^ets tlieiii outof the drug market.
It acts as a; peculiar ;kind of tranquilizer witb' many people like Bruce,
and buvs ustinie.lt seems to me there -are' a hell of a lot^pf'thmgs m
tjie world worse tlian t^vkihs some mp'di'^e. every day.. "'=''/ [■' \:'' '"'^ .V^",
' You know it is not' -ideal butwe'.a'rrffc^c^d witb u-pltbltc Ke.alth
problem. We do notr have tiie'facilities' to treat these, all of these
people. If vou.just tliiiili about it, you Idiow, there are millions of
.people in this country who every night, go to — I come from Michigan
and calltliem beer gardens. InBostontbey are taverns. They go to the
tavern every. night, and drinl^ bjeer and watch color television and they
staffjrer liome and stagger to work every nibrning and back to the
tavern at night. ,-,>' . .
We have.no treatment for these people. We have nothing to offer
them. Therefore, society maintains these therapeutic institutions knovrn
as breweries, and this goes on with millions and millions of people.
Dr. Casriel knows how to treat them, bijt he ig only one man^ an^ it
is expensive and it IS diracult. _ c ., !" .. ^,r
', So that those people who drink beer every night aren't "any differ-
ent than: the people who are taking lieroin. All too frequently when
they get somebody stabilized on, methadone, you know, he starts driiik-
ing, too, or taking cocaiiip. Methadone isn't the answer 'to, everybody.
It is not a paradise. It is not the answer to eveiy' patient. It is the
answer to a lot of them, at least for a time.
- The same thing is, true of the therapeutic comiidunities.. My feeling
is you can't fight something with nothing. Sd you can't take drugs
away from somebody and put him in one of the commonplace com-
munities. You substitute righteousness, and righteousness is a very
powerful and delightful feeling. So that they get along fine like that.
.,; But the number of graduates of therapeutic. communities who then
tend to drink too much is more than anybody would 'really like to
talk about.
We are faced with a problem which is not just drugs, it is not just
heroin. There is a problem of people whose lives are not meaningful,
whose lives are unsatisfied. There is no feeling to them and their num-
ber is legion, there are millions of them and we really have to think
in those terms. ''*'^
So assume vre get involved with the kind of thinking I think rep-
resentative of Mr. Horan, if you get rid of the drugs you get rid of
the problem , that is unconscionable. That is shocking.
I think I will stop here.
Mr. Pepper. That is very fascinating. Doctor, to hear you talk
about it.
INIr. ]Mann, do 3^011 have any questions ?
Mr. Maxx. I get the impression that your institutional situation did
not permit you to have a thorough psychiatric followup on the pa-
tients that you got back from Dr. Revici's crash program?
Dr. Davidsox. Right. You see, our institutional situation is such
that we can't offer anything but methadone. We operate treating 450
patients in an area which is probably a third the size of this room,
believe it or not.
Mr. Manx. That is all I have.
328
Chairman Pepper. Mr. Steiger.
Mr. Steiger. Yes, Mr. Chairman.
Doctor, not in defense of Mr. Horan at all, but really — I heard
differently than you did. I didn't hear him say anything different.
The only thing, you would get a high off methadone if you were not
addicted to something else. I don't know how he feels about if you do
away with the drug you do away with the problem.
But I am interested, I guess, and what you are really saying is
that — which seems to be, again, what Mr. Horan said — is that meth-
adone is no panacea but it is the best we got.
Dr. Davidson. That is right. But, you see, what he talked about,
you have to wait 4 years before you put somebody on methadone.
Mr. Rangel. He said two.
Dr. Davidson. Two is in the FDA guidelines. He wanted Dole's
original of 4 years.
Mr. Steiger. He quoted Dr. Dole's original guidelines.
Dr. Davidson. And what in Heaven's name is somebody going to
do for 4 years ?
Mr. Steiger. Without getting into a debate situation, apparently
he has more concern because he sees it as a much more limited view
of it, he is much more concerned on hooking the innocent on metha-
done, I gather, which is a concern you can appreciate from his stand-
point.
I would like to ask you. Doctor, New York has apparently found
some way to permit the investigation of Perse. Have you ever at-
tempted to get Massachusetts to permit it ?
Dr. Davidson. No, I haven't.
Mr. Steiger. Do you know if it would be possible ?
Dr. Davidson. I don't, actually. I have been waiting for Federal
Commission, because they were supposed to answer within a month.
I am on that application as one of the principal investigators, and I
thought that would be the best way to go about it.
Mr. Steiger. If for some reason they continue to drag their feet,
do you think you might investigate the possibility in Massachusetts?
Dr. Davidson. I don't know. That is interstate commerce. New
York can get into it because it doesn't cross State lines.
Mr. Steiger. Manufacture it up there ?
Dr. Davidson. I don't know.
Mr. Steiger. Because I want to get it to my saloons. "We don't even
have color TV.
Doctor, I think you indicated in Arizona they are saloons.
You indicated an awareness of the devious nature of the addict,
and T think all of us, because of our vast experience of some year of
rending, so we know everything there is to know, would agree with
that, and therefore, don't you wonder at the Bruces who say, "Doctor,
you are doing a hell of a job and T am in great shape now "because of
you." Does that ever occur to you that Bruce is a pretty good con man,
too ?
Dr. Davidson. Oh, yes; he is telling me what T like to hear. "\"\lien-
ever anybody tells me' that T deal with him twice. But it also happens
to be true.
329
Mr. Steiger. Assuming that Perse is what it appears to be and you
tested it to your satisfaction, would you still feel the same about
methadone ?
Dr. Davidson. No.
Mr. Steiger. That is what I wanted.
Was there a uniformity in the substance, itself, were you able to
examine the substance on any kind of qualitative basis, microscopi-
cally or
Dr. Davidsox. Well, I visited Dr. Revici a number of times. He
likes Chinese food and so do I. We discussed this, but. you know, he is
a kind of experimental scientist, and each dosage unit is different, so
I think I noted in my paper that patients aren't treated with stand-
ard amounts and this made for some difficulty in that we must really
properly evaluate this medication.
Mr. Steiger. I see. Did you ever observe the effects on somebody
who was intoxicated from alcohol ?
Dr. Da\t[dsox. No. I haven't.
Mr. Steiger. Thank you. Mr. Chairman.
Chairman Pepper. Mr. Winn.
Mr. Winn. Thank you, Mr. Chairman.
On the memorandum that was furnished us. you said about
35, and I think you sent 45 to 50 patients down to Dr. Revici
now. and that was effective in about ,50 percent of your patients. Then
you got to talking about the withdrawal and maybe I didn't catch it,
l3ut how many of these 45 or 50 have you actually witnessed, whether
they experienced withdrawal symptoms, or not?
Dr. Davidson. I have seen about 10 of them during the period of
treatment.
Mr. Winn. And you don't have any followup on the ones that you
were able to followup on? Were any of those 10 — would any of those
10 be included in the ones that you were able to follow up ?
Dr. Davidson. Yes.
Mr. Winn. I think it is exceptionally discouraging — that is prob-
ably not the right word — that you haven't been able to follow up in
one way or the other, or have a med student or someone follow up on
the other patients, because really 45 or 50. I suppose to you miglit be
very indicative of how good Perse is, but I don't think FDA or any-
one Avould call that really a true, true test, probably as far as num-
bers are concerned, compared to Dr. Revici's experience.
Dr. Davidson. That is true; but I just don't have the facilities for
doing it. I have to depend on the patient coming back.
Mr. Winn. I think it would enter into the overall picture whether
they are detoxified, or it would give me a better idea if you had a
hundred out of a hundred. "\'\nien we send out a questionnaire to
150.000 people, if we got only 12 answers back we wouldn't feel like we
got a total picture.
Mr. Rangel. Will Mr. Winn yield ?
Mr. Winn. Yes.
Mr. Rangel. I think the evidence submitted by the doctor here was
merely supportive of what had already been submitted by Dr. Revici.
So I do believe that he has much more followup of the type that cer-
tainly I would be looking for rather than just relying on this.
60-296— 71— pt. 1 22
w
Mr, WiNx.nltiiink tlie questioi!, Charley, is there seeins ?o be ;i iiille
discrepancy in tlie testimonv of this afternoon, of tvhetlifer' tlier.e rfeallv
is a -Nvithdrawal symptom with Perse. ■^'>"-"- Joi o1 ii b
Mr. Raxgel. Well, I didn't find a conflict. It did seem to'TDe tliat if
yon were com])arin.Q; the sniffles and red eyes with what is really a
tifagic, human experience to see someone actually .wing tlirough with-
dr.awa'l, that one can say that Perse does all that' ft is claimed to do in
the area of ■ detoxification.
, Mr. Wixx. I would sav thy symptom was neofli^ible. but there was
a little deyiation. . \ ' "'
jMr. Raxge'l. I say, I haven't heard any drug addict with' their pro-
pensity to enlarge the agony they have gone through as a result of an
inhuman society\ I haven't heard any drug addict claim that life was
better for him in the area of withdrawal than it actually was. ■'"'■ '■■
, In the area of Perse I think most of them would like to believe, from
my experience, they have gone through horrendous experiences and
now they are o''ean*and decent citizens, but most of them mad^ it ap-
parentl.y. relatively simply as a result of Dr. Revici's clinio. ' •'-
INIr. Wixx. Dr." Davidson says that Dr. Revici often changes the
dosage units in the mix of his drug which might be one of the prob-
lems over at FDA right now, T don't know, T am not defending them
for their being so slow, but it is possible they have run into this
vdriatioii^'; ^*^
Did you run into that?
Dr. Casetel. He is a perfectidmst: He would like to have one tablet
given and that is all you would need. He has been modifying the thing
over the years. Some work a little bit better. I don't see any difference.
t give you a general clinical opinion of 14 months with about a hun-
dred people. There is barely, any side effect. There is no problem in
withdrawing. n!."i
Mr. Wix:Sr. But in this difference in the mix, is it mainly in the tab-
let or in the liquid ?
Dr. Casriel. If you read my original paper, the first four kids I
gave it to I got a guy who complained he suffered headaches. AVe went
back, and he said we added too much sulfur. We took out some sulfur;
Since that time we have had no trouble. Since that time he adds a little
more peroxide, regardless of what I did.
Mr. Wixx. You might not want that in the record.
Dr. Casriel. The thing is basically since our first four kids he has
T-educed the sulfur content and sometimes he eliminates it and some-
times he puts it in.
The clinical application is that these kids withdrew without any of
the undue side effects.
Mr. Wixx. Were most of the patients that you sent down there what
we call kids, under 21 ?
Dr. Da\tdsox. No.
Mr. Wixx. Over 21 ?
Dr. Davidsox. Yes.
Mr. Wixx. Well. I have asked the question before: W[\^t are we
talking about percentagewise in blacks and whites and Spanish-Amer-
icans, just roughly?
Dr. Davidsox. I would say that is was about 70 percent white, 80
percent black. I would say about 80 percent over 21.
3^1:
•f.-Mr. Vv^ixx. Dr. Rosen. ,;,, f. ^ i :• " • ■
Dr. RosEx. I just wanted to answer the question about tlie aleplietl,;?
ism' if you wanted to know about the withdrawal from that, tivv
,,,,^^ithdrawal from alcohol is much more lifei-threatening. If you have
a patient who has experienced that once, you can expect that in the
next withdrawal from alcohol they would again have at least that
much in t.ei'ms of convulsions and delirium tremens.
•Tiln my experieiice, and among that I have had about seven, I would
say, who have had previous delirhim tremens and convulsions iji al-
coholic withdrawal, and each one of those went through the with-
drawal without even the shakes, whi(^,h was unbelievable to me.
• Mi;. AVixx. r?r. I}avidson, you have had ti<3^. experieiice ;.^vith
alcoholism?
- !jDr. Davidsox. No.
•lyir. -Wixx^. Thank you, Mr. Chairman.
jj''0iairman Pepper. Is th^t all?
.^jklr. Sandman.
Mr. Saxdmax. No questions.
^^ . ]\^r. Blommer. No questions.
;:',:;yIr.';RAXGEL.:^^o questions. _ ;^^:;r,- r., ; o.d ^. .,4
Chairman Pepper. ]Mn Davidson, we are very much indebted to you
for ccyming and giving us the benefit of your experience as a man of
thought in the profession and what you have had to say is of great
interest. ' • •, .
'. ( The study previously reierred to follows : )
[Exhibit No. 15]
Results of Preliminary Pebse Study
In tlie past few months Dr. Davidson, associate director of the Boston City
Hosiptal Drug Abuse Clinic, has sent approximately 30 people to New York
to undergo withdrawal from heroin and/or methadone with Perse, a new, non-
addictive drug. The patients were given a series of daily injections and oral
dosages of Perse by its inventor, Dr. Emanuel Revici. The treatment lasted
approximately 5 days with varied, but overall encouraging results. Upon their
return to Boston those patients that could be reached were asked to fill out a
questionnaire involving the effect of Perse on various withdrawal symptoms and
the overall success of the new "cure" for opiate addiction.
Out of all the subjects involved in this particular study only 12 filled out
this form. Ten of these had undergone drug withdrawal before. Four were
addicted to heroin only at the time. (One patient underwent Perse therapy
twice— the first time withdrawing from methadone, the second from heroin—
and filled out a form for each experience.) Eight patients were on both heroin
and methadone, methadone only, or another similar opiate. The majority of the
patients recorded "slight" or "moderate" ovei-all withdrawal symptoms ex-
perienced with Perse ; only three i-ecorded that the symptoms were "bad."
The following is a runthrough of the individual responses to the specific symp-
toms experienced both with and without Perse recorded in the questionnaires :
The "rnnnning nose" withdrawal characteristic was quite diminished with
Perse, and recorded by most as "bad" without Perse.
"Diarrhea" varied from "none" to "moderate" with Perse (with only one
exception in which it was noted as "bad") and from "moderate" to "bad" with-
out (with only one exception in which there was "none").
"Vomiting" was recorded by four patients as being "moderate," by the rest
as "none" with Perse ; by three as "bad" or "moderate," and the rest as "none"
without Pei-se.
Four patients found "leg pain" "bad," three "moderate," and the rest "none"
with Perse ; five found it "bad" and the rest mostly "moderate" or "slight" with-
out Perse.
332
"Stomach cramps" were found to be generally "slight" with only one "bad"
with Perse ; and "moderate" or "bad" with one "none" without it.
The "no sleep" symptom varied a lot with Perse — three "bad." three "none,"
the rest "moderate" ; without Perse — generally "bad" or "moderate."
The sympton of "irritability" varied also with about sis patients recording
"none," two "bad," the others "slight" or "moderate" with Perse; while the
majority noted the symptom as "bad," with the rest "moderate' or "slight,"
without.
With Perse "tension and nerviousness" was recorded by most as "bad" with
some "moderate" or "slight" and one "none." Without Perse, all put down "bad"
with the exception of one "slight."
"Craving" seemed notably diminished with Perse, the majority recording
"none." Without it, the symptom was noted by most as "bad."
In answer to the last symptom, "tiredness," seven recorded it as "bad" with
three "slight" or "none" and two "moderate" with Per.se ; while eight noted it
as "bad," the rest "moderate" or "slight" and one "none" without Perse.
All patients, with the exception of two, recorded that Perse made their with-
drawal symptoms better. The two that differed said that Perse had "no effect"
and were, incidentally, addicted to rather high daily dosages of methadone.
Methadone addicts have been found to require a longer period to withdraw than
do heroin addicts. Most likely the chances of a successful withdrawal for these
people would have been greater if the perse therapy had been continued over a
longer period of time.
In response to the question involving the overall success of withdrawal on
Perse the majority of the patients said that it was indeed "successful," with two
stating that it was "partially" so and two that it was "not successful." Again,
these last two were addicted to methadone and probably needed more time which
this particular study was not set up to give.
Many of the users involved remarked verbally as well as in the questionnaire
that they were struck by the fact that they experienced "no craving" for dope
on Perse. One girl mentioned that she "forgot what it was like to be stoned."
That perse seems to block off the craving for drugs in most people is an important
attribute. This craving or the desire to return to drugs after experiencing the
usual withdrawal distress and being clean is the result of "complex rationaliza-
tions which are difficult for the nonaddict to \inderstand." ^
A person assumes several different attitudes as he becomes addicted to drugs :
He sees himself as an addict : he desires to increase his dosage ; he is constantly
dependent on the drug ; and he sees the drug as a kind of panacea and various
moral taboos wear off as the immediate beneficial effects of the drug become
realized. Inherent in all this is a "reversal of effects" ^ in which the opiate "orig-
inally foreign to the body, becomes intrinsic" ^ as the union between it and the
brain cells grows stronger. It becomes a nutritive element — a "means of carrying
out the business of the entire organism." ^ This reversal occurs gradually and
permiates deeply.
Drug addiction itself and the accompanying attitudes are all the result of the
user's awareness and fear of withdrawal distress. Even after "successful" with-
drawal these attitudes, although formed as a result of withdrawal distress, per-
sists independent of it. Therefore the fact that perse seems to block off the
desire for opiates is of considerable value in the face of the deep seated, some-
what irreversible nature of drug addiction.
There were problems encountered in the study which revealed the need to
"tease out" psychological from physical withdrawal symptoms. Strangely enough,
withdrawal symptoms have been known to reoccur in some after a year of ab-
stainence from narcotics. Perhaps a double-blind study would solve some of the
problem in separating the psychological from the physical and help evaluate
perse.
Certain patients involved in this pioneer study were not psychologically ready
to withdraw from their addiction. Obviously a study of this kind can only be
useful to addicts who are ready for it. Perhaps a preliminary preparation of
patients involved in further perse studies would somewhat insure their readiness
to undergo withdrawal and to respond as objectively as possible.
^Alfred R. Llndesmith, "Opiate Addiction"; (Princlpia Press of Illinois, Inc., 1957)
p. 12."..
2 Ibid., p. 29.
3 Ibid., p. 29.
*Ibid.. p. 29.
333
The Perse experiment also revealed the need for a standardized environment
conducive to drug withdrawal. Some patients were placed together and left
on a "ward" with nothing to do but dwell on their symptoms ; while others had
to find their own acco^nmodations outside and report to Dr. Revici daily. With-
drawal patients need people around them. Patients left alone have been known to
suffer longer distress. A supportive staff would help to guide and encourage the
patients in their individual interests and activities ; to maintain a therapeutic
atoniisphere conducive to both psychological withdrawal from the whole drug
milieu and physical withdrawal from the drug itself.
Again, in order to receive pertinent, cogent results from a study like this the
environment must be standardized and rehabilitative. The dosages of the
Perse administered must also be standardized according to the extent of the
individual patient's addiction. Because of the preliminary nature of this experi-
ment these things were not fully accomplished. Different dosages were given
to different patients, the extent of whose addiction was not often clear. Some
people needed more than the allotted time for withdrawal as has been pointed
out. A fixed potentcy and a definite schedule should be maintained in relation
to each patient.
Enough followup information on each subject involved is also important if
there are accurate, cumulative results to be gained. All of the patients were not
able to be located following the study and less than half filled out the ques-
tionnaire needed in this evaluation.
That there is a definite need for a more solid, clear method to be followed
for future studies with Perse is obvious. Preliminary preparation of patients, a
rehabilitative environment, a supportive staff, standardized dosages of Perse,
and extensive followups of each subject would all help in revealing more clearly
the merits of Perse. But i-egardless of the beginning nature of this study and
its often varied results, it is obvious that Perse causes a definite altei'ing of
withdrawal distress. Indeed, many heroin addicts reported complete success
with Perse ; and the overall effect of the drug on those addicted to methadone
— a notoriously difficult drug to kick — were encouraging enough to warrant
more extensive study. Methadone itself has been proven to be a very beneficial
tranquilizer to heroin addicts of certain temperaments. Its only drawback
is that it is addictive. If Perse could solve this problem methadone could be
used more freely in drug therapy.
This preliminary study with Perse has revealed the strong possibility that a
nonaddictive cure for narcotics addiction has been discovered. The dilemma of
addiction becomes more urgent every day and this new medication could pos-
sibly be a cure. This in itself is enough to warrant more extensive tests of Perse.
Perse Study
Nflmp
Date of trpfltment
Date of this repori-
Have von ever withdrawn before? Yes
Drugs used when Perse started :
Heroin How much
Methadone TTow much
No
Bad
Othpv TTow much
rate 4
Symptoms during withdrawal :
1. None 2 Slight S ModP
With perse
0th
er times
Running nose .
... 1 2 3
4
4
4
4 1
4
4
4
4
4
4
1 2
I 2
I 2
2
2
2
1 2
1 2
1 2
1 2
3
3
3
3
3
3
3
3
3
3
4
Diarrhea
1 2 3
4
Vomiting-.. .ii. ..-.-.-' -.-.:.- ..
...12 3
4
Leg pai n .<; .c...'. i-ji-ji . .J. .'
Stomach cramps-
No sleep ... ... ...
...12 3
...12 3
1 2 3
4
4
4
Irritability .
... 1 2 3
4
Tension, nervousness
Craving
... 1 2 3
... 1 2 3
4
4
Fatigue tiredness
...12 3
4
Perse injections made symptoms Better
Withdrawal Snccpssfnl Partiallv
Wnrsp
Not
_ No
effect-
334
'""^li'anTOanl^ETPPEiL That concludes tKel'iearing for the day and we
wish to thank all the., witnesses and the members of the committee for
-the patience they have shown.
'i. We will recess until lO .a.m., June 2, in v' :{)]■,) :^'^'<:li): • '
'"''■^ (Tlie folloAvino- statemeiit was i-ec-eivctl irir t1i6 rf>(for(1'.\
[Exhibit No. 16]
Statement of Wiixiam T. Beaver, M.D., Associate Professor, Department op
Pharmacology, Georgetown University, Schools of Medicine and Dentistry
It has come to my attention that the Select Committee on Crime has solicited
testimony reg-ardinjr the impact on medical practice of banning all imports of
opium and opium alkaloids into the United States and the feasibility of com-
pletely substituting synthetic narcotic analgestics for those opium alkaloids
and their semisynthetic derivatives currently in medical use. Ber-ause such a
move would have a very substantial impact in certain areas of the practice of
medicine and the conduct of medical research, and because you re contemplat-
ing making certain very widely used and long accepted drugs totally unavailable
for the treatment of pain and other illness, it is, of course, fundamental that you
consider a broad sampling of medical opinion and practice.
For the past 8 years I have been engaged in extensive controlled trials of
analgesics in cancer patients and patients with postoperative pain to compare
the therapeutic efficacy and side effect liability of a large number of naturally
occurring and synthetic analgesics. I have published both the results of these
studies and general review articles on the clinical pharmacology and relative
therapeutic merit of these drugs. Simultaneously, T have been involved either
directly or on a consulting basis in the day-to-day management of pain problems
in thousands of patients with severe pain, predominantly due to advanced cancer.
I have lectured extensively to medical students, hospital house staffs, and groups
of medical practitioners on the optimal use of analgesics in the management of
pain. In addition, I have served as a consultant to many governmental and non-
governmental agencies in this subject area, and am a member of the Panel on
Drugs for the Relief of Pain of the NAS-NRS Drug Efficacy Study. I am there-
fore deeply interested in the substance and outcome of these hearings.
After reading several statements presented to your committee in April, I feel
that insufficient emphasis has been placed on the sisrnificance. indeed the present
indespensability, of some of the opium derivatives in the optimal therapv of pa-
tients with particular types of painful and nonpainful conditions. While it is true
that the development of a variety of totally synthetic analgesics and antitussives
over the course of the last 30 years has freed us from a total dependence on opium
imports in the event of a national emergency, and while it is true that certain
of these totally synthtetic compounds may be freely substituted for naturally oc-
curring compounds in specific clinical situations and may in fact ht^ drugs of
choice in preference to naturally occurring compounds of some of these situa-
tions, it is by no means the ea.se that such a substitution can be made in all
clinical situations without patients suffering some or perhaps even serious
detriment.
Anions analgesics, none have properties which are entirely identical. They
very in their potency, in the maximal analgesia obtainable by do«es which have
been proven safe, and in the speed of onset and duration of their action. Some are
very much more effective than others Avhen administered by mouth, while a
tendency to irritate tissues sets practical limits to the size of the dose of certain
drugs which may b^ injected hypo<lermically. The potent analge.sirs differ in their
effect on mood, their tendency to produce sedation, their abuse liability and the
pattern of their side effect profiles. Many of the newer synthetic agents have
never been used to an adequate extent in certain special patient populations fe.g..
children, women in early pregnancy, tolerant patients requiring very high doses
of narcotics or patients concurrently receiving certain potentially interactin,g
medications) to establish their relative safety under these circumstances. Like-
wise, there are certain clinical situations where only a single drug seems ever
to have been given a careful therapeutic trial. For example, morphine is so
extensively and universally used in acute pulmonary edema that there is little
evidence to indicate whether other narcotics would prove effective in this condi-
335
. ■ - ' ■ ■ . ,/.•■. ■,!■',,■
tiou. While uoue of ttie natm-al or synthetic analgesics could be classed as very
expensive drugs, there are cost differtnials which may be significant. Finally,
patients exhibiting allergic or idiosyncratic reactions to one narcotic may tolerate
another without difficulty, a fact which alone would seem to justify having a
variety of alternative agents available.
In view of the fact that numerous totally synthetic analgesics and anti-
tussives have been available for many years and have been very heavily pro-
moted to the practitioner by the pharmaceutical industry, the continuing reliance
of the physician on opium alkaloids in particular clinical situations cannot
simply be ascribed to therapeutic conservatism. On the contrary, there is, if
anything, a general tendency for the physician to embrace the use of a new
drug somewhat prematurely in the hopes that it will provide a therapeutic
advantage over the drug or drugs which he had been previously prescribing. Drugs
which have withstood the test of time such as digitalis glycosides, penicillin,
atropine, the barbiturates, aspirin, morphine, and codeine have done so because
both controlled scientific experiments and vast clinical experience have shown
them, in competition with newer agents, to be drugs of choice in certain clinical
situations.
The very existence of a substantial body of clinical and experimental informa-
tion about a drug greatly enhances the value of this drug in rational therapeutics,
because it delineates the full spectrum of a drug's therapeutic possibilities, defines
precisely those situations in which the agent may be of particular value, and by
forewarning the physician, minimizes the likelihood of the occurrence of un-
expected adverse effects. The published world literature on morphine, and to a
lesser extent on codeine and nalorphine, substantially exceeds that available
for any of the total synthetics. If these agents were to be made unavailable, the
physician, and hence the i)atient, would loose the benefit of medicine's vatst col-
lective experience with these drugs. Furthiermore, since it is impossible for any
individual physician to become equally expert in the use of all available drug
therapies for every disease or symptom he treats, good medical practice dictates
that the physician become thoroughly familiar with and proficient in the use of
a few of the many drugs usually available for the treatment of a particular
problem. Then, in the absence of an overriding consideration to tlie contrary, he
restricts his prescribing to those agents with which he has had the most ex-
tensive personal experience, an approach which favors the most judicious ad-
justment of dosage regimen and provides optimal therapeutic benefits while
minimizing the omnipresent risk of adverse effects to therapy. Great numbers of
physicians routinely use opium derived narcotics and antagonists as drugs of
first choice in many clinical situations, and have develope<l confidence and have
become proficient in the use of these specific agents. If these drugs are now to be
outlawed, the patient may suffer not only by having a less well understood and
inve.stigated agent substituted for one whose therapeutic potential and adverse
effects have been more thoroughly explored, but also because his physician has
been deprived of the therapeutic tools with which he is moist familiar.
In addition to its deleterious effect on patient care, the proposed ban would
have a most unfortunate impact on both basic and applied re.search in such areas
as the development of superior analgesics, investigation of the mechanisms in-
volved in the action of analgesics and narcotic antagonists, investigation of the
mechanisms involved in the development of tolerance and psychic and physical
deiiendence on narcotics, and efforts to use antagonists such as naloxone (derived
from the opium alkaloid thebaine) as treatments for narcotic addiction. Research
in certain of these areas would be substantially impeded and in others rendered
altogether impossible.
Much of the problem derives from the fact that morphine, codeine and
nalorphine have consistentl.v served as standards of comparison for agents in
their respective classes, and have generally served as prototypes and tools in
exploring the general pharmacology of narcotics and narcotic antagonists. If
these agents were made unavailable, a vast body of experimental data which has
thus far been accumulated in the world literature would be rendered obsolete.
It would therefore be impossible to make an orderly progression along many
lines of research without completely repeating masses of old experiments sub-
stituting synthetic compounds for the naturally derived alkaloids originally
used. Even if small amounts of natural alkaloids continued to be available
strictly for research purposes, the value of future work with them would be
substantially vitiated because experimental studies depending on these agents
336
would be deprived of any clinical relevance. There would likewise be absolutely
no incentive for the pharmaceutical industry to explore such currently fruitful
areas as the thebaine derivatives in search of potential nonaddicting analgesics
or antagonists with a potential for use in the treatment of drug dependence.
SPECIFIC DRUGS
The proposed ban would make the following drugs, all of which have some
currently recognized therapeutic use, unavailable for legitimate medical use in
the Unite<l States :
opium
paregoric
morphine
papaveretum ( Pantopon )
hydromonihone (Dilaudid)
oxymorphone ( Numorphan )
nalorphine ( Nalline )
naloxone (Narcan)
codeine
dihydroeodeine (Paracodin, etc.)
hydrocodone (Hycodan, etc.)
oxycodone ( Pereodan )
papaverine
noscapine
thebaine (not used medically as such, hut vital for .synthesis of other agents).
While I am inclined to regard only four of the.se drugs (morphine, codeine,
nalorphine and naloxone) as of fundamental importance in medical practice and
reseai'ch, certain of the others are extensively prescribed and have particular
properties which render them useful in special circumstances. For example,
oxymorphone and hydromorphone are the only potent analgesics available in
the form of suppositories, a dosage form which has special use in patients with
chronic pain, particularly in a geriatric population; unlike most narcotic anal-
gesics, the codeine congeners (dihydrocodeine, hydrocodone, and oxycodone) are
characterized by a high level of efficacy when administered by the oral route;
paregoric is probably the most widely used drug for the treatment of diarrhea.
MORPHINE
Mori>hine was isolated from opium in 1803 and in the intervening years, many
semisynthetic derivatives and totally synthetic compounds have appeared to
challenge its therapeutic primacy. While several of these have characteristics
which recommend their use under certain circumstances, none have been shown
to be generally siii>erior to morphine in the relief of severe pain. Indeed, mor-
phine is frequently used when other analgesics are not effective, and is the main-
stay of therapy in the very severe pain associated with acute visceral colic, myo-
cardial infarction, severe postoperative pain and pain associated with severe
injuries, and the pain of terminal cancer. I am especially concerned with the
impact of making morphine unavailable for those unfortunate patients with
the very severest sort of pain.
There are many clinical situations in which one or more of the synthetic ix>tent
analgesics such as meperidine, methadone, levorphanol and the recently de-
velopefl antagonist-analgesic, pentazocine (Talwin) may be substituted for mor-
phine. The major problem in using these agents as substitutes for niorjihine
generally api>ears in patients with very severe pain who would require higher
than ordinary doses of morphine for its relief. In contradi-stinction to our knowl-
edge concerning the effects of high doses of morphine, very little information is
available concerning the effect of very large parenteral doses of any of lln>s«^
synthetic agents. It is known that doses of over l.")0 milligrams of im^peridiiie
may lead to convuLsions, a complication not encountered with morphine. When
the dose of injectable i>entazocine is pushed to 60 milligrams and beyond, the
instance of p.sychotominimetic side effects increases substantially. Again, this
is not an adverse effect noted with morphine. AVhile no specitic unusual untoward
effects of high doses of levorphanol or methadone have been report(>d. exi)eri-
ence with do-ses of these two agents equivalent in analgesic effect to more than
10-15 milligrams of morphine is very limited. Therefore, while these agents may
337
be satisfactory substitutes in these higher dose ranges, such doses are not recom-
mended in the labeling. High doses of methadone and levorphanol are often
associated with an appreciable incidence of tissue irritation, and their use by
the intravenous route is not recommended. Even less experience is available
concerning the effects of high doses of such other morphine substitutes as
phenazocine and anileridine.
Meperidine and its congeners are superior to morphine for use in labor and
delivery because their rapid onset and short duration of action minimizes the
risk to the newborn infant. They are al.so often used postoperatively, as adjuncts
to anesthesia and as analgesics in brief painful procedures. However, this same
property of rapid onset and short duration of action constitutes a liability when
the physician wishes to treat persistent pain.
As noted above, various of the synthetic morphine substitutes have limitations
in terms of a lack of knowledge concerning their effects in one or another
of certain special patient groups such as children, women in early pregnancy
and patients concurrently receiving certain other potent medications. For ex-
ample, individuals being treated with monoamine-oxidase inhibitors have ex-
perienced fatal reactions when given ordinary therapeutic doses of meperidine.
This reaction does not seem to occur in such patients when morphine is used as
an analgesic, and morphine is therefore the recommended potent analgesic in this
group of patients.
With the exception of pentazocine, all of the potent synthetic narcotics have
an abuse liability comparable to that of morphine. Indeed, meperidine has proven
much more of an abuse problem than morphine in doctors, dentists, nurses and
other paramedical personnel, probably because of a mistaken impression that
it is "safer" than morphine in this respect.
As a research tool, morphine has been utilized as the standard of comparison
in virtually all of the modern controlled trials of analgesic efficacy and side effect
liability involving semisynthetic and totally synthetic potent injectable analgesics.
It has likewise been used at the Addiction Research Center in Lexington as the
standard for evaluating the abuse liability of these agents. These comparative
studies form the backbone of our knowledge concerning the relative therapeutic
merits and liabilities of every single potent analgesic currently available. The
continuing availability of morphine as a standard of comparison is absolutely es-
sential if the quest for more effective and safer potent analgesics is to progress
Tinhindered.
Morphine has likewise been used as the primary tool in the vast majority of
studies of clinical and animal pharmacology aimed at elucidating the mechanism
of action of narcotic analgesics and the interaction of these substances with nar-
cotic antagonists. Morphine is so generally accepted as the prototype potent
analgesic that teaching medical students and young physicians the pharmacology-
and rational use of these drugs almost invariably involves presenting a detailed
analysis of the pharmacology and therpeutic properties of the prototype, mor-
phine, followed by a briefer presentation of the ways in which the semisynthetic
and totally synthetic potent analgesics differ from this prototype.
In summary, while synthetics can be substituted for morphine in the majority
of patients requiring a potent analgesic, there is serious doubt as to the feasibility
of making such a substitution in a significant minority of such patients. In addi-
tion, the elimination of morphine would have a major adverse effect on the prog-
ress of our research in the fields of narcotics, analgesics, and drug dependence.
CODEINE
Like morphine, codeine has been in therapeutic use for over one hundred years
and is currently regarded as one of the basic or fundamental drugs in medicine.
This agent is usually used orally and occupies a different therapeutic niche than
morphine. Oral codeine is used in the treatment of moderate to moderately severe
pain and is generally considered, with the possible exception of aspirin, to be the
single most useful mild analge.sic. Although codeine is present to a very small
extent in opium, the demand for codeine is so great that virtually all of the avail-
able supply is synthesized from morphine. In addition to its use as a mild anal-
gesic codeine finds extensive use as an antitussive.
Codeine has several properties which make it uniquely valuable among the nar-
cotic analgesics. The drug has excellent oral efficacy, a property not shared by
most of the other narcotics. In conjunction with this, codeine has substantially
338
less abuse liability than agents such as morphine, meperidine, methadone, levor-
phanol, and the other fully potent narcotics.
Along with aspirin, codeine has served as the preeminent standard of com-
parison for mild analgesics. It therefore assumes a similar importance in
relation to our understanding of the pharmacology and therapeutic usefulness
of thee mild analgesics as morphine assumes in relation to our understanding of
the potent injectionable analgesics. However, it is in the area of day-today patient
care that the loss of codeine would be most acutely felt. Propoxyphene (Darvon)
is the only drug currently on the American market with properties comi)arable
to those of codeine. Propoxyphene is definitely less potent than codeine, the best
available estimates indicating that 90-120 mg. of propoxyphene must be ad-
ministered to equal the effect of 60 mg. of codeine. However, the maximum
recommended daily dose of propoxyphene is 60 mg. four times a day whereas
codeine is frequently u.sed in doses of up to 120 mg. every 3 to 4 hours. There
is little recorded clinical experiences with doses of propoxyphene above those
recommended, but what experience does exist indicates that very unpleasant
cumulative toxic effects appear when the total daily dose is in the neighborhood
of 600 mg. On the other hand, codeine may be administered over a very wide
dosage range to achieve successive increments of analgesia. The net effect of
this discrepancy is that while propoxyphene, usually in combination with aspirin
or other antipyretic-analgesics, is a useful analygesic in the lower range of mild
to moderate pain, it usually does not produce satisfactory relief of moderate
to moderately severe pain, whereas codeine is capable of doing so. Were codeine
to be removed from the market, huge numbers of patients whose pain problems
are currently being adequately managed with codeine would have to be given
drugs with unquestionably greater abuse liability such as meperidine or metha-
done to achieve equally .satisfactory pain relief.
Oral pentazocine has been suggested as a potential substitute for codeine as
a mild analgesic. However, oral pentazocine has a decided propensity to produce
psychotomimetic reactions in certain patients. While this is an acceptable risk
If the alternative is the use of potent narcotics in patients with chronic pain
problems, this increased incidence of adverse effects is not justifiable when the
pain could be equally well managed by the usually used doses of codeine.
Codeine also has excellent antitussive activity and is generally regarded as
a standard of comparison for other antitussives. The best nonnarcotic anti-
tussive, dextromethoraphan, is not generally regarded as fully equal to codeine
in antitussive efficacy, particularly in the more intractible sorts of cough prob-
lems. The unavailability of codeine as an antitu.ssive would force practitioners
to prescribe drugs with substantially greater dependence liability, .«iuch as metha-
done, to patients who are currently receiving satisfactory relief from the safer
drug, codeine.
With the exception of those drugs discussed above I know of no other syn-
thetic analgesics or antitussives whose safety and efficacy has been explored
to such a point that they could be even suggested as potential adequate substitutes
for codeine.
NALORPHINE
Nalorphine bears much the same relation.<^hip to studies of narcotic antagonists
as morphine does to studies of potent analgesics. Nalorphine was the first narcotic
antagonist introduced into clinical medicine and has remained the most widely
used antagonist and the standard of comparison for drugs in this category.
There is substantially more in the way of experimental and clinical data available
concerning nalorphine than any other narcotic antagonist. I would point out at
this juncture that of the three narcotic antagonists currently on the market
(nalorphine, levallorphan, and naloxone) two are derived from opium alkaloid.s
and the projiosed ban would leave us with only one of these three (levallorphan)
availal>le for medical practice and research.
NALOXONE
Naloxone, a derivative of thebaine. is absolutely unique in being a narcotic
antagonist of exceptional potency without any measureable atronistic activity.
As such, it may eventually displace both nalorphine and levallorphan from the
therapeutic .scene. Wlien administered alone to an individual who has liad no
prior narcotics, naloxone produced no measureable effects whatsoever. On the
339
other hand, it is capable of swiftly and decisively reversing all of the life threat-
ening aspects of acute narcotic overdose. It is also the only antagonist capable
of reversing the respiratory depression produced by the antagonist-analgesic,
pentazocine (Talwin). For the above reasons it is absolutely essential that this
drug remain on the market. Although naloxone is unlikely to be used with great
frequency, to those individuals who need its rather unique properties, its avail-
ability could well be a matter of life or death.
As the committee is quite aware, in addition to its use in the treatment of
overdose with narcotics or narcotic-antagonist analgesics, naloxone is currently
the subject of great interest as a potential treatment for narcotic addiction. The
work of Fink and his associates has, I think, established that naloxone could
potentially be of very great value in this population of patients. The sole prob-
lem is developing a dosage form of naloxone or a congener of naloxone which
would have an adequate duration of action. The proposed ban would, needless to
say. completely abort this entire promising avenue of research.
In addition to naloxone, there are a variety of other thebaine derivatives in
an experimental stage. Some of these have promise as potent analgesics with
reduced dependence liability while others are antagonists which may prove of
value in the treatment of narcotic dependence. In addition, naloxone itself is
currently serving as a very important tool in unraveling the complexities of the
interaction of narcotic antagonists with narcotics and exploring certain facets of
the mechanism of drug dependence.
In conclusion, I would state categorically that the proposed ban on the importa-
tion of opium with the resultant unavailability of opium alkaloids would be seri-
ously detrimental to patient welfare and to many vital research activities in the
Tnited States. This very high price might conceivably be justified if there were
substantial reason to believe that the proposed ban would definitely effect a sig-
nificant i-eduction in the availability of illicit heroin in this country. However,
consideration of the current global picture in relation to the sources and trade in
illicit opium and heroin, and familiarity with the history of international efforts
to control illicit opium production and the diversion of illicit opium production into
illicit channels, makes it clearly evident that the proposed ban would be very
unlikely to have any impact whatsoever on the availability of illicit narcotics,
and might even have the effect of Increasing the supply of illicit heroin by favor-
ing the diversion of the opium currently used for medical purposes into illicit
channels. In addition, efforts on the part of the Government to deprive the Ameri-
can people of drugs which are universally recognized as valuable in the relief of
pain and other conditions, and to dictate to physicians a regimen of medical
practice which will widely be regarded by those physicians as detrimental to
the welfare of their patients, is certain to be strongly resented and to precipitate
massive resistance on the part of medical practitioners and academicians. Most
regretably, this resentment could easily take the form of a general unwillingness
to cooperate in other, entirely laudable and reasonable programs designed to
attack the many facets of our national drug abuse problem.
I would therefore urge that the recommendations of the committee recognize
the current importance of opium alkaloids in medical practice and research, and
advise against any action on the part of the U.S. Government, certainly
any unilateral action which fails to insure the cooperation of opium produciiii;:
countries, which would restrict the availability of these valuable substances for
legitimate medical use.
(Whereupon at 4:50 p.m. the hearing was adjourned, to reconvene
atlOa.m., Jime2, 1971.)
NARCOTICS RESEARCH, REHABILITATION,
AND TREATMENT
HEARINGS
BEFORE THE
SELECT COMMITTEE ON CRIME
HOUSE OF REPRESENTATIVES
NINETY-SECOND CONGRESS
FIRST SESSION
PURSUANT TO
H. RES. 115. A RESOLUTION CREATING A SELECT COMMITTEE
TO CONDUCT STUDIES AND INVESTIGATIONS OF CRIME IN
THE UNITED STATES
PART 2 OF 2 PARTS
JUNE 2, 3, 4, AND 23, 1971. WASHINGTON, D.C.
Serial No. 92-1
Printed for the use of the Select Committee on Crime
U.S. GOVERNMENT PRINTING OFFICE
60-296 WASHINGTON : 1971
For sale by the Superintendent of Documents, U.S. Government Printing Office,
Washington, D.C, 20402 - Price $1.50
UNlVtRSOI SCKOQL of \M \M^^
SELECT COMMITTEE ON CRIME
CLAUDE PEPPER, Florida, Chairman
JEROME R. WALDIE, California CHARLES E. WIGGINS. California
FRANK J. BRASCO, New York SAM STEIGER, Arizona
JAMES R. MANN, South Carolina LARRY WINN, Jr., Kansas
MORGAN F. MURPHY, Illinois CHARLES W. SANDMAN. Jr., New Jersey
CHARLES B. RANGEL, New York WILLIAM J. KEATING, Ohio
Paul L. Perito, Chief Counsel
Michael W. Blommer, Associate Chief Counsel
(n)
^
q:
I
to
rv
CONTENTS
Fag«
April 26 1
April 27 77
April 28 209
June 2 341
June 3 391
June 4 481
June 23 553
Oral Statements by Government Witnesses
Health, Education, and Welfare, Department of:
Food and Drug Administration:
Edwards, Dr. Charles C, Commissioner 393
Gardner, Dr. Elmer A., Consultant to the Director, Bureau of
Drugs 393
Jennings, Dr. John, Associate Commissioner for Medical Afifairs_ 393
Health Services and Mental Health Administration:
National Institute of Mental Health:
Besteman, Dr. Karst, Acting Director, Division of Narcotics
and Drug Abuse 430.439
Brown, Dr. Berlram, Director 430,439
Martin, Dr. Wiiiiam, Chief, Addiction Research Center,
Lexington, Ky 435,439
van Hoek, Dr. Robert, Associate Administrator for Operations. 430, 439
Narcotics and Dangerous Drugs, Bureau of:
lugersoll, Hon. John E., Director 344,439
Lewis, Dr. Edward, Chief Medical Officer 344,439
Miller, Donald E., Chief Council 344,439
Treasury, Department of, Hon. Eugene T. Rossides, Assistant Secretary,
Enforcement and Operations 61
Oral Statements by Public Witnesses
AREBA (Accelerated Reeducation of Emotions, Behavior, and Attitudes),
Dr. Daniel H. Casriel, director; accompanied bj' Rev. Raymond Massej-
and Dr. Walter Rosen 273
Brickley, Hon. James H., Lieutenant Governor, State of Michigan (on
behalf of Gov. William G. MiUiken) 614
Brill, Dr. Henry, director, Pillgrim State (N.Y.) Hospital 51
Carter, Hon. James, Governor, State of Georgia 608
Casriel, Dr. Daniel H., director, AREBA (Accelerated Reeducation of
Emotions, Behavior, and Attitudes) 273
Chambers, Dr. Carl, director, division of research. New York State
Narcotic Addiction Control Commission 558
Davidson, Dr. Gerald E., associate director. Drug Dependency Clinic,
Boston City Hospital 322
Drug Dependency Clinic, Boston City Hospital, Dr. Gerald E. Davidson,
associate director 322
DuPont, Dr. Robert L., Director, District of Columbia Narcotics Treat-
ment Administration , 143
Eddy, Dr. Nathan B., Chairman, Committee on Problems of Drug Depend-
ence, Division of Medical Sciences, National Academy of Sciences-
National Research Council -^^.-- 29
Gearing, Dr. R. Frances, associate professor, division of epidemiology,
Columbia University School of Public Health and Administrative
Medicine 105
Georgia, State of,_G.Qy, James Carter 608
(m)
o
IV
Page
GoUance, Dr. Harvey, associate director, Beth Israel Medical Center... 239
Hesse, Rayburn F., special assistant to the chairman, Federal-State rela-
tions, New York State Narcotic Addiction Control Commission 558
Holden, William, department head, MITRE Corp '" 80
Holton, Hon. Linwood, Governor, Commonwealth of Virginia. _" 594
Horan, Robert F., Jr., Commonwealth attorney, Fairfax County, Va """ 2.55
Illinois Drug Abuse Program, Dr. Jerome H. Jaffe, director . 210
Institute of Applied Biology, Rev. Raymond Massey " " 273
Jaffe, David, department staff, MITR,E Corp ..._.' "ko
Jaffe, Dr. Jerome H., director, Illinois Drug Abuse Program.!.!."^!.!'' 210
Jones, Howard A., commissioner. New York State Narcotic Addiction
Control Commission _ _ 553
Kramer, Dr. John C, assistant professor, department of psychiatry and
human behavior, department of medical pharmacology, University of
California (Irvine) _ _ _ 642
Kurland, Dr. Albert A., director, Maryland State Psychiatric" Research
Center ' ^q
McCoy, William O., Maryland State Psychiatric Research Center, l/.... 506
Maryland State Psychiatric Research Center:
Kurland, Dr. Albert A., director 5O5
McCoy, William I. .II 506
Taylor, Robert '/_ 507
Massey, Rev. Raymond, Institute of Applied Biology '_ I_I 273
Michigan, State of, I.t. Gov. James H. Brickley Con behalf of Gov. William
G. Milliken) ... _. _. __ C14
MITRE Corp I'.".!.'.'-'.!'.'.'.!!'.'.'.!".!!". 80
Holden, William, department head.
Jaffe, David, department staff.
Yondorf, Dr. Walter, associate director, national command and con-
trol division.
Narcotics Treatment Administration, District of Columbia, Dr. Robert L.
DuPont, Director _ 243
New York State Narcotic Addiction Control Commission:
Chambers, Dr. Carl, director, division of research 558
Hesse, Rayburn F., special assistant to the chairman, Federal-State
relations 55§
Jones, Howard A., commissioner 553
Pennsylvania, Commonwealth of, Gov. Milton Shapp .......I' 602
Resnick, Dr. Richard B., associate professor, department of psvchiatrv.
New York Medical College "_ ^ 539
Rosen, Dr. Walter, New York, N.Y ^ 273
Seevers, Dr. Maurice H., cimirman, department of pharmacology, University
of Micliigan Medical School I. " 9
Shapp, Hon. Milton, Governor, Commonwealth of Pennsylvania. I. "1 ^11 602
Taylor, Robert, Maryland State Psychiatric Research Center 507
Villarreal, Dr. Juhan E., associate professor of pharmacology. University
of Michigan Medical School '_'_ "_ 433
Virginia, Commonwealth of. Gov. Linwood Holton '." 594
Yondorf, Dr. Walter, associate director, national command and control
division, MITRE Corp gO
Exhibits Received for the Record
exhibit no. 1
American Medical Association, Dr. Richard S. Wilbur, deputy executive
vice president, letter dated July 9, 1971, to Paul L. Perito, chief counsel.
Select Committee on Crime 16
EXHIBIT NO. 2
Seevers, Dr. Maurice H., chairman, department of pharmacology, Univer-
sity of Michigan Medical School, curriculum vitae ". 22
EXHIBIT NO. 3
Defense, U.S. Department of. Dr. Louis M. Rousselot, Assistant Secre-
tary, Health and Environment, letter dated June 28, 1971, to Chairman
Pepper, with attachments 24
•v
EXHIBIT NO. 4 (a) AND (b)
Eddy, Dr. Nathan B., Chairman, Committee on Problems of Drug De-
pendence, Division of Medical Sciences, National Academy of Sciences-
National Research Council: Page
(a) Prepared statement 40
(b) Curriculum vitae _^___ 42
EXHIBIT NO. 5 (a) AND (b)
Brill, Dr. Henry, director. Pilgrim State Hospital, New York, N.Y.:
(a) Prepared statement ,58
(b) Curriculum vitae .59
EXHIBIT NO. 6
State, Department of, David M. Abshire, Assistant Secretary for Congres-
sional Relations, letter dated Jul}' 2, 1971, to Chairman Pepper, with
attachments 70
EXHIBIT NO. 7
Treasury, Department of, Eugene T. Rossides, Assistant Secretarj'' for
Enforcement and Operations, curriculum vitae 75
EXHIBIT NO. 8 (a) AND (b)
Jaffe, David, department staflf, MITRE Corp.:
(a) Supplemental statement 101
(b) Curriculum vitae 102
EXHIBIT NO. 9
Ulrich, William F., manager, apphcations research, scientific instruments
division, Beckman Instruments, Inc., prepared statement (dated
June 27, 1970) 103
EXHIBIT NO. 10 (aj AND (b)
Gearing, Dr. Francis R., associate professor, division of epidemiology,
Columbia University School of Public Health and Administrative
Medicine :
(a) Paper entitled "Successes and Failures in Methadone Mainte-
nance Treatment of Heroin Addiction in New York City" 121
(b) Position paper entitled "Methadone — A Valid Treatment Tech-
nique" 138
EXHIBIT NO. 11 (a) THROUGH (8)
DuPont, Dr. Robert L., director. District of Columbia Narcotics Treat-
ment Administration:
(a) Article entitled "Profile of a Heroin Addict" 166
(b) Study entitled "Summary of 6-Month Followup Study" 178
(c) Brief collection of statistical information entitled "Dr. DuPont's
Numbers 183
(d) An administrative order setting forth guidelines for methadone
treatment 183
(e) Article entitled "A Study of Narcotics Addicted Offenders at the
D.C. Jail" 195
EXHIBIT NO. 12
Jaffe, Dr. Jerome H., director, Illinois Drug Abuse Program, curriculum
vitae 236
VI
EXHIBIT NO. 13 (a) THROUGH (C))
Page
GoUance, Dr. Harvey, associate director, Beth Israel Medical Center:
(a) Article entitled "Methadone Maintenance Treatment Program".. 249
(b) Letter dated May 7, 1971, to Chris Nolde, associate counsel,
Select Committee on Crime 253
(c) Letter dated Nov. 11, 1970, to Dr. Vincent P. Dole, Rockefeller
University from C'arlos Y. Benavides, Jr., assistant district
attorney, Laredo, Tex 254
EXHIBIT NO. 14 (3k) THROUGH (g)
Casriel Dr. Daniel H., director, AREBA (Accelerated Reeducation of
Emotions, Behavior, and Attitudes) :
(a) Article entitled "The Case Against Methadone" 296
(b) Article entitled "Casriel Institute of Group Dynamics, New
York, N.Y." (discussion of Dr. Revici paper on Perse) 302
(c) Submission entitled "Significant Therapeutic Benefits Based on
Peer Treatment in the Casriel Institute and AREBA" 311
(d) Introduction and explanation of the AREBA program 314
(e) Reprint of article from the Medical Tribvuie- World Wide Report
entitled "Therapy of Narcotic Addicts Sparks Psychiatric Theory". 315
(f) Article reprinted from the Sandoz Panorama entitled "The Family
Physician and the Narcotics Addict" '_ 317
(g) Curriculum vitae 320
EXHIBIT NO. 15
Davidson, Dr. Gerald E., associate director, drug dependency clinic,
Boston City Hospital, studv entitled "Results of Preliminary Perse
Study" 1 1 331
EXHIBIT NO. 16
Beaver, Dr. William T., associate professor, department of pharmacology,
Georgetown University School of Medicine and Dentistry, prepared
statement 334
EXHIBIT NO. 17 (a) THROUGH (e)
Health, Education, and Welfare, Department of:
(a) Jennings, Dr. John, Associate Commissioner for Medical Affairs,
Food and Drug Administration, prepared statement 420
(b) Edwards, Dr. Charles C, Commissioner, Food and Drug Admin-
istration, memorandum dated r\Iay 14, 1971, with attachments. 422
(c) van Hoek, Dr. Robert, Associate Administrator for Operations,
Health Services and Mental Health Administration, prepared
statement 430
(d) Brown, Dr. Bertram S., Director, National Insititue of Mental
Health, Health Services and Mental Health Administration,
prepared statement 469
(e) Steinfeld, Dr. Jesse L., Surgeon General, letter dated June 21,
1971, to Chairman Pepper 480
EXHIBIT NO. IS
Villarreal, Dr. Julian E., associate professor of pharmacology, Universitj^
of Michigan Medical School, prepared statement 502
EXHIBIT NO. 19
Agriculture, Department Of, N. D. Bayley, Director of Science and Educa-
tion, Office of the Secretary, letter dated July 23, 1971, to Chairman
Pepper, re thebaine 510
EXHIBIT NO. 20
Kurland, Dr. Albert A., director, Maryland State Psychiatric Research
Center, prepared statement 520
vn
EXHIBIT NO. 21 (a) and (b)
Pare
New York State Narcotic Addiction Control Commission, Howard A. Jones,
Chairman-designate :
(a) Letter dated June 22, 1971, to the committee, re summary of
New Yorl4.State drug report 578
(b) Prepared statement 580
EXHIBIT NO. 22
Holton, Hon. Linwood, Governor, Commonwealth of Virginia, prepared
statement 597
EXHIBIT NO. 23
Shapp, Hon. Milton, *. lovernor, Commonwealth of Pennsylvania, pre-
pared statement 606
EXHIBIT NO. 24
Carter, Hon. James, Governor, State of Georgia, prepared statement 612
EXHIBIT NO. 25
Brickley, Hon. James H., Lieutenant Governor, State of Michigan, pre-
pared statement 617
EXHIBIT NO. 26 (a) THROUGH (f)
Letters and statements of officials of various cities regarding problems
of drug abuse:
(a) Boston, Mass., Mavor Kevin A. White 628
(b) Detroit, Mich., Mayor Roman S. Gribbs 630
(c) Hartford, Conn., Mayor George A. Athanson 631
(d) New Haven, Conu., Mayor Bartholomew A. Guida 634
(e) Philadelphia, Pa.:
O'Neill, Joseph F., police commissioner 637
Sofer, Dr. Leon, deput}^ health commissioner, office of
mental liealth/mental retardation 638
(f) Washington, D.C., Maj^or Walter E. Washington 640
EXHIBIT NO. 27
Kramer, Dr. John C, assistant professor, department of psychiatry and
human behavior, department of medical pharmacology. University
of California (Irvine) , prepared statement 662
EXHIBIT NO. 28
Statement submitted on behalf of S. B. Penick & Co., Merck & Co., Inc.,
and Mallinckrodt Chemical Works 670
EXHIBIT NO. 29
Becker, Arnold, public defender, Rockland County, N.Y., statement 677
EXHIBIT NO. 30
Andrews, Rev. Stanley M., Liberty Lobby, prepared statement 679
EXHIBIT NO. 31
Benson, Dr. Richard S., letter dated August 4, 1971, to Chairman Pepper,
re transcendental meditation (with enclosures) 681
EXHIBIT NO. 32
Copy of letter sent to drug companies by Chairman Pepper re research
concerning narcotic blockage and atagonistic drugs 689
NARCOTICS RESEARCH, REHABILITATION, AND
TREATMENT
WEDNESDAY, JUNE 2, 1971
House of Representatives,
Select Committee on Crime,
Washijigton, D.C.
The committee met, pursuant to notice, at 10 :10 a.m., in room 2325,
Rayburn House Office Building, the Honorable Claude Pepper (chair-
man) presiding.
Present : Representatives Pepper, Waldie, Brasco, Mann, Murphy,
Rangel, Steiger, Winn, Sandman, and Keating.
Also present : Paul Perito, chief counsel; and Michael W. Blommer,
associate chief counsel.
Chairman Pepper. The committee will come to order, please.
The Select Committee on Crime today continues its hearings into
the multiple aspects of the heroin addiction crisis in the United States.
In the past, ^Ye have held hearings throughout the country, and during
each of those hearings, we have heard urgent pleas for assistance. This
series of hearings, which be^an last month, is designed to find the best
ways of providing that assistance. It is my belief that the scientific
and technical genius of America has not been fully enlisted in the
light against heroin addiction. I think that some officials are being less
than candid in their professed dedication to fight drug abuse, for
surely a nation which can send men to the moon, sustain them on the
moon, and then bring them safely home, can find the means to effec-
tively control the heroin epidemic, and find those means now.
In Vietnam, where our soldiers have the benefit of every conceiv-
able technological device, implements of war so sophisticated that they
existed only in science fiction novels a few years ago, we seem in-
capable of helping these very same soldiers when they become en-
slaved in the vicious trap of drug addiction.
So, we are sitting here this week to find out what the Federal Gov-
ernment and the States are doing and are not doing, what kind of
research is under way, what kind of treatment and rehabilitation pro-
grams have proven successful. And, to be frank, what we heard in our
hearings last month convinces me that we are not doing enough. Our
scientists are working on some new and potentially breakthrough
drugs to combat addiction, yet they are working on shoestring budgets.
Upon reflection, it seems to me that we should not be surprised that so
little has been done, but, rather, given the meager resources available
to these men, that so much has been done.
I also believe that the Federal Government has not assumed its full
and proper burden for combating the heroin addiction crisis. ^Vhile I
(341)
\
\
342
have no desire to preempt the authority of the States in this matter,
it seems to me that, in many ways, a substantial portion of the burden
of drug abuse problems must, by reason of their magnitude and scope,
fall upon the Federal Government. Let me clarify that statement. I am
not blaming the Federal Government for causing heroin addiction. I
am not accusing Federal agents for laxity in the performance of their
duties. But we must face facts. Heroin is not indigenous to this coun-
try. It is grown and processed overseas, and then smuggled into the
United States. Notwithstanding the valiant and dedicated work of
our customs and narcotics agents, and we commend both in the highest
way, they concede that it is impossible to effectively halt the smuggling
of heroin into this country. Narcotics and custom officials have told
our committee that less than 20 percent of the heroin smuggled into
this country is seized. It is clear that these dedicated men are faced
with an impossible task. But, notwithstanding the impossibility of
effectively halting heroin smuggling, it appears to me that the Fed-
eral Government must assume the burden of financing programs that
combat the addiction caused by the heroin that leaks into this country.
From what this committee has heard in these hearings to date, the
Federal Government has yet to take upon itself adequately, I believe,
this burden. We will take more testimony on this point in the course
of this week.
You may recall that in its report on heroin to the 91st Congress, this
committee suggested the possibility of a ban on the importation of licit
opium into the United States.
Our thinking was that the only way to halt heroin smuggling is to
halt opium growing. As an admittedly long-range project, we sug-
gested that if Congress banned the importation of licit opium, that is,
morphine and codeine, other nations of the world might be willing to
follow suit. Ideally, the opium-producing countries of the world might
then react favorably to international suggestions to halt altogether
production of the opium poppy. At the least, such a move might give
our diplomatic negotiators something to point to when we press for-
eign nations to help us solve this problem.
We also believe that such a ban would be an effective tool for law
enforcement officers. When he testified before this committee last
month, Mr. Eugene T. Rossides, assistant secretary of the Treasury
for Enforcement and Operations, confirmed our belief, saying that
such a ban would indeed be useful.
A nation without opium derivative painkillers, of course, must
seek alternative painkilling and cough-suppressing drugs. We have
heard impressive testimony that powerful synthetics are now avail-
able, although opinion is admittedly divided on this point.
Our first witness today, John Ingersoll, Director of the Federal
Bureau of Narcotics and Dangerous Drugs, over a year ago urged the
nations of the world to redouble their efforts to find effective and
completely acceptable synthetic substitutes for opium-based medicines
such as morphine and codeine. At that time, Mr, Ingersoll said that
the eradication of opium crops was the "only realistic, long-range so-
lution to the heroin problem," We agree with that position, and look
forward to Mr. Ingersoll 's further enlightenment on this point.
343
Also testifying today is Dr. Charles Edwards, Commissioner of the
Food and Drug Administration. The FDA has recently promulgated
new guidelines for the use of methadone as a maintenance drug in
addiction programs. These guidelines are designed to reduce illicit di-
version of methadone from private physicians and unscrupulous clinic
operators, "^^^lile many experts have advised us that methadone may
be the best drug we have now to treat heroin addiction, it is clear that
the use of methadone has dangers of its own, and must be carefully
controlled.
The rest of these hearings will deal with research underway to
produce drugs better than methadone, not addictive in character and
not harmful in some respects in which methadone is for treating ad-
dicts, as well as the rehabilitation of drug addicts. Although we must
make a distinction between curing an addict of his addiction and re-
integrating him into society, as a committee on crime, we are obviously
anxious to fully explore any treatment approach which offers the hope
of reducing crime in the streets and returning the addict to a pro-
ductive and law abiding life.
Our earlier hearings have indicated that there are some highly
promising new antiaddiction drugs on the horizon. We want to know
the status of this research, the adequacy of this research, and what
more, if anything, the Federal Government can do to help. AVe are
spending, as we all Imow, hundreds of millions of dollars in trying
to keep heroin out of this country and dealing with it once it gets
into this country. If we could find some sort of a blocking drug or
some sort of immunizing drug, thereby tending to take the market
away from the pusher and the seller, you can see how much it would
contribute to the reduction of crime.
We will question individual scientists who have worked with these
new drugs, as well as the Government officials who have the overall
responsibility for the Federal role in this area.
"When the scientific community can talk of developing a vaccine
that for a lifetime would ward off the possibility of drug addiction,
I think this Congress ought to know about that research and help
fund it to the fullest extent.
We are also very concerned about the state of treatment and reha-
bilitation facilities in the Nation. It is estimated that we have 200,000
to 300,000 heroin addicts in the United States. It is estimated that
our great city of New York has perhaps a hundred thousand of them.
The rest are all over the country.
So, what we want to know is what is the state of the treatment and
rehabilitation facilities in the Nation? Are they adequate for the
challenge? Are there enough of them? Are they properly dispersed?
What techniques have succeeded and which have failed ?
I think Congress wants to know the answer to these questions and
must know the answer to these questions if we are to spend intelli-
gently the taxpayers' money on these programs.
The last dav of these hearings, June 23, will focus specifically on
the adequacv of our treatment and rehabilitation f anil -ties. We expect
to have 'with us several Governors who will tell us vrhat their States
are doing to handle the addiction crisis, and what have been their
successes and failures, and what they think Congress can or should
do to help.
344
We hope these hearings will provide the muscle needed to mobilize
a great nation against an epidemic that threatens to destroy us if it
continues unchecked.
Now, as I said, we are ^'ery much pleased today to have as our first
witness the Honorable John Ingersoll. Mr. Ingersoll is the Director
of the Bureau of Narcotics and Dangerous Drugs, a position he has
ably held since August 1968. Prior to his present appointment, Mr.
Ingersoll served as Assistant Director of the Justice Department's
Office of Law Enforcement Assistance.
From July 1966 to April 1968, he served as chief of police in
Charlotte, N.C., and prior to that, as director of field services for
the International Association of Chiefs of Police.
He served with the Oakland, Calif., police force from 1957 to 1961,
beginning as a patrolman and advancing to investigator, supervisor,
chief's aide, administrative assistant, and director of planning and
research.
Mr. Ingersoll received an A.B. degree in criminology in 1956 from
the University of California at Berkeley and did graduate work in
the field of general public administration and criminology.
Mr. Ingersoll has recently returned from a tour of Soutlieast Asia
to survey the state of America's efforts to curtail the smuggling of
heroin into this country.
Mr. Ingersoll is accompanied today by Dr. Edward Lewis, Chief
Medical Officer of the Bureau of Narcotics and Dangerous Drugs.
Dr. Lewis is on your riirht and oui' left. He is also accompanied
by Mr. Donald E. Miller, Chief Counsel of the Bureau.
We are delighted to have Dr. T^ewis and Mr. Miller.
Mr. Perito, our chief counsel, will you inquire?
Mr. Perito. Thank you, Mr. Chairman.
Mr. Ingersoll, I understand you hixxv a prepared statement; is that
coi'T'ect ?
STATEMENT OF HON. JOHN E. INGERSOLL. DIRECTOE, BUREAU
OF NARCOTICS AND DANGEROUS DRUGS; ACCOMPANIED BY
DR. EDWARD LEWIS, CHIEF MEDICAL OFFICER; AND DONALD
E. MILLER, CHIEF COUNSEL
Mr. Ingersoll. That is correct, sir.
Mr. Perito. Would you care to read that statement?
Mr. Ingersoll. If I may.
Mr. Perito. Please proceed.
Mr. Ingersoll. Mr. Chairman and distinguished members of the
select committee, it is a pleasure once again to appear before you. IMr.
Miller and Dr. Lewis are with me to assist the committee in its inquiry
today and will be available to answer questions as well as myself.
At the outset, Mr. Chairman, let me thank you and congratulate
the committee and its staff for its energetic and diligent efforts to
investigate the circumstances of illicit drug production, distribution,
and abuse. You have gathered an impressive array of information and
have provided all concerned with much food for thought in your
reports. Moreover, one of your members, Congressman ^Iur[)hy. in
345
collaboration with Congressman Robert Steele, has just recently
added another valuable report based upon an around-the-world study
mission. All of these, hopefully, will assist us in finding the way to
solve the tragedy of drug abuse, particularly heroin addiction in the
United States.
In January 1970, when I first represented the United States at the
United Nations Commission on Narcotic Drugs (CND), I stated that
only a total ban on opium production would eliminate the scourge of
opiate addiction. I suggested the same thing at the second special ses-
sion of the Commission in September 1970. I intend to make the point
again in October of this year when the Commission meets in its 24th
regular session.
I wish I could say that other members of the Commission, and
indeed world opinion generally, agreed with this position. Unfortu-
nately, that is not the case. There is no magic wand which, with a
wave, can dry up all of the poppyfields and opium productions of the
world. The problem is complicated by deep-rooted politico-socio-eco-
nomic factors which influence both the ability and the incentive to
suppress production and a geography which would preclude enforce-
ment of such an edict in some of the most prolific growing areas. For
example, in the remote wild northeastern part of Burma, or indeed in
the northern mountains of Thailand where I spent some time a few
weeks ago, where it is estimated, in the case of Burma, some 400 tons
of opium are produced annually, the central government is not in
control of insurgents who use opium production to finance their causes.
The same is true in northern Thailand and, in some respects, in north-
western Laos.
Some countries, such as India, Yugoslavia, Japan, and the U.S.S.R.
are opposed to a worldwide abolition on the grounds that they are
controlling production and not permitting significant diversion. The
Turkish Government has been trying to pass legislation to do this
since 1966, but unsuccessfully. We are confident that the Turkish
Government could enforce a total ban. I must add, however, that we
caiuiot expect that success on the part of the Turkish Government will
solve our own heroin problem completely. We shall still have to con-
tend with the problem of illicit production elsewhere in the world. We
are beginning to feel the effects of that production on our own
population.
Other competent witnesses have told you that the substitution of
opium-based drugs with synthetics is technically feasible, but they
have also pointed out some practical medical problems. One is finding
a substitute that provides all of codeine's characteristics — analgesic,
mild sedative, and antitussive — and which is acceptable to pharma-
ceutical and medical practitioners. Industry has not yet been able to
replicate the combination of properties that make codeine an inex-
pensive but highly useful drug to treat common ailments such as
mid-level pain and flu. Neither has industry found the way to syn-
thesize codeine itself, altliough a considerable expenditure is being
invested in research to that end. Presently 90 percent of the raw opium
imported into the United States is eventually used for codeine manu-
facture. The medical use for codeine throughout the world has pro-
gressively increased from 18 tons in 193.5 to 68 tons in 1954, to 107
346
tons in 1962 and to 155 tons in 1969. The United States consumes
about 16 percent of world production. May I add parenthetically, Mr.
Chairman, that it requires about 10 units of opium to produce one unit
of codeine.
It seems that there are safe and effective substitutes and synthetic
equivalents for morphine, which is a severe painkiller. Indeed, some
are reported to be superior for use in man. But it is equally apparent
that worldwide, the medical preference for drugs derived from opium
remains strong; that is, the annual increases in production and con-
sumption are indicative. Proposals to ban opium production, world-
wide, have not met with support and there is no evidence that even
the American medical community would accept such a move without
extensive consultations.
Nonetheless, we feel that advocacy of such a ban is a proper posi-
tion. We shall also continue to work for increased international con-
trols, particularly to control production, until complete abolition be-
comes a reality.
Mr. Chairman, you asked also for my views regarding methadone
maintenance procedures and whether there is a black market in
methadone.
In recognition of the acceptance of methadone on an investigational
basis in the treatment of heroin addiction the Food and Drug Ad-
ministration and the Bureau of Narcotics and Dangerous Drugs
jointly issued methadone maintenance regulations effective April 2,
1971.
The regulations provide for advance approval of such programs
by the two agencies with a maximum amount of flexibility. The stand-
ards were agreed upon after an intensive study of many existing pro-
grams and after consultation with leading scientific authorities around
the country. The regulations, if faithfully followed, insure that pa-
tients receive adequate treatment and protection, that scientifically
useful data can be generated and that possibilities of di^-ersion of the
drug into illicit channels are minimized.
Each methadone program is also required to register with BNDD
in order to conduct research with a schedule II substance. Our inspec-
tional program will cover all methadone clinics on a periodic basis to
insure that proper safeguards are maintained to prevent diversion.
Safeguard requriments will be that methadone supplies be securely
locked up with limited access ; that a complete and accurate record be
maintained of all methadone receipts and dispositions ; and that pa-
tients be regularly monitored through urinalysis and observation to
insure that they are taking the methadone dispensed to them.
I am confident that with diligent regulatory efforts by both FDA
and BNDD we can effectively curtail the existing diversion problems.
Where flagrant violators are uncovered, we intend to vigorously press
for corrective measures.
Failure to conduct such programs within a framework of proper
controls involves hazards to the individual and to society. Great cau-
tion needs to be exercised in the selection of patients for treatment be-
cause participation entails a high IcacI of narcotic dependence which
many young persons, who are only peripherally involved in the abuse
of narcotic di'iigs, could avoid by less radical forms of treatment. We
must be sure that programs of treatment are not causing more cases
347
of methadone addiction than they are preventino; continued cases of
heroin addiction. We hope that longer acting substances will soon be
made available. This would I'educe the risks of diversion and make the
whole program more attractive to the patient.
Complete cure of addicts from narcotic use has not been accom-
plished in any statistically significant numbers. On the other hand,
once an addict is stabilized on methadone, he apparently is more re-
ceptive to reintegration into a normal, acceptable way of life in the
community.
Methadone is available illicitly in many areas of the country, pri-
marily in retail level quantities.
Our regions report an increasing trend of methadone availability
and a corresponding price decrease. During the 7-month period from
December 1969 through June 1970, BNDD purchases and seizures of
methadone totaled 8.202 dosage units. In the succeeding 7-month pe-
riod from July 1970 through Januarv 1971, BNDD purchases and
seizures totaled 33,981 dosage units. This fourfold increase reflects a
disturbing trend.
The methadone we presently encounter on the street is primarily of
legitimate manufacture. During the last 10 months, from July 1970
through April 1971, our laboratories have examined 217 exhilDits of
methadone submitted by our agents and State and local enforcement
officials. This repi-esents roughly 1 percent of all drug exhibits sub-
mitted for analysis.
Two dosage levels of commercially manufactured tablets have been
encountered — the 5 and 10 milligram sizes. Some exhibits have been in
an orange juice preparation, in capsules, foil-wrapped powder and in
liquid form ready for injection.
The synthesis of methadone is a fairly complicated process and only
two clandestine laboratory operations have been uncovered in this
country in the past 20 years. One laboratory, capable of producing
large quantities of methadone, was seized in Tupelo, Miss., about 2
years ago, and the other laboratory was found in New York during
1952. And we presently have one investigation involving the possi-
bility of a clandestine methadone laboratory.
Methadone sells illicitly on average for about 60 cents per tablet. It
appears to be coming from patients in maintenance programs who are
selling the methadone dispensed to them, or in some instances, trading
it for heroin ; loose prescribing practices by some physicians account
in part for the drug available on the street; there are security prob-
lems in many clinics which result in the pilferage of methadone ; and
there are also some instances where patients are simultaneously en-
rolled in more than one program and they sell the excess methadone
dispensed to them.
We believe that the new regulations, while closely guarding against
diversions_ of methadone, will at the same time allow the medical
and scientific communities to continue studies to determine the extent
to which methadone maintenance techniques may be used in the man-
agement of morphine-type dependence ; but I emphasize again that the
program depends upon the willingness of practitioners to follow rea-
sonable guidelines and prevent diversion, and some have done a com-
mendable job.
348
SOUTHEAST ASIA
As you know also, Mr. Chairman, I recently visited countries in
Southeast Asia primarily involved in opium production and distribu-
tion ; that is, South Vietnam, Thailand, Laos, and Burma, in addition
to other Asian countries and Australia. In speaking with Government
leaders of these countries, including President Thieu, I stressed the
seriousness with which the U.S. Government views the ready avail-
ability of heroin in South Vietnam which is threatening our service-
men in the area and people in the United States as well. The need for
immediate corrective action to suppress this illicit traffic, wherever
possible, was strongly emphasized in addition to the promotion of re-
gional and international action to deal with both short- and long-range
aspects of the problem.
Earlier, I briefly touched on some of the conditions that contribute
to continued opium production in the area. It is known also that insur-
gents protect or have an ownership interest in the refineries that process
opium into morphine base and sometimes further into heroin. The
typical refinery is on a small tributary of the Mekong River near the
juncture of the Burma-Thai-Laos borders. It will be in an isolated
area with a military defense perimeter guarding all ground ap-
proaches. Nevertheless, it is easily portable and may be moved from
one section of the area to another. Although in Burma and Thailand
the refineries are operated by insurgents, in Laos thej^ are protected by
elements of the Royal Laotian Armed Forces. While the management
and ownership of the Laotian refineries appear to be primarily in the
hands of a consortium of ethnic Chinese, some reports suggest that a
senior Royal Lao Army officer may hold an ownership interest in a few
of these facilities.
Most of the narcotics buyers and distributors in the tri-bordor area
are ethnic Chinese, although they may be citizens of the countries in
which they live.
While many of these buyers pool their purchases, no syndicate ap-
pears to be involved. The opium, morphine base, and heroin purchased
in this area eventually find their way into Bangkok, Vientiane, and
Luang Prabang, where additional processing may take place before
delivery to Saigon, Hong Kong, and other international markets.
The most important processing appears to occur in the Tachilek
area of Burma. But refineries throughout the border area are turning
opium into the virtually pure white heroin that is widely available in
South Vietnam. An increasing demand for this heroin also appears to
be reflected in a steady rise in its price; $1,780 per kilogram in mid-
April 1971, compared with $1,240 in September 1970.
Further, the establishment of new refineries in the last 15 months
to produce 95 percent pure heroin appears due to the sudden increase
of a large and relatively affluent market in South Vietnam.
This has far reaching and disturbing possibilities in addition to the
immediate concern for the military user. The illicit introduction in
substantial quantities into the domestic regions of the United States
has already started. Heroin addicts in South Vietnam can readily
support a $2 or $3 dollar-a-day habit, but they will not be able to do
so when they return to the United States where it may cost $50 a day.
349
They will add to the ranks of our expanding addict population and
resort to crime to support their affliction, if they are not treated in
time.
Immediate actions that have been taken recently include the fol-
lowing :
(1) President Thieu has appointed a special task force reporting
directly to him ;
(2) Corruption at Soutli Vietnam airports and other customs entry
posts is being cliecked in an effort to halt the illegal importation of
narcotics and other contraband ;
(3) Additional BNDD agents are being assigned to augment the
present statl' assigned in the Far East ;
(4) United States and other countries; military and civilian mail-
ing procedures and regulations are being reexamined to tighten up
loopholes in mailing privileges that might permit illicit transport of
drugs ;
(5) Department of Defense officials have focused their attention on
improving military controls. They are initiating treatment programs
within the Defense Establishment and also within the Veterans' Ad-
ministration for discharged personnel.
Additional actions have been recommended which are presently being
considered by higher authority.
That concludes my statement, Mr. Chairman, and I will be happy to
respond to any questions that I can.
Chairman Pepper. Just a few questions, Mr. Ingersoll. We thank
you very much for your valuable statement and your bringing to us
the valuable experience that you have brought.
Do I understand you to say that in the Southeast Asian area you do
not find evidence of the sort of criminal conspiracy, sort of a gangster
operation, which is generally assumed to be the kind of operation that
brings the heroin from Turkey into this country ? You do not find that
same type of organized crime conspiracy bringing the heroin in from
Southeast Asia that you would find, perhaps, in the relationship with
the opium produced in Turkey ?
Mr. Ingersoll. No; I do not think that is what I intended to say,
Mr. Chairman. I think that there is organization but it is not a large
syndicated operation that we might see in the United States or in the
traditional opium and heroin distribution channels.
Chairman Pepper. Well, who are the people that are responsible for
bringing heroin from Southeast Asia into Saigon and other markets
and into the United States ?
Mr. Ingersoll. I think, generally, Mr. Chairman, that you can attrib-
ute most of the movement and the trade in heroin in that part of the
world to the people who have traditionally carried on trade in South-
east Asia ; that is, people of Chinese extraction.
Chairman Pepper. Do you find any official condoning of it or official
participation in that movement ?
Mr. Ingersoll. Oh, very definitely ; yes, sir. There are a lot of people,
officials of various governments, who appear to be receiving or profit-
ing from the trade and who are protecting the trade.
As I pointed out in my statement, some government officials of these
countries are directly involved, they may have an ownership interest
or at least they are exacting tribute for protecting the flow.
60-2.96 — 71— pt. 2 2
350
I would also point out as I did in my statement, that there are many
people who have no affiliation with a recognized government who are
equally involved and in many cases the central government has abso-
lutely no control or at least no desire to control those groups of people.
There is a definite relationship.
Chairman Pepper. In general, we are giving military and economic
aid to the governments where that type of corruption appears ; are we
not?
Mr. Ingersoll. Yes, sir.
Chairman Pepper. Does it seem that we could not put more pressure
on them? If we are going to continue to give them our military and
economic aid, do you think it would be effective if we put more pressure
on them to insist that they try to curb this operation that is contributing
so much to the detriment of this country ?
Mr. IxGERsoT.L. I think that would be effective and I can report to
you, sir, that more pressure is being put on. There is a tremendous
amount of activity regarding the problem on the part of all of our
missions in Soutlieast Asia at this time.
Chairman Pepper. It would seem to me, since we have such a close
relationship to, for example. South Vietnam, that we might insist they
allow us to put customs inspectors or some of your agents in there
with theirs to try to stop this smuggling.
Mr. Ingersoll. As a matter of fact, we have customs advisers in
Vietnam ?nd the Bureau of Customs has just added to that force in
the last couple of weeks and I am adding personnel to our representa-
tion there as well.
The problem in the past has been that we have not had the proper
response from the customs of South Vietnam, and again, I can report
to you that in the past few weeks there has been a tremendous shakeup
of the South Vietnamese Customs Service and I think that we have to
watch what happens as a result of this.
Chairman Pepper. Well, I would think that in dealing with those
people, giving them all the aid that we are giving them, that we would
be justifiocl in taking a very strong position in respect to those govern-
ments. They are prostituting, perverting our own men who we send
over there to help them, and they are sending a stream of opium to
contaminate our citizenry back to this country. It seems to me we
would be justified in taking a very hard and firm line with those
governments and seeing to it, if we have to participate in the enforce-
ment program, that they do enforce these restrictions against bringing
opium into this country.
Mr. Ingersoll. We have done that and we are continuing to do so.
"\^Tien I visited with President Thieu and the Prime Minister I was
accompanied by Ambassador Bunker and General Abrams and the
three of us together were as forceful as I think anybody possibly can
be on the highest officials of that government.
Chairman Pepper. I notice you said here with respect to Laos that
some of the Royal Laotian Armed Forces were protecting some of
these people. Do you find high officials in South Vietnam and some of
these other oounti-ies involved either in protecting or participating in
these movements ?
Mr. Ingersoll. I think it is questionable as to whether there are very
high officials involved. I think that it would be at an operating level or
351
at a functionary level for the most part. For example, one member of
the South Vietnamese Legislature was apprehended coming into Ton
Son Nhut with a quantity of heroin and he is still in custody. I doubt
whether ])olicymakers are involved.
I should also point out that in Laos, opium production and distribu-
tion is not restricted by law at the present time. TJiere is no law that
speaks to this in any respect. A law is in the drafting stage. It was
to have been introduced into the legislature about 2 weeks ago, but I
do not know whether it has passed or not. The Laotian Government
consulted with us on this and we made some suggestions which would
further strengthen it.
In the meantime, the Laotian national police have made some
seizures, extra legally, and I think this indicates a willingness or an
agreement that the government will support us. But I have to point
out again, sir, that the Government of Laos is not in control of all of
its territory. It is not even in complete control of some of the people
who work for it, presumably.
Chairman Pepper. Well, now, you referred also to Burma and
Thailand, I believe, where there were areas that were not under the
control of the government, where the opium poppy is produced and
from which opium is smuggled to outside areas.
Have we offered to help them gain control over those areas? "V\^iat
has been the response to our offer ?
INIr. IxGEPtSOLL. Let me take them in order and start with Burma first,
if I may. Burma, as you know, is a nonalined nation and particularly
it resists any effort, or any indication of being influenced by either the
United States or the U.S.S.R. We have no assistance programs except
one small one which is almost complete. We have very little economic
or other transactions with Burma.
When I visited Burma, I was wearing my hat as U.S. representative
to the United Nations Commission on Narcotic Drugs and I was really
trying to sell those officials on accepting United Nations programs.
The results were frustrating and disappointing in Burma and I
should also repeat again that Burma is a major producer of opium in
that part of the world. The best that I could get from them was a
response that they would consider a visit by the United Nations
Secretariat on this matter.
Chairman Pepper. What about Thailand ?
Mr. Ingersoll. In Thailand, where we have assistance programs, it
was agreed that we would develop a joint working arrangement so
that we could deal with the problem on two fronts. The Thai Govern-
ment is extremely interested in improving the life and the economy
of the hill tribes "that produce most of the opium, by converting them
from opium producers to the production of other crops or other ways
of earning a living. This is a long range kind of a program which, in
my judgment, is going to take a generation, or two, or three to achieve.
I suggested at the same time we might work together in interdicting
the traffic dealing with the problem at hand, the immediate problem,
and it was agreed at that time that we would work out a joint program
together.
Chairman Pepper. If we were to offer, through a concert of nations
to the countries where opium is produced, a program under which
352
their farmers who have been growing opium could ^row something
else and not sustain any reduction in income, would it be possible to
get those governments to enforce efi'ectively a prohibition against the
growing of the opium poppy ?
Mr. Ingersoll. I think that would be the ideal solution. I think we
could achieve that in Laos. I doubt that we could achieve it in Burma.
And I think that proposition is part of the arrangement or part of the
program that will develop with time.
Chairman Pepper. Now, how much money have we offered and how
much have we put up so far toward such a program as that?
Mr. IxGERSOLL. "VVe have not made an offer yet, because we are still
developing the program, but I should say that the Thai Government
has permitted the United Nations to do a survey of opium production
in Thailand and it has produced a report which will call for a pro-
gram which, over a period of 4 or 5 years, will be regarded as a pilot
project and several of the Meo villages where opium is produced in
an effort to do just that. This program is presently funded at a rate
of $5 million. I do not think that the funds now available are going
to be enough ; additional money will be needed.
Chairman Pepper. As I understand it, we have a United Nations
special fund to deal with this problem. We committed $2 million to
that fund and we put up $1 million. Germany has put up, I believe,
$20,000. Have we put up $1 million?
Mr. IxGERSOLL. We pledged $2 million and we already contributed
$1 million.
Chairman Pepper. Now, what other nations have pledged or made
a contribution?
Mr. Ingersoll. Well, I understand that Sweden has made a contri-
bution in the neighborhood, as I recall, of about $30,000. Turkey has
made a contribution of $5,000, and the Holy See has given $1,000.
Chairman Pepper. How about West Germany ?
Mr. Ingersoll. West Germany has not yet made its contribution.
They indicated to me that they are going to contribute a million
marks, about $280,000.
Chairman Pepper. We were up at the United Nations the other day
and conferred with these United Nations narcotics representatives, the
people that are directing this special fund, and they advised us that
they are preparing a program now. You are our representative on that
Commission ; are vou not ?
Mr. Ingersoll. Yes, sir.
Chairman Pepper. Are you going to press for a larger appropria-
tion so that we would be prepared to offer to these nations where the
poppy is grown, substitute crops and equivalent income ?
Are you disposed to press for that program and ask the Government
and Congress for more monej' to press for the adoption of that
program ?
i\Ir. Ingersoll. Yes, Mr. Chairman. The special fund was estab-
lished at the U.S. initiative and certainly, we have a deep and abiding
interest in seeing that the fund not only grows but that it is used
effectively.
Next October, at the meeting of the Commission on Narcotic Drugs,
one of the matters to be considered will be the short- and long-term
353
programs that the Secretariat has developed as a result of the instruc-
tions from the Commission when the fund was established by resolu-
tion last fall.
Chairman Pepper. Mr. Ingersoll, would you make the best estimate
that you can as to how much heroin is costing- the United States today
in its efforts to keep it out and the effort to stop its distribution in the
United States ; the crime that results from trying to get the money to
buy it? What would you estimate that heroin is costing the United
States a year?
Mr. IxGERSOLL. Well, that is a very difficult question to answer, of
couise. It is difficult to estimate what crime generally is costing the
United States. I think that the direct costs of purchases, of the trans-
actions in heroin, could be measured in terms of $350-$400 million,
but I think when you apply all of the indirect costs, and so on, that
you can increase that figure by about 10 times and if you appl}^ it
against the drains on our gross national product, I think you are talk-
ing about a drain of maybe $3 to $3i/^ billion.
Chairman Pepper. $3 to $31^ billion. Not to speak of the lives and
the careers, the lives lost and the careers ruined and all that. So, that
the United States would be justified in making a very large investment
in stopping the growing of the opium poppy in the world. We could
spend a lot of money toward that kind of a program and still come out
way ahead, financially ; could we not ?
Mr. IxGERSOLL. I think that is true, but, of course, we always have to
negotiate the willingness and the concurrence of the government of the
territory concerned in which the opium poppy is grown.
Chairman Pepper, Now, what percentage of the heroin coming into
this country today emanates in Turkey, or originates in Turkey ?
Mr. Ingersoll. Again, Mr. Chairman, I cannot give you a precise
figure because as you know, this traffic is clandestine and all we know is
what we seize, what we surface. I can say that the vast majority of
heroin that is consumed in the United States is produced from opium
that originally was grown in Turkey,
Chairman Pepper. Now, how much money are we making available
to Turkey to try to deal with this problem, to curb the production of
opium or to displace the production of the opium poppy in Turkey ?
Mr. IxGERSOLL. In the last 2 years or so we have provided a $3 mil-
lion loan to Turkey.
Chairman Pepper. $3 million loan.
Mr. Ingersoll. Yes, sir; plus the value of a number of personnel
from my organization and from other agencies of the Federal
Government.
Chairman Pepper. Compared to the cost of the heroin that comes
from Turkey to the people of this country, that is a very small amount.
]\Ir. Ingersoll. Yes. sir.
Chairman Pepper, Now, one other question, Mr, Ingersoll. Based on
your knowledge, is opium or the proceeds from the sale of opium used
to finance Communist insurgency in Burma, Thailand, Laos, and South
Vietnam ?
Mr, Ingersoll, The insurgency in those countries, Mr, Chairman, is
not limited to Communist insurgency. As a matter of fact, I have been
354
told that much of the insurgency in northern Thailand is motivated by
farmers trying to protect their opium production.
That is a very, very confused area of the world. Nobody knows who
is fighting whom half of the time and you do not know wliat the alle-
giance of any particular group is, and even if this is determined it may
change from one year to another. But there is no question in my mind
that there is a clear relationship between opium production and insur-
gency, be it for whatever purpose, political or economic motives, in
those tribal areas.
The proceeds derived from opium sales are used to purchase arms
and as I mentioned before, production and transportation is pro-
tected by armed militia, irregular forces, and there is a clear rela-
tionship in my judgment, between the two.
Chairman Pepper. Just two other questions, Mr. Ingersoll.
Would you favor action by the Congress forbidding the importa-
tion of products of the opium poppy even for medicinal purposes into
the United States?
Mr. Ingersoll. Mr. Chairman, I pointed out in my prepared state-
ment that at the present time there are some practical problems with
that, and I would like to give you some statistical data, if I may, to
support this point. The amount of opium imported since 1966 has
been relatively stable. It is in the neighborhood of — it runs between
122 to 177 tons each year. In 1970, by includino; some of the opium
previously stockpiled in the I'''nited States, some 200 tons of opium
were placed in the extraction process. From this, almost 23 tons of
morphine were extracted, and from this almost 22 tons of morphine
were converted to codeine.
Codeine is the critical problem, as I mentioned in my statement
and as Drs. Brill. Eddv, and Seevers mentioned in their testimony
earlier. Codeine is an inexpensive, highly useful, and widely used
medicine to treat n vnriety of ailments and I am told that there is
nothing better for 'he svmptomatic treatment of flu, for example. At
the present time there is no substitute thfit combines all of the three
principal properties of codeine: until we find that sulistitute or until
we are able to synthesize codeine itself, then T question whether Ave
have any choice but to continue the importation of opium.
Chairman Pepper. Would it help you in terms of law enforcement
if we did not have to bring in any legitimate products of opium to this
country?
Mr. Ingersoll. Again. Mr. Chairman, there is verv little, if any
diversion of opium from legitimate U.S. channels. When narcotic?
are found in the illicit traffic that come from legitimate sources, thev
are usually there because of theft or burglary or something of this
nature, but the industry in this country has done a remarkable and
very commendable job of keeping opium under control and keeping it
within legal distribution channels. So as far as leakage is concerned,
from that source, it is not a problem.
Chairman Pepper. On the othei- hand, the fnct that opium ponpios
may be grown for legit hnato purposes makes it difficult to detect that
part which is diverted to an illegitimate purpose in the areas where it
is grown.
355
]Mr, Ingeksoll. Yes, sir; tliat is correct, and, of course, diversion
occurs at the point of cultivation and harvest.
Chairman Pepper. Yes ; now, one other question, Mr. IngersoU. You
know, this committee has pressed very hard to get the Government to
impose a quota system upon amphetamines in this country, and we
have called attention, as has the Interstate and Foreign Commerce
Committee of the House, to the fact that some 8 billion amphetamine
pills are being produced in this country every year and about half of
them have been going into the black market.
We were pleased to see, therefore, that you recommended and the
Department of Justice recently proposed an embargo, the quota sys-
tem, on amphetamines and methamphetamines, as our amendment of-
fered in the House last year proposed to do.
Now, we were unhappy, however, to observe that there were two
substances that were left out of that proposed quota system popularly
Ivnown as Preludin and Ritalin and we had the experience that Sweden
has had. When they left those two substances off of the control system,
immediately abuse swept to those two drugs and they had practically
the same situation they had before the amphetamines were controlled.
^^Hiy did the Department of Justice, I presume on your recommenda-
tion, leave out Ritalin and Preludin from the quota system ?
]\Ir. Ingersoll. Well, Mr. Chairman, we have given serious consid-
eration to moving phenmetrazine and methylphenidate — Preludin and
Ritalin — into schedule II. But while we recognize that these drugs have
had serious potential for abuse and have been abused in other coun-
tries, we have not seen this type of abuse in the United States.
Each of these drugs in the United States is manufactured by a sin-
gle manufacturer with limited channels of distribution and, unlike
the amphetamines, the controls inherent in schedule III seem to be
adequate at this time to prevent diversion and to protect the public
health and safety.
To look at it from another angle, we see that the amphetamine prob-
lem is so significant that we have focused primarily on them, but we
are still continuing to investigate the abuse of methylphenidate and
phenmetrazine.
Chairman Pepper. Excuse me. Is there medical need for Preludin
and Ritalin ? There has been shown that there is no medical need for
amphetamines to speak of. What medical need justifies the continued
production and distribution of Preludin and Ritalin ?
Mr. Ingersoll. I can ask Dr. Lewis to give you a medical answer
to that question, if you would like.
Chairman Pepper. We would be glad to have it because we are very
much concerned. Would you be willing, or on the advice of your
doctor and counsel here — we have an amendment pending that would
put those two substances under the quota system along with ampheta-
mines. Would you and your organization support such an amendment,
Mr. Ingersoll ?
Mr. Ingersoll. I think I would have to see the amendent first and
examine it first, Mr. Chairman.
Chairman Pepper. Put Preludin and Ritalin in schedule II just as
amphetamines are put in schedule II by the recent action of the De-
partment of Justice.
356
Mr. IxGERSOLL. Well, again, Mr. Chairman, I have to point out that
we are examining this question at this time and if it is determined
that administrative action should be taken under Public Law 91-513,
we will initiate such action.
Chairman Pepper. You have been examining this amphetamine
problem quite a long time, too, and we finally got around to it. I do not
know how long the administrative and judicial review procedures are
going to take. These things still are spewed out on the public of the
United States while we go through all these administrative proced-
ures. That is the reason this committee had hoped that Congress could
put them under an embargo, under a quota system, and let the others
justify their continuation, if they could.
Did your doctor — your physician wish to give any comments on
the matter I asked you about, about Kitalin and Preludin ?
Dr. Lewis. Mr. Chairman, Ritalin is a mild central nervous sys-
tem stimulant and its prime use has been in cases of hyperactivity
in children of certain types which is made available pursuant to a pre-
scription of a physician. The Preludin is a mild central nervous sys-
tem stimulant and an appetite suppressant.
I think the question as to the medical need of these two drugs would
be one that would probably need to be addressed by the entire medical
community in perspective. I do not think there are that many hyper-
active children of the type that respond well to Ritalin to require
such mass prescribing of this drug. The appetite suppressant effects
of Preludin have been considered by some members of the profession
as very good.
Chairman Pepper. Did not Sweden discover when they left those
two substances out of their control that the abuse turned right over
to those drugs ?
Dr. Lewis. Yes, sir.
Chairman Pepper. Mr. Waldie.
Mr. Waldie. Mr. Ingersoll, I commend you on your testimony and
upon the revelations that you have made to the committee concerning
the fertile triangle problem in Southeast Asia. Are you familiar with
the article in Ramparts magazine of last month concerning that traffic ?
Mr. Ingersoll. Yes, sir ; I have read it.
Mr. Waldie. I would like to ask you some questions concerning peo-
ple of high position in their governments who were identified in that
article to determine whether or not your own inquiry on your recent
trip would confirm conclusions in the article that these people are in
fact involved in the opium trade.
First, can you confirm whether General Rathikoune of the Royal
Laos Government Army and Air Force is involved in the opium
traffic?
Mr. Ingersoll. Could you give me his full name, Mr. Waldie?
Mr. Waldie. 0-u-a-n-e is his first name.
Mr. Ingersoll. Wliat is his surname ?
Mr. Waldie. R-a-t-h-i-k-o-u-n-e, according to the article.
Mr. Ingersoll It is general speculation that he is; yes, sir.
Mr. Waldie. According to the article, he has sevei'al refineries in a
number of villages and his opium is purchased from a Chinese-
Burmese merchant called Chan Chi-foo. Did that name come into your
purview during your trip ?
357
Mr. Ingersoll. Yes ; I am familiar with that name.
Mr. Waldie. He theoretically has 1,000 to 2,000 men in a feudal army
that guard and assist him in transporting the opium.
Mr. Ingersoll. I recognize the name as being the head of an in-
surgency group of Burma. Whether or not the claim that was made
in the article is true about his involvement in opium is not proven one
way or the other at this time. It is reported that he is now in prison.
Mr. Waldie. Then, did you come across information concerning
Generalissimo Chiang Kai-shek's 93d Division, Kuomintang troops
which were left over after the evacuation of the mainland in Burma ?
Mr. Ingersoll. The KMT and their successors who are still active
in those areas are the groups that I refer to as the Chinese irregulars.
Yes ; it is true that they are involved in some of the insurgency action
and that they carry on an exchange of opium and arms trade.
Mr. Waldie. And are they also in the employ of the Central Intelli-
gence Agency for counterinsurgency operations in China ?
Mr. Ingersoll. No ; that is not a true statement as far as I know.
Mr. Waldie. Are they presently supported by Chiang Kai-shek?
Does he still maintain contact with them and do they still hold alle-
giance to him and does he still support them financially ?
Mr. Ingersoll. I am not certain what their allegiance is, Mr.
W^aldie, but I am told that he is not supporting them financially.
Mr. Waldie. Did you come across any indication of participation in
the traffic of opium in the fertile triangle by Air America ?
Mr. Ingersoll. I think that in the past. Air America planes have
loeen used unwittingly to transport or to haul opium just as TWA and
many others have been used to conceal heroin smuggling into the
United States, but I can say that it has not been the policy of the
management of that airline or the other airlines to provide transporta-
tion for the illicit distribution of opium.
Mr. Waldie. Well, I would assume it would not be their policy.
Were you able to visit Long Cheng in Laos ?
Mr. Ingersoll. No, sir ; I did not.
Mr. Waldie. Are you familiar with the allegations as to the role
that Long Chen plays in the opium traffic in the fertile triangle ? Well,
let me tell you what those allegations are. Long Cheng was established
by the Central Intelligence Agency as the base for support of Gen-
eral Vang Pao and Meo tribesmen. It is alleged that Long Clieng is
the base to which all the Meo production of opium is brought for
distribution throughout the rest of the world or wherever it is then
distributed. Did you hear such allegations during your recent trip in
Laos?
Mr. Ingersoll. No, sir ; I did not.
Mr. Waldie. Did you hear any allegations that Long Cheng was
used in any way as a distribution point for opium ?
Mr. Ingersoll. No, sir ; I did not.
Mr. Waldte. The United Nations Commission on Drugs and Nar-
cotics estimates that since 1966, 80 percent of the world's 1,200 tons
of illicit opium has come from Southeast Asia. This directly contra-
dicts official U.S. claims that 80 percent comes from Turkey. Which
claim, in your view, is the correct one ?
Mr. Ingersoll. I think the finding of the LTnited Nations is correct
as far as world production is concerned. We have said that the ma-
358
jority of the heroin problem in the United States, not in the rest of the
world, but in the United States, is derived from Turkish opium pro-
duction and illicit diversion of Turkish opium production.
Mr. Waldie. Now, I presume that figure of 80 percent represents
the percentage of opium discovered in illicit traffic in the United States
which is of Turkish origin.
Mr. Ingersoll. That is correct, sir.
Mr. Waldie. What is the date of that conclusion ?
Mr. Ingersoll. That was a figure used by the old Bureau of Nar-
cotics, but I do not know the precise date. When I became Director of
the new Bureau of Narcotics and Dangerous Drugs, I asked for data
to support that precise figure and when it was not forthcoming, I
dropped the use of the 80 percent figure which had been used tradi-
tionally for some time. The best I can say now is that still the over-
whelming majority comes from that source. But whether it is 80 per-
cent or whether it is 70 percent, I just cannot tell j^ou.
Mr. Waldie. Is there any way of making such a determination?
Mr. Ingersoll. The best we can do is indicate what appears to be
the original source from our seizures, but once opium is processed into
heroin and is seized in the form of heroin in the United States, it is
beyond our technical capacity to trace it scientifically to its origin,
but from our intelligence and from common knowledge of traffic pat-
terns, and so on, we make these assumptions.
ISIr. Waldie. Is it a correct statement of fact to say that once opium
is produced into heroin, its source as opium cannot be determined?
Mr. Ingersoll. At the present state of the art its source cannot be
traced scientifically.
Mr. Waldie. On what basis was the conclusion derived that 80 per-
cent of the illicit opium in this country originated in Turkey?
Mr. Ingersoll. I think that basis has been lost with the passage of
time. I am not able to find out w^hen that statement was first made or
what tlie basis was, but basically it was from assumptions derived
from seizures of heroin and on the knowledge of the traffic patterns.
' Mr. Waldie. Was it your conclusion, as you completed your tour,
that in terms of the fertile triangle, the governments involved, Burma,
Thailand, and Laos, were capable of preventing the production of
opium and the distribution of opium due to the international market ?
Were they so inclined ?
j\fr. Ingersoll. I don't believe the Government of Burma has that
capal)ility at this time. I don't think the Thai Government has that
capability without securing the area of production, but Laos probably
has the capability. Whether it has the incentive, or not, is another
question.
Mr. Waldie. Does Thailand have the incentive?
Mr. Ingersoll. I think the primary objective of the Thai Govern-
ment, including the King, is to do that by changing the life style of the
opium producers.
Mv. Wai-die. Changing them from what life style to what?
Mr. Ingersoll. Changing the life style from the very primitive
slash- and burn-type of agriculture they engage in now to a more
stable and productive form of agriculture. This is going to require
not only the development of agricultui-al expertise, but it is going to
359
require the provision of markets, provision of transportation facili-
ties between the producing areas and markets, and so on.
Mr. Waldie. I assume that is their desire. Do we have time, given
the nature and extent of the problem in our country and among our
troops in Southeast Asia, to support a policy which would be that long
in duration to obtain success ?
Mr. Ingersoll. Not in my opinion, sir, and this is why I made it
very clear to the Thai Government officials that our concern was one
of the immediate traffic; that we should direct our attention to the
problem of today but still continue the efforts to deal with the long-
range corrective action.
Mr. Waldie. In that regard, and for my final question, what have
you recommended, or what has our Government recommended in terms
of actions to meet th<? problems of today in Thailand and in Laos?
Mr. Ingeksoll. My. Waldie, I just returned from this trip in the
last 2 weeks and these recommendations are still in preparation. Much
of the information and the knowledge that I gained was provided
from classified sources and I think at this time that I can't go beyond
my statement where I indicated the immediate action that is being
taken. One of the things that we are very interested in doing is in-
creasing the capability of the Thai national police to deal with the in-
terdiction of traffic, and I think this is the general area that we are
going to focus on.
Mr. Waldie. I do not intend this as criticism of you, but it does
seem to me that whenever we get to the heart of the solution of these
problems, we, as Congressmen, are met with a response from the exec-
utive branch saying that this is from classified sources and that we are
not permitted to discuss it.
Am I fair in concluding that up to this moment in time, there have
been no proposals directed dealing with the inuriediate and urgent
problem of control of the narcotics traffic in Thailand or in Laos?
Mr. IxGEESOLL. jSTo, sir; that is not correct. I have submitted a re-
port with proposals to my superiors in the executive branch of Gov-
ernment and those proposals are now under consideration. I will be
very happy to discuss with this committee tlie proposals in executive
session.
Mr. Waldie. Then am I correct in saying that prior to your submis-
sion of proposals, no proposals have been entertained, nor action un-
dertaken, to control this ti-affic in those two countries ?
Mr. Ingersoll. It is not a question that we have just started con-
sidering something in the last 2 or 3 weeks. We have been formulat-
ing proposals or potential possible lines of action for some time.
Mr. Waldie. For what length of time ?
Mr. IxGERSOLL. Intensively, since perhaps the last quarter of last
year.
Mr. Waldie. Prior to that time, is it fair to conclude that there had
been no consideration of such proposals ?
Mr. Ingersoll. No. sir. We have had personnel stationed in South-
east Asia dealing with this problem for a period of years.
Mr. Waldie. Well, as a Member of Congress, I am aware that we
have been considering dealing with this problem for a number of
360
years, but I have been frustrated by my recognition that we have not
proceeded beyond consideration of the problem.
I am attempting to find out what we have done or what we are pro-
posing to do, and I gather from your response to that, that we have
done very little, but we are proposing to do much more, but that which
we are proposing you are not at liberty to disclose to the American
public at this stage.
Is that fair?
;Mr. Ingersoll. The President of the United States was asked this
question yesterday at his news conference and he specified the general
lines of action the Government is considering. The first item he men-
tioned was getting at the source, working with foreign governments
where the drugs come from, including the Government of South
Vietnam where they have a special responsibility.
Continuing, he mentioned vigorous prosecution of those who are
pushers ; he emphasized that we need to accelerate a program of treat-
ing the addict; and that, incidentallj^, insofar as servicemen are con-
cerned, it means treating them before they are released from the mili-
tary if they are addicted to heroin or hard drugs.
Mr. Waldie. Is that a fair summary of the proposals which you
submitted and which are classified ?
Mr. Ingersoll. The statement of the President last night outlines
in very broad terms the directions that we are pursuing; yes, sir.
Mr. Waldie. Then, Mr. Chairman, I would have no further ques-
tions, but only a comment. I would suggest that the committee, at an
appropriate time, go into executive session to listen to the precise pro-
posals Mr. Ingersoll has made to the President which are classified.
Chairman Perper. Very good. The Chair will take that up with the
committee. I am glad to have that.
Mr. Steiger?
Mr. Steiger. Thank you, Mr. Chairman.
Mr. Ingersoll, in the main, the whole prospect of outlawing opium
on any kind of international basis, I gather from your remarks, is
tenuous at best.
Mr, Ingersoll. Outlawing the production of opium would not get at
the illicit traffic unless and until the governments of those territories
in which it is produced illicitly have the incentive and the capacity to
eliminate its production.
Mr. Steiger. But the prospect of actually outlawing its production
and therefore making all production illicit is at best somewhere in the
distant future.
]\lr. Ingersoll. I think that is correct, and in the interim we have to
work to improve international controls.
Mr. Steiger. Aren't we really kidding ourselves when we talk about
elaborate programs to buy oif the illicit producer, the cuirent illicit
producers, because by his nature, if he is an insurgent or entrepreneur,
he is a guy who is going to take advantage of whatever harvest comes
his way and then obviously it is going to be veiy^ difficult because he
has now developed an expertise in the production of opium.
It would be easy to pay him for not growing opium, but it seems to
me it would be awfully tough to enforce his not growing it somewhere
else. From our own experience in this country — we are probably the
361
only country in history to develop the fantastic expertise in paying
people not to grow things — complete control and cooperation fail to
surmount the problem.
So it seems to me, and on the basis of your remarks, that until we get
the American medical community and the world to forego the con-
venience of codeine, which seems to be the only remaining rationale
for the production of opium, and therefore make opium illicit inter-
nationally, and then enforce it, that we are just playing games with the
people who are too sophisticated to be seduced by that kind of a
program.
I don't mean to discount these efforts, but I just don't think they are
realistic.
Mr. Ingersoll. Some proposals are not realistic on a short-term
basis, but in the long term, again given the moneys and wills to do it,
a great deal can be done to reduce the production of opium.
Mr. Steiger. I have a few specific questions, Mr. Ingersoll.
I was impressed with your testimony and I wish to thank you for it.
On page 5 of your prepared testimony you mentioned, in the dis-
cussion of illicit metliadone, one of your recommendations was
that the patients be monitored regularly through urinalysis and
observation.
You are aware, I am sure, that the sophisticated user who wants to
beat the urinalysis has got a great variety of ways of beating urinalysis,
I am sure.
Are you aware of the- fact that urinalysis is neither absolute nor
anything more than an indication that the guy, if he wants to beat
the system
Mr. Ingersoll. There is no doubt that there are ways of beating
the system, and one of the reasons for insisting on tight controls and
for close supervision of getting the specimen is to minimize the ])rob-
ability that the patient is not complying with the aims of the program.
One of the purposes of the urinalysis is to determine whether or not he
is taking methadone. The other purpose is to detect the presence of
other opiates, barbiturates, or amphetamines.
Mr. Steiger. There are, of course, a number of methods in which,
even if he uses his own urine, which is not always the case in urinalysis,
but even if he uses his own urine, there are physical and chemical de-
vices he can use to mask the use of heroin. We have had testimony to
that effect — it was medical testimony — and I assume it is accurate.
But again my point is, and you made the point, methadone is a sub-
stitution of an addiction of a less-offensive nature, but still an addict,
and as such lends itself to illicit traffic.
On page 10 of your report you mentioned a series of steps you are
taking, the immediate action that Mr. Waldie referred to in his
questions.
I am curious, in item number 3, you say you are adding additional
Bureau of Narcotics and Dangerous Drugs agents to the Far East.
How many are we talking about ?
Mr. Ingersoll. This month I will be sending three more to the Far
East.
Mr. Steiger. And how many have we got there now, approximated ?
Mr. Ingersoll. By the end of July we will have 15 agents in the Far
East, located in five stations.
362
Mr, Steiger. If you were goin^ to control the flow with your people,
how many would you need, assuming; cost was no object ?
Mr. Ingersoll. Man for man, our agents overseas are more i^roduc-
tive than they are in the United States.
Mr. Steiger. In seizures ?
Mr. Ingersoll. As far as seizures are concerned ; yes, sir.
Mr. Steiger. Also, they are exposed to more traffic.
Mr. Ingersoll. Tliey are right in the middle of the traffic. I should
think that we could adequately justify putting agents in the area num-
bering in the hundreds, again depending on the degree of cooperation
that we receive from the host government. Of course, at the present time
we could not support many more agents in the area.
Mr. Steiger. I understand, but you could effectively use many times
this number of agents, many times the 15, and in line with the chair-
man's line of questioning in which we are dealing with a problem that
represents a $3.5 billion cost to the Government, it would seem that we
are indeed being pennywise and pound-foolish in these areas.
Have you asked for more money so that you can put more people
at this particular source of the drug?
Mr. Ingersoll. Yes. Mr. Steiger, in the last 2 years or so that we
have been operating the new Bureau of Narcotics and Dangerous
Drugs, we have had to deal with our problems in a priority order.
"We started off with about 500 agents. Todav, or nt least by
the end of June, we will have in tlie neighborhood of 1,300
agents. This has been a substantial growth in a law enforcement agency
that deals with a very complicated, complex, technical kind of a prob-
lem. There is a question of training, there is the matter of experience,
supporting staff, equipment, space, and so on.
In this fiscal year alone Congress authorized some 450 new agent
positions. In the preceding 2 j^ears we increased by 100 and 150,
respectively.
We have handled this large increase without diluting the effective-
ness of the main body of agents. During fiscal 1972 we have to settle
down, give the agents advance training, develop our supervisory staff,
and so on. In the years coming we are going to continue to ask for large
incremental increases until we are better able to handle the problem.
Mr. Steiger. The problem, then, is not only a money problem, but
it is also simply a pragmatic problem, structuring, and so fo7-th.
Mr. Ingersoll. There is no pool of professional people that we can
draw from to do this work. We have to select, train, and develop them
ourselves.
Mr. Steiger. One last question. In response to the chairman's in-
quiry about the kind of structuring of the trade in the Far East, you
mentioned that it appeared to be at best a very loose organization made
up mainly of ethnic Chinese. In the transport from Singapore, Plong
Kong, and the other international markets of the finished product, or
semifinished product, do we find the same general organizational effort
in the United States in bringing it into the United States that we do
in bringing in the Turkish product? Is organized crime involved? Are
the same general people involved in financing it and transporting it
as they do the Turkish product from France ?
363
Mr, Ingersoll. No, sir. This particular traffic, which I might say
is still a very small proportion of the heroin traffic into the United
States, is composed largely of independent groups of people.
Some of them, many of them as a matter of fact, are ex-servicemen
■vvho have got back out to the Far East to deal in this and other forms
of conti-aband traffic.
Mr. Steiger. So that the organized crime traffic in heroin is primar-
ily sustained from the Turkish source and not from this Far East
source at this point ?
Mr. Ingersoll. Yes ; except that I should also mention that there are
more people than just those who we traditionally classify as members
of organized crime involved in this traffic as well. There is a good deal
of competitive effort and dispersion of efforts.
]\lr. Steiger. You are talking about the total picture ?
Mr.lNGERSOLL. Ycs, sir. I mean Europe, as well.
Mr. Steiger. Yes.
Mr. Ingersoll. The producers of heroin in Europe will sell to any-
body who has the money, and more and more people have made con-
tact with them and are providing the money. So it is not restricted to
just one identifiable group.
Mr. Steiger. Thank you.
Thank you, Mr. Chairman.
Chairman Pepper. Mr. Brasco.
Mr. Brasco. I am sorry I was late, Mr. Chairman, but I had to attend
another hearing.
Mr. Ingersoll, several weeks ago I had the opportunity to sit at an
informal meeting of Members of Congress from the Queens area in
New York, in which we heard a number of representatives of differ-
ent veterans organizations complain about this growing number of
servicemen who are becoming addicted to heroin, drug abusers in gen-
eral. There was a representative of the Department of Defense, whose
name I can't recall at this time, but at that point the veterans organi-
zations had some people with them who were talking a figure of as
high as 70 percent in terms of hard-core addiction and ranging on
down to abuse of other substances, other than heroin.
The Department of Defense individual, as I recall, said the figure
was something like 35 to 40 percent.
I am wondering whether or not your trip could shed any light on
this point as to whether we know how many of our servicemen are
becoming involved as drug abusers in Vietnam or in the Southeast
Asia area.
jMr. Ingersoll. I am dependent, Mr. Brasco, on Department of De-
fense information as far as servicemen are concerned, and in my most
recent trip I really didn't focus on marihuana abuse and matters of
that nature. I was immediately, and almost exclusively, concerned
with the growing heroin problem.
Our military officials in Vietnam have conducted surveys which at
different periods of time report different things. As I recall, the last
general kind of survey like this was in the high forties — 48, 49 percent.
The abuse problem varies as to age, as to rank, length of time in the
country, and a variety of other factors. For example, these surveys
report no heroin use among officers, even junior officers, but they do
364
report marihuana among junior grade officers. Tliey report that in the
lower enlisted grades, heroin abuse is most prevalent, and that there
is A^ery little of it, if any, in the NCO ranks or the officer ranks.
They report that in some surveys, that in the neighborhood of 10
or 15 percent in some areas, have rejoorted that they have used heroin.
What "used" means, I don't know. AMiether it means once, twice, or
whether they are addicted, is impossible to determine from these
surveys. The rate of heroin use as adduced from CID investigations
is increasing tragically. In 1970 CID made 1,146 apprehensions for
heroin possession and distribution. In the first 3 months of this year
they have already made over 1,000 such apprehensions. The appre-
hension I'ate last year was about six per 1,000 troops, and the rate this
year has doubled to over 12 per 1,000. Over 4,000 servicemen have
gone through amnesty programs in the first 3 months of this program.
The amnest}' program is a detoxification session lasting from maybe a
week to 3 weeks in 15 different centers. How many of these w-ere really
addicts and how many people were malingerers is hard to tell because
they don't get the results of the examinations back for several weeks,
and by that time the man has been reassigned or is no longer in the
center.
The other item of importance pertains to autopsy-proven deaths due
to heroin overdoses. As I recall in the last 6 months of last year, some
60 overdose deaths were reported.
As to the statistical tables I have seen, I have some questions about
the validity of sui'veys and what they report. We have tried surveys
in the United States and we have found that people very often respond
to a question like this with the answer that they think you want or
because they think that it is going to get them out of some unpleasant
duty or something of this nature.
Mr. Brasco. I agree, but suffice it to say that the rate of abuse
among the servicemen is alarmingly high.
jMr. Ixc4ERSOLL. There is no question about that. It is my judgment,
and another conclusion I made from this last trip, that the presence
of a lai'ge marihuana market in Vietnam caused traffickers in heroin to
believe they could find a market for their product, as well.
Mr. Brasco. Let me ask you this : Also at that particular meeting,
and I am sure that disturbs us all, the Depai-tment of Defense repre-
sentative indicated, when it was asked of him what we are doing, if
anything, with respect to trying to clamp down on the South Viet-
namese who are engaged in illicit drug traffic in terms of selling it to
our troops, the reply was, and I guess in the inscrutable logic of the
Asian, that they are the hosts and we are the guests, and I am won-
dering whether or not — this meeting, as I said, was several weeks
ago — I am wondering whether or not your trip has indicated any
degree or willingness on the part of the Government of South Viet-
nam to become involved in clamping down on this traffic, because my
distinct impression from the Department of Defense representative
at that time was that the Department of Defense efforts were, in his
opinion, frustrated because of that guest-host relationship, and I am
wondering whether or not you perceive any willingness on the part
of the South Vietnamese Government to cooperate ?
365
Mr. Ingersoll, "Well, before I went to South Vietnam I had heard
from my briefings, pretrip briefings, that a common response to rep-
resentatives to the South Vietnamese Government was, "This is an
American problem." 1 let it be known as forcefully as I could that such
a response was not going to be an acceptable answer as far as I was
concerned. Consequently, I didn't hear it once. To the contrary, I
heard statements of concern by President Thieu and the Prime Min-
ister, which were followed up by action.
During the week I was there the President appointed a very close
adviser to head up a special task force reporting directly to him to
monitor all of the activities of the various ministries of the South
Vietnam Government which had a responsibility for this. The week
following my visit there, about 130 people from the customs services
were transferred. There are some pending disciplinary actions, per-
haps criminal actions, against those for whom provable charges of
corruption, malfeasance, or nonfeasance of duty, can be levied.
The South Vietnamese Government has been made well aware not
only of our concern, but have been made well aware of the fact that we
are insisting that sometliing be done to stop the importation of heroin
into the territory of South Vietnam.
Mr. Brasco. Let me ask you this, Mr. Ingersoll: As a matter of
policy, are any of our military police or other law enforcement peo-
ple that we may have in the area, permitted to particij)ate in arrests
that may involve South Vietnamese civilians? It just seems to me
that — I thinlv we are in agreement — the South Vietnamese, to the
extent that they grow drugs or import them, are a source of the
problem.
If they have sole control over it, it would be sort of like asking a
burglar to call the police station and advise them of the next time and
place that he intends to burglarize someone's apartment, and to that
extent I am wondering whether or not that is a combined effort with
our people and theirs or are we solely relying on the Government of
South Vietnam to work in this area of suppression of the drug traffic ?
Mr. Ingersoll. No. At the present there is a combined effort and it
is becoming a closer collaborative effort. Out in the provinces there are
joint narcotic teams including representatives of our military investi-
gative agencies, who work hand in hand with the Vietnam police.
At the seat of government, itself, the BNDD agent there, is provid-
ing information, leads, investigative leads, and monitoring to see that
they are followed up.
AH of this has happened very recently, of course. In the past, collabo-
ration was inadequate, but it is now becoming increasingly satisfactory.
Mr. Brasco. Thank you.
Chairman Pepper. Mr. Winn.
Mr. Winn. Thank you, Mr. Chairman.
I have two short questions. The chairman referred to the pressures
that we might be able to put on the countries that we are furnishing
military and monetary aid to, but isn't the real secret to this problem,
and I agree with the philosophy, that it sounds good, but as you point
out, it looks to me like the real problems are the uncontrollables. Those
are the bad guys to start with.
60-296 — 71— pt.
366
And it seems to me tliat we Avould be forced into a position of being
blackmailed by those groujos, that if we didn't pay off in large sums
of money or whatever they might desire, they would put us over the
barrel, so to speak, and continue to grow poppies and whatever they
wanted; right?
Mr. Ingersoll. That is correct when j^ou look at it on a worldwide
basis. Certainly the greatest amount of opium is produced illicitly
in countries where it is illegal to do it in the first place, and where
the law is not adequately enforced.
As I said in my prepared statement, we could be somewhat opti-
mistic on the ability of the Government of Turkey to enforce a total
ban because of the relative stability of that Government, for at least
the Central Government does have control of its territory for the most
part, particularly where opium is produced.
In these areas in Southeast Asia where opium is produced in large
quantities, there is a large local addict population, as well, and the
great bulk of it, probably the majority of it, is consumed locally
in Southeast Asia. This is probably one of the reasons why it hasn't
been a significant problem to us before, and probably one of the reasons
why we just haven't paid adequate attention to it before. We, like
others, have not considered it as our problem.
It is similar to the drug problem in general. Wlien it was confined
to the ghettos, it wasn't given a high resolution priority. Even though
some people were concerned with it 20 years ago, and predicted with
astute accuracy what was going to happen if something wasn't done,
this was not transformed into the necessary action to control its
spread. Now, we are faced with the same kind of circmnstances in
Southeast Asia.
The more successful we are in reducing the flow of heroin or opiate
alkaloids from other parts of the world, the more important that
source is going to be as a supplier to the United States. We fully rec-
ofi-nize this. We have been shifting our attention in that direction, but
we are still required to deal with the most immediate problem over
on the other side of the world first.
Mr. Winn. But you pointed out Burma, I believe, as an example,
and there are some others, where we don't have any military or mone-
tary pressure on those countries.
Mr. Ingersoll. That is correct.
Mr. Winn. This is what makes the problem really a tough one, in
my opinion.
Mr. Ingersoll. It is an immensely tough problem, Mr. Wmn, and
in the case of Burma, I think our only hope is to bring about inter-
national influence, hopefully through the United Nations.
Hopefully some day Burma will permit a U.N. survey of the prob-
lem and adopt recommendations that are made. One of the results
of this survey will be that other governments will recognize the im-
portance of Burma in this whole activity and governments that have
more credits with the Government of Burma than we do will use this
influence to bring about an improved condition.
Mr. Winn. But your plan is for the long range, the long run.
Mr. Ingersoll. I am concerned with both the long-range and the
short-range problem of interrupting the traffic. If we can get at the
367
distribution, then we can at least keep the thing under some reasonable
level of control until we can see the effects of the long-range programs.
Mr. AVixx. Than],: you, and I commend you for your testimony
today.
Thank you. ]Mr. Chairman.
Chairman Pepper. Mr. Mann.
Mr. Manx. Thank you, Mr. Chairman.
To what do you attribute the recent flurry of cooperation by the
South Vietnamese Government in this problem ?
Mr. Ingersoll. I think it is fair to say that they have been made
pointedly aware of the nature of tlic problem.
The problem has gotten increasingly worse mitil it is now at the
l)oint of a crisis. The South Vietnamese Government has been in-
formed of that and they have reacted as I have described.
I should point out, too, that the white heroin that is presently being
used by our troops, first appeared on the scene about 15 months ago.
Before that there had been no heroin of this kind detected in Vietnam.
Mr. ]Maxx. On the domestic scene I recognize that increased person-
nel will make you more effective in seizures and in controlling the
illicit drug traffic of which I understand Ave now probably intercept
20 percent of the illicit importations of heroin ?
Mr. Ix'GERSOLL. That is somebody else's figure, Mr. Mann, not mine.
Mr. Max'x\ Do you have a guess ?
Mr. Ix'GERSOLL. I don't have any ; no, sir.
Mr. Max^^x". Other than additional persomiel, which we all recognize
as essential, vrhat other law enforcement tools can you suggest to
handle this problem ?
Mr. IxGERsoLL. We are making efforts to develop technical aids that
will make the job of detecting drugs easier. With the implementation
of Public Law 91-513, which became fully effective on May 1, we have
a new legal tool that will assist us greatly.
We focus our sights on the major distributors. We are soliciting
and obtaining increasing support and cooperation from State and
local police agencies in this matter, in the law enforcement area.
But law enforcement deals with systems. It is the first aid agency of
society. It is not the curative, not the doctor, and it doesn't eliminate
causes of these problems. Our society has gotten itself into an unfor-
tunate state of affairs regarding drugs because it has assumed that by
passing laws and enforcing them, tlie problem will go away.
So it seems to me that while you can expect the law enforcement
agencies to do the first aid work, if you want a cure, then we have got
to go back to the basic causes and find out what can be done from that
end. We have to look to improved and increased rehabilitation pro-
grams. We have to find out more about drugs and why people use
them, knowing of the debilitating consequences.
The cliairman mentioned the possibility of immunizing people
against drug abuse. I think that this is an area well worth exploring
and, as a matter of fact, my organization is exploring this possibility
at this time. I would like to get the medical practitioners of this
country to be interested in that area of inquiry. If we can deal with
the problem on all of the fronts that we well know, and deal with it
368
effectively, then maybe we will have an effect on it. But in order to do
that, we have to have the full support and the will of the people.
One of the places I stopped at during this trip was Japan. Ten years
ago Japan was in a condition very much like our own. Today they
claim that drug abuse is now under complete control. I asked the
police how they did it, how they arrived at that happy state of affairs.
The most important thing they told me was that they had the support
of the people to do what had to be done in order to get it under control.
Regrettably, I don't think we have that support here, yet.
Mr. Mann. Thank you.
Thank you, Mr. Chairman.
Chairman Pepper. Mr. Sandman.
Mr. Sandman. Do you believe that they really have it under
control ?
Mr. Ingersoll. They certainly don't have the problem that we have,
Mr. Sandman.
Mr. Sandman. Now, the figures that you gave, Mr. Ingersoll, I don't
know whether I understood you correctly or not. Were those figures of
arrests in 1970 — 1,146 — were they just arrests in Southeast Asia?
Mv. Ingersoll. They were made in South Vietnam by military
authorities.
Mr. Sandman. And the first 3 months of this year it jumped to
1,082?
Mr. Ingersoll. Yes, sir.
Mr. Sandman. Now, the percentage figures that you used, of a thou-
sand men in the armed services in that area, how many would you
say liaA^e been exposed to the use of an opiate ?
Mr. Ingersoll. Theoretically, all of them have had the opportunity
to use it.
Mr. Sandman. I mean those who did use it.
Mr. Ingersoll. I don't laiow that I can give you an answer beyond
the data that I provided before, Mr. Sandman. Anything else would
either be a recitation of the surveys that the military have taken,
which indicate that in some groups, in some units, the rate is 10 to 15
percent who have reported the use of it.
Mr. Sandman. You mean one out of every 10 men in the armed
services have used an opiate ?
Mr. Ingersoll. No, sir. That isn't what I mean at all. I mean if you
take the lower enlisted grades who were in two different units, one in
a group coming home, one in a holding-type of unit, and if you project
wliat was reported from surveys in those organizations to the entire
military forces in the country, then you comd say that. But what I
am saying is that of the few hundred people, and I can't remember
hoM- many people answered these questionnaires, some 10 or 15 percent
of that group said that they had used heroin at one time of another.
Mr. Sandman, Based upon that kind of a finding, you can hardly
put much value on that ; can you ?
Mr. Ingersoll. That is my point. That is why I do iiot attach a
significant value as applied to the military at large.
Mr. Sandman. Right. So the point I am making, sir, tliese astro-
nomically high figures cannot be accurate. No one can make me believe
that one out of every 10 soldiers has used lieroin, or anything like it.
369
Mr. Ingersoll. I agree. The problem is primarily found in the
younger age groups and the lower enlisted grades.
Mr. Sandman. I agree.
Now, if you ban the growing of opium entirely — I don't know the
answer to this question — would it have a drastic effect upon the phar-
maceutical industry? Are these drugs needed? Can they be replaced?
Mr. Ingersoll. I think that industry representatives could answer
that question better than I can ; but from the information I have, the
principal therapeutic substance that is derived from opium right now,
codeine, cannot be replaced adequately, and certainly not at the same
price, as economically or as easily as codeine is used. Codeine has
antitussive, analgesic, and mild sedative characteristics. All of these
are necessary for treating some very common ailments, and nobody
has found the way to either synthesize codeine itself or to come up
wdth an alternative that has all three of these characteristics.
Mr. Sandman. Now, within the United States, what would 3^ou say
your percentage of increase in the use of heroin, the opiates was in
1970 as compared to 1960 ?
Mr. Ingersoll. I can't answer that question, Mr. Sandman.
Mr. Sandman. In round figures, has it been a drastic increase?
Mr. Ingersoll. In that 1-year period?
Mr. Sandman. Yes, sir.
Mr. Ingersoll. No, sir. I think the drastic increase occurred during
the 1960's.
Mr. Sandiman. Right. In fact, you haven't had the rate of increase
in 1970 at all, have you, that you know of ?
JMr. Ingersoll. It is hard for me to answer that question because
we don't have accurate statistics. Over the years some data have been
collected which are not representative of the entire population.
Mr. Sandman. That is it. Of the 50 States, how many States do
you feel have statistics on the use of the opiate drugs that are worth
anything at all?
Mr. Ingersoll. Probably two.
Mr. Sandman. Two. And what States are those?
Mr. Ingersoll. New York and California.
Mr. Sandman. I agree with you. The others have no statistics that
are worth anything. And New Jersey is one of those.
You have only 15 men in all of Southeast Asia, 15 agents, which, of
course, is not nearly enough to do the job I am sure you want to be
done. Now, in the 50 States, even the big metropolitan States, you have
the same kind of a problem ; don't you ?
]\Ir. Ingersoll. As far as our own personnel strength is concerned,
yes.
Mr. Sandman. All right. Now, how about as far as the State per-
sonnel are concerned ?
Mr. Ingersoll. This is something that has changed in the last couple
of years. In 1968 there probably were not more than a few hundred
State and local police officers who were truly expert in the field of
drug control. During the last 2 years we have trained and oriented
some 40,000 police officers throughout the United States in varying
degrees of intensity. The results, particularly in cities where we have
trained not only specialists but uniformed officers, have shown great
370
improvement as far as the ability of the police departments to deal
with this problem.
But law enforcement agencies, except maybe on the west coast or in
New York, for the most part, didn't have either the expertise or the
staff to engage the drug control situation until the late 1960's in any
substantial way.
Mr. Sandman. In 1965, for example, I know my own State, in the
whole State of New Jersey, they had less than 10 agents in the whole
State. We are right next to the "big source of supply in New York. Do
you know whether or not, for example, that State has increased the
number of people it has working in conjunction with your agents?
Mr. Ingersoll. Yes. Wlien you include the State police and all of
the municipal and county and borough police together, it has in-
creased. I couldn't tell you how much.
Mr. Sandman. Are they taking advantage of your training
program ?
Mr. Ingersoll. Yes, sir.
Mr. Sandman. They are ?
Mr Ingersoll. Yes.
Mr. Sandman. Thank you.
Chairman Pepper. Before I call upon the next member, ]\Ir. Murphy
of Illinois, I think note should be taken of the fact that he has been
to Asia and made a very careful study of this subject and has filed a
report with the Foreign Affairs Committee of the House of Repre-
sentatives.
Mr. Murphy, would you like to question the witness ?
Mr. Murphy. Thank you, Mr. Chairman. I will follow your sugges-
tion. I will file a report with the Select Committee on Crime about
our recent tour and factfinding trip to Southeast Asia.
(The report referred to is a matter of public record and was retained
in the committee files.)
Mr. Murphy. Mr. Ingersoll, you mentioned on page 10 that im-
mediate actions have been taken. I am very interested in your first
notation. You say President Thieu has appointed a special task force
reporting directly to him.
Now, I talked directly with Vice President Ky when I was in South
Vietnam. He recognized that the heroin addiction problem among
troops was of epidemic proportions. Contrary to what my colleagues
from New Jersey just mentioned about the one out of 10. 1 have Army
surveys, though I will not reveal the name of the individual who gave
me tlie survey, which notes that in some units the percentage of usage
is as high as 50 percent ; in other miits, 30 to 35 percent. I agree with
you that it is very low among officers, but it is, nevertheless, very high
among E-5's and below.
As far as the question of Mr. Sandman is concerned regarding when
the fellows are approached when they get into Vietnam, we talked to
literally hundreds of privates and corporals, who assured us they
were not in Vietnam 15 days when they were contacted by a fellow
American or some member of the South Vietnamese population as to
the availability of heroin and where they could obtain their source
of heroin.
371
So it is a problem I think that belies any figures given. I agree that
nobody wants to admit he is a heroin addict, but the problem is ram-
pant in Asia, and especially in South Vietnam, and the Army is very
concerned about it.
Getting back to President Thieu, Vice President Ky said he recog-
nized the problem to be of epidemic proportions amongst the troops in
South Vietnam, but he said his hands were tied by President Thieu
in that President Thieu would not give him the responsibility or the
obligation to clean up this problem or at least make an attempt. He
added that were he given the responsibility or authority, he would
make concrete results in 2 to 3 months.
Now, you say that there has been a flurry of activity since my trip
and since your trip.
'r. I am wondering, is there real cooperation on the part of the South
Vietnamese Government or do they simply tell you they are going
to cooperate ? Did you actually see any effort being made ?
Mr. Ingersoll. I didn't see it firsthand, Mr. Murphy, but I am con-
tinuing to get reports that indicate that action is being taken. I will
give you several examples.
One is the transfei'S and movements, the shakeup of their customs
service. Another is that they have now put a qualified individual in
charge of their narcotics control effort on the part of the national po-
lice. This is a measure we have been trying to get them to do for a
year or more. They are increasing the size of the central squad, the
central unit of police, and giving them countrywide freedom of
movement. In the provinces there is activity in terms of developing
localized narcotics expertise. As far as arrests or seizures are con-
cerned, I don't have any indication of what has resulted from this ac-
tivity, yet.
Mr. Murphy. But specifically, Jolm, Soul Alley, or Scag Alley — I
don't know whether you made an attempt to go down there.
Mr. Ingersoll. Yes.
Mr. IMuRPHY. If you talk to anybody over there, they will tell you
there are from 400 to 800 American deserters living in that area. It is
an area comprising four or five blocks and you don't have to be any
great investigator. All you have to do is have two legs and eyes to
guide yourself down there, and you can buy your heroin in vials openly
on the street.
A 9-year old boy offered to sell it to me, and a colleague of mine
from New York, on the Foreign Affairs Committee, Congressman
Halpern, just had his picture in the New York Times actually trans-
acting a sale on the street.
These are the things that lead me to believe we are getting nothing
but lip service from the South Vietnamese Government.
Mr. Ingersoll. Mr. Murphy, I think at the time you were there what
you say may very well have been true, and I am not trying to reduce
or say the problem is not serious, but what I reported to this commit-
tee today is what has happened during the last few weeks. I am in an
uncomfortable position. I am not here taking credit for what has
been done; it all started happening after you were there with Con-
gressman Steele, after Congressman Halpern was there, and while I
372
was there. Your visits probably stimulated a good deal of activity,
themselves.
As far as Scag Alley is concerned, oiir military is placing more and
more locations where heroin is available off limits, and I understand
that there was a sweep through Scag Alley about a week or 10 days
ago.
Chairman Pepper. If my colleague will yield, I think he would be
interested to know how many people have been shot or put in prison
who have been engaged in this traffic.
Mr. Mtjrphy. Well, as John indicated before, Mr. Chairman, I
know they did arrest a South Vietnamese legislator and I think he is
still in jail.
Mr. Ingersoll. Yes. He is still in custody.
Mr. Murphy. But as far as shooting people, I don't think they have
done too much. They would have to talk to the Shah of Iran. He is
a specialist in that.
Chairman Pepper. There are other ways to get rid of them.
Mr. Murphy. Did they ever give you any figures on the deaths due
to overdoses of heroin ?
J. Mr. Ingersoll. They gave me two sets of figures, Mr. Murphy. One
was based on autopsy proven deaths and the other was clinical findings.
Mr. Murphy. Do you have those with you ?
Mr. Ingersoll. I don't have them with me and I can't call them up
at this moment.
Mr. Murphy. Now, getting over to Turkey now, you mentioned
in your question by one of my colleagues here that $3 million have
been given to Turkey. This subject was brought up on my visit to Tur-
key, and unfortunately all those supplies, meaning shortwave radios
and jeeps and the rest of that, stood on the dock for over a year and
have not been put into use because of some type of customs which pre-
vented anyone in Turkey from knowing who had the responsibility to
pay.
So I am wondering if this is an example of the type of aid and
whether you have any suggestions as to how we could bypass some of
this redtape in these countries.
I am not blaming this administration. But I am wonderinsf if you
have any ideas. If we give these people shortwave radios, give them
the tools with which to fight this. The tools did not trickle down to
the people who need them, and until this is so, all the aid in the world
is not going to do us any good.
INIr. Ingersoll. I don't know who told you that stuff was still sitting
on the dock, but it is not. There was a long delay because, for reasons
I can't explain, one part of the government had to pay the customs duty
on the equipment that was coming in, and nobody had an appropria-
tion or authorization to pay this.
Well, eventually the transfer of funds occurred and the equipment
was cleared.
Now, this happened twice. The problem has been resolved and equip-
ment that is going over there now or that has gone over in the past
few months has cleared quickly. But I don't think that any of it had
stayed on as long as a year. It had stayed on for 3, 4, 5 months, which
was more than annoying to us and we made our annoyance known.
373
Mr. Murphy. John, one problem you and I discussed before your
trip was the fact that ex-GI's return to Bangkok and set themselves
up in this opium and heroin trade. One fellow in particular owns the
Five Star Bar and Louufre. I was wondering, do you have anj^ sug-
gestions as to how we would eradicate that problem ? Have you made
any to the President, or are any under consideration ?
Mr. Ingersoll. We had that man in custody in the United States
about a year ago but our agents made a fatal legal error and his case
was dismissed. The problem of ex-servicemen is not only in Bangkok
but also in Okinawa, and we are increasing our investigations there
and intensifying our activities there, too.
Under the new Controlled Substances Act we have a new device
available to us which will permit us to prosecute any person who
manufactures for or causes distribution to the United States while in
a foreign area when he appears in the United States.
We intend to make use of that device for these people when they
come back into the United States or when they are subject to extra-
dition. In the meantime, hopefull3/ we can get the Thai police to prose-
cute for violations that are occurring in Thailand.
Mr. Murphy. In my trip, Mr. Ingersoll, I talked to a lot of your
men, and by the way, before the committee, I would like to compliment
Mr. Ingersoll and his men that he has stationed around the world.
They, in my opinion, do a magnificent job.
One of the problems that I discussed with some of your men, Mr.
Ingersoll, was this problem of the availability of funds to make pur-
chases on the market, and the use of these funds to buy witnesses and
information.
One particular problem was that you had to go to the embassies with
the general consuls around, and if you needed a large amount of
money, this need created a lot of redtape. There was also the fact that
it exposed the particular arrest or buy that they were going to be
involved in and chances of leakage were very great.
Do you have any recommendations you would like to have Con-
gress consider in the form of a special fund, covert fund, that you
could use ?
Mr. IxGERsoLL. I prefer not to discuss that in an open session, if you
don't mind, Mr. Murph3^
Mr. Murphy. I mean just in general terms. I don't mean in specific
terms.
Mr. Ingersoll. We have investigative funds. Congress has con-
sistently, over the past 2 years, increased these funds significantly. I
think we can use more. I am at a point now where I can determine how
to use these funds intelligently. I have to admit that 2 years ago, or
even a year ago, I wasn't as certain about how to use a large amount
of funds intelligently, and I saw no justification to ask the Congress
for vast amounts of money when I didn't know how I was going to
spend it.
Now I think I am at the point where I can use more money and use
it effectively.
Mr. Murphy. Thank you, Mr. Chairman. Thank you.
Mr. Steiger. Mr. Chairman, excuse me, if the gentleman will yield.
I think the record ought to reflect that the gentleman's comment as to
374
the purchase of Avitnesses — I suspect what the gentleman meant was
any expenses involved.
Mr. Murphy. I meant to say "informants." I wish to correct the
record.
Mr. Steiger. Thank you.
Chairman Pepper. Mr. Keating ?
I^Ir. Keating. Thank you, Mr. Chairman.
Mr. Ingersoll, earlier you indicated that the people who sell heroin
go to those who have already been using marihuana. I may not have
quoted you accuratel}^, but I got the distinction — they seem to be the
best source of potential heroin users. Is that correct ?
jSIr. Ingersoll. No. That isn't what I meant, Mr. Keating. What I
was describing was an environment where marihuana had been widely
used with little interference, few sanctions. The point is that this is
an environment of people who are highly susceptible to drug abuse.
There is a reputation of susceptibility to drug use that Americans are
getting around the world. "\^nierever our young people go, their acces-
sibility to illicit drugs is not only guaranteed but they are helped to
get to them by the traffickers.
What I am saying is that when there is a tolerance for the use or
the abuse of one drug such as marihuana, and it is widely known, then
there are people who deal in other drugs who are going to try to
exploit the market, and the market is there. This is a national problem,
not just one of Vietnam.
Mr. Keating. All right. Well, that is the point I was trying to make
and I didn't say it as well as you.
Now, would that hold true in the United States, too ?
Mr. Ingersoll. I am satisfied that it not only will hold true, but it
has held true.
Mr. Iveating. So tliat where there is an environment of the use of
some drug, including marihuana, it provides an area that is suscepti-
ble to
Mr. Ingersoll. I think it is very obvious from our experience during
the last 10 years that people — even the use of marihuana has expanded
tremendously, explosively. We are all bothered and debating whether
we should legalize it, or not. There is nobody who can make an un-
qualified scientific judgment as to the harm or the lack of harm that
attends marihuana consumption. And while we are in this state of flux
and indecision, what is happening? People are not just using mari-
huana. Over the last 5 or 6 years they have gone to hashish, the resin
of the cannabis plant that some people say is 5 to 10 times stronger per
unit than the marihuana that was previously used. We have seen a
tremendous increase, as the chairman and others have pointed out, in
the use of heroin. Heroin was once confined to specifically identifiable
segments of our society. Now it is everj'whei-e. We have seen the in-
creased abuse of other drugs such as LSD. We have seen the increased
abuse of stinmlants and the depressants, and wo have a society of drug
abusers here. And every illicit drug entrepreneur around the world
has tried to exploit this.
Mr. Keating. That is precisely tlie point I am trying to make. And
those, if I could extend what you are saying, who then tolerate
the use of marihuana are creating, in effect, a greater problem in drug
abuse in this country.
375
Mr. Ingersoll. I think so, because marihuana is an agent of drug
abuse.
Mr. Keating. Do you have any idea how long we tolerated the use
among the members of the armed services in South Vietnam — ^^prior to
getting to this point, as you indicated, 15 months ago — of the use of
white powder heroin ? I don't have to know precisely, but
Mr. Ingersoll. My first trip to Vietnam was in 1968, the fall of
1968, and the use of marihuana was widespread at that time.
Mr. Keating. And was this tolerated by the armed services for too
long and to too great an extent which led to the use of heroin or built
up the enviromnent in which heroin then became part of the problem ?
jNIr. Ingersoll. Mr. Keating, I don't want to be pvit in the position
of using hindsight as to the military problems, and I am not going to
sit here condemning the way things were done in the military. It
is obvious that the military had many other problems in Vietnam in
addition to this.
But I do think, on the basis of hindsight, that more direct and
more effective action might have been taken against marihuana when
it was just a small problem. Marihuana was not a problem among the
Vietnamese ; the American troops provided the market for marihuana.
Had it been dealt with forthrightly at the beginning, perhaps
we could liave avoided the difficulties we are having today.
Mr. Keating. I agree that it is easy to have hindsight in these mat-
ters and what is past is past, except we have to build for the future
on what has transpired before, and the fact is that we ignored the
problem for too long and didn't understand what potential was cre-
ated by the use of marihuana in these areas.
I think that sums it up really.
Now, especially in an area where there is some control exercised and
capable of being exercised over the men in the service and in South
Vietnam, the Army can control its men to a large extent and what
comes in and out of camps.
I would like to move on, if I can, to another area. Enough has been
said, I think, regarding the pressure on these governments.
T\niat concerns me is the feeling of sensitivity toward the feelings of
some of these countries. I have been placed in two situations recently
where I have asked why our country has not taken a public position
with respect to Turkey and with respect to some of these other coun-
tries, why we are so concerned that we can't take a public position on
their exercising greater restriction over the illicit flow of drugs within
Turkey. And all I get is a, well, we can't do that. We have to be con-
cerned about their feelings.
They say we will try and work in other channels. But I thinJc the
progress that we have made in areas like Turkey has not been suffi-
cient, and this is — I think you have done an excellent job here today
and I think you have done an excellent job in your Department and
don't for 1 minute consider this a criticism of you — but I think the pol-
icy statement of our country" should be that Turkey is a great source
of supply and condemn them for it.
Estimates will run anywhere from 50 to 80 percent, and T agree with
you it is difficult to pinpoint it. But it seems to me that if the United
Nations is sensitive, if the State Department is sensitive under different
376
administrations to publicly say we want Turkey to stop this, then they
shouldn't be.
Now, we all talk about it, but is there such an official position ? I have
been told that there is not.
Mr. Ingersoll. The position is quite clear, Mr. Keating, and I can
make my point by quoting from a statement I made in January of
1970, before the United Nations Commission on Narcotic Drugs, where
I said :
We should all look forward to the day when opium is not needed at all, and
we urge WHO to bring this possibility into sharp focus as a vital issue as soon as
possible.
The Government of India has previously stated that opium production is barely
profitable and probably not of real economic value to the country. Surely this is
also true in Turkey where, in comparison with the Turkish economy as a whole,
poppy cultivation is of negligible importance. Legal exports of opium earned only
1.7 million U.S. dollars in foreign exchange for Turkey in 1967, or only one-third
of 1 percent of all its export earnings. The total income to Turkish economy,
including exports, internal distribution, and poppy seeds, probably does not exceed
5 million U.S. dollars.
Further, the importance of poppies to the individual farmer in Turkey does
not appear too significant in view of the cash component of his total income. It
is estimated that the average income per farm in Turkey is about $1,000 per year
whereas the average income to farmers derived from poppy growing is only about
50 U.S. dollars per year.
I have singled out Turkey only to illustrate what must surely be the condi-
tion in other opium-producing countries. Most certainly the social consequences
of continuing opium production far exceed either the medical or economic advan-
tages of having it available. Halfway measures will not suffice.
This statement was criticized for 3 or 4 weeks during the Commis-
sion meeting after that, but this is the position that we are taking with
respect to Turkey and other countries which we have consistently held
for over a year, at least.
Mr. Keating. I recognize that in Thailand and countries like that
they have areas that the Government can't control, but I don't believe
that is true in Turkey, and I think Turkey can control a great ma-
jority of its product and it just seems to me that wc ought to be
carping away at Turkey and those countries which can control it.
They can do a job like India and Russia, and buy in the crop and do
things like that, and I don't see why we don't keep telling th.em to
do it. I compliment you on the statement you made.
I would like to have seen it stronger. I am sure you got a lot of
criticism for it, even as it was. It was nicel}^ said and I don't think
I would be quite as nice.
But I do think we ought to apply public condemnation, wc ought
to apply economic measures because we are talking about our national
interest, and our national interest is in the youth today, and unless we
pursue this strongly and firmly with the foreign countries, I think we
are not really performing a service for our country.
They always feel free to condemn the United States and I don't
think wc should be so nice about the problem. I know I am making a
statement instead of asking questions.
How many clinics are there dispensing methadone in the United
States today ; approximately ?
Mr. Ingersoll. 275, Mr. Keating.
377
Mr, Keating. Are sufficient precautions being taken by these clinics
prior to the entry of people into the methadone programs? Are the
individuals being checked out carefully enough ? _
Mr. Ingersoll. The ones who arc complying with the law are taking
adequate precautions. There are cases of individual practitioners who
are prescribing methadone under a justification that it is a doctor's
pri\'ilege to prescribe what he thinks is best for the patient at hand,
notwithstanding our guidelines or other medical judgment. A good
deal of diversion is occurring because of loose prescribing practices by
people who are not operating within the framework of the guidelines.
Unfortunately there are some large, almost what you could call
"methadone mills" operating in some areas, and many of these are
operated by doctors. In one case we have presented a request for crim-
inal prosecution against a doctor. The prosecutor has not yet accepted
the case. I might add that this individual finally has stopped running
a methadone operation and has moved to another part of the country.
We have another case under investigation which will be presented
for prosecnition in the very neai- future, where huge quantities of this
substance are doled out to practically anybody who comes in and asks
for it. Under the new regulations we can control diversion from those
methadone clinics and at the same time permit them to operate within
the framework of the law.
Mr. Keating. Are there many operating outside of the framework
of the law, aside from individual physicians ?
Mr. Ingersoll. This is hard to say. There are some who in the
past have had investigational new drug applications but who have
not followed established protocol standards, and in these cases, noAv
that we have the regulatory authority to deal with them, we are con-
ducting investigations of their activities. In conjunction with FDA, if
they don't comply with the regulations, then their authority to engage
in this kind of activity will be revoked.
Mr. Keating. Has the medical association, on a national scale or
local scale, taken any position on the use of synthetic drugs?
Mr. Ingersoll. No, sir. They have not issued any policy statement.
I understand that the matter is under consideration at this time with
regard to the medical association.
Mr. Keating. Isn't this an area that they should be taking the lead
in, or encouraged to take the lead, medical practitioners?
Mr. Ingersoll. Certainly they are the ones who are going to have
to convince the medical practitioners as to the desirability of using
substitutes.
Mr, Keating. Now, one more comment on an observation you made
which I think is excellent. In effect you said law enforcement is just
as good as people want it to be, and I am a firm believer in that, and
when the people speak up and support the law enforcement officials
in this area, and w^e recognize what you said earlier about marihuana
]3roviding- the environment for which we expand the use of drugs,
then I think we are going to, in this country, make real progress.
It is true in law enforcement generally, but it is especially true
in this area. I commend you for your comments and thank you for
your participation.
378
Chairman Pepper. We will take a temporary recess and go over
and answer the quoiTim call, and then come back and resume Mr.
Ingersoll's testimony.
(A brief recess was taken.)
Chairman Pepper. The committee will come to order, please.
Mr. Rangel.
Mr. Rangel. Thank you, Mr. Chairman.
Mr. Ingersoll, the responses I have received since I have been down
here, from the Office of the President, the State Department, the
Attorney General, and the Office of the Federal Bureau of Investi-
gation, indicate that your Bureau has the responsibility for stemming
the illicit flow of drugs into the United States. Is that a fair descrip-
tion of your responsibilities and that of your Bureau?
Mr. Ingersoll. We have the primary responsibility and, of course,
the Bureau of Customs has responsibility at ports and border crossings.
Mr. Rangel. You say you have 1,500 agents?
Mr. Ingersoll. No, sir. About 1,300 at this time.
Mr. Rangel. How many of these agents are assigned to foreign
countries in connection with the international traffic?
Mr. Ingersoll, Of the agents, 61.
Mr. Rangel. Of those 61, roughly 15 will be assigned to Southeast
Asia?
Mr. Ingersoll. At this tim.e ; yes, sir.
I should point out also, Mr. Rangel, that we also have responsibility
for controlling domestic traffic on an international level, as well. So
most of our personnel are stationed within the United States.
Mr. Rangel. Well, let us talk about your domestic responsibilities.
When I was prosecuting narcotics cases in the southern district of Xew
York, I found that upward of 80 percent of the cases made by the
Federal Bureau of Narcotics under the Harrison Act were addict
pushers that were convicted in our office. Is that basically the same
today ?
I might add, in addition to that, that they were black and Puerto
Rican.
Mr. Ingersoll. That is not true today, sir.
Mr. Rangel. So that if the major responsibility that you have is the
internal flow of narcotics into this country, and you are restricted to
61 agents for the international trafficking of drugs, and the President
of the United States says that your agency has the sole or the primary
responsibility, let us see what we are talking about when you try to do
your job to prevent the inflow of narcotics into the United States.
Number 1, is not your Bureau restricted in what it can do or say
by the U.S. State Department ?
Mr. Ingersoll. I am not sure I understand that question.
Mr. Rangel. Well, in your international travels for the purpose of
restricting drugs from flowing into the United States, you have the
opportunity to deal with political leaders of ceitain states, and isn't
the extent of any agreements that you can enter into restricted by our
State Department ?
Mr. Ingersoll. Certainly the State Department has input in any
agreements that we reach ; yes.
Mr. Rangel. Let me put it another way: Do you have by law or
policy any power to enforce any agreement with any foreign power?
379
Mr. Ingersoll. I am not at all sure that I understand your question,
Mr. Rangel.
Mr. Rangel. I will rephrase it.
Mr. Ingersoll. All right.
Mr. Rangel. I am concerned that when the President of the United
States says there is going to be a national effort to stop the inflow of
drugs into the United States and then they go further and give this
responsibility to your agency as to whether or not they have also given
you the power to do anything about the international trafficking of
drugs, and I see nothing in the law which empowers you to enter into
any type of treaties or to apply any economic sanctions with the heads
of any State.
Mr. Ingersoll. "When I am dealing with officials of foreign govern-
ments, I am acting as a representative of the President of the United
States.
Mr. Rangel. Now, as it relates to the Department of Defense, in in-
quiries that were made of you, you are unfamiliar even with the drug
addiction problem as it exists within the military and this properly
falls wdthin the Department of Defense ; is that correct ?
Mr. Ingersoll. I am not personally intimately acquainted but T
have people on my staff who are well acquainted with the problem in
the military.
Mr. Rangel. But in connection with your primary responsibility of
the internal flow of narcotic drugs, this responsibility is somewhat
sliared by the Department of Defense as relates to the military ?
Mr. Ingersoll. Yes. I would say that the control of drugs is shared
in more w^ays than just that in the United States.
i Mr. Rangel. And as it relates to the CIA, they, too, have a responsi-
bility to investigate the international flow of drugs ; don't they ?
Mr. Ingersoll. They have no statutory responsibility that I am
aware of. However, they do cooperate with us and provide a great deal
of information about international traffic to us.
Mr. Rangel. Now, how can you generalize the impact of the CIA
information w^hen Ramparts magazine. Congressmen Murphy and
Steele, and your personal trip over there were really the source or the
reasons why there has been some movement by the South Vietnamese '?
Mr. Ingersoll. I don't know that. I am not that familiar with CIA
operations, and I just couldn't answer that question.
Mr. Rangel. Well, I have a letter from the CIA which indicates that
they have a very close— actually CIA has for some time been this Bu-
reau's strongest partner in identifying foreign sources and routes of
illegal trade and traffic — in other words, it seems to be from your
agency as well as the CIA that there is a very close relationship "^that
exists, as it relates to the international trafficking of drugs.
Mr. Ingersoll. There is a close relationship in terms of sharing in-
formation and moving information back and forth, but I am* not
familiar with either the authority or the policy or the practices of CIA
m terms of influencing other goverimaents. But as far as operational in-
formation is concerned, the letter is precisely accurate.
Mr. Rangel. Yet you believe, as you testified, that Congressmen
JMurphy and Steele's visits, coupled with your visit, was probably the
motivating factor of having any reaction to the drug traffic as it relates
to South V letnam ?
380
Mr. Ingersoll. No. I don't recall sajdng that, Mi-. Kangel. I said that
they were part of the motivating factor. I think that our Ambassador
Bunker, for example, in Vietnam, has probably been the major ener-
gizer, as far as that operation there is concerned. Our embassies have
the responsibility for carrying on U.S. policy in foreign countries.
_ Mr. Eangel. Well, then, that would be by far the most severe restric-
tions of the responsibilities of the Federal Bureau of Narcotics and
Dangerous Drugs ; would it not ?
Mr. Ingersoll. Mr. Rangel, the Bureau of Narcotics and Dangerous
Drugs, aside from myself as the U.S. representative to the U.N. Com-
mission on Narcotic Drugs, is not involved in negotiating with foreign
governments agreements to develop a policy as to whether, for ex-
ample, opium is going to be produced or not going to be produced.
Our people are over there to work with those governments in a vari-
ety of modalities. One is to train the police, to assist in their training.
to provide them information which will improve their operations, to
assist them in their operations. But we have no unilateral or separate
authority in a foreign country to enforce the law of that country and
our presence there is to protect the interests of the United States as
best we can with the limited resources we have, and with the restric-
tions that are placed upon us by the foreign government concerned.
Mr. Rangel. Now, that satisfies my questioning — as to the impact
that you could possibly have on any host nation.
Now, as it relates to your domestic responsibility, you have recently
increased your number of agents from 500 to roughly 1,300, 1,500, and
at the same time the drug addiction population has exploded thousands
of times in the last 10 years. So that it is safe to say that no matter how
many men you have, that you will not be able to decrease the amount of
drugs that is coming into the United States at the present time ?
Mr. Ingersoll. I can't completely agree with that — with the conclu-
sion of that, but I agree, and as I said before, that law enforcement by
itself without support of other programs is not going to solve the
problem.
Mr. Rangel. We are not talking about the socioeconomic programs.
I am merely talking about patrolling our borders and stopping the im-
portation of drugs into these United States. Certainly the doubling of
men, almost tripling of men, has had no evidence of a decrease in
importation.
Mr. Ingersoll. Let me point out, sir, that doubling or almost tri-
pling has occurred only in the last 2 years. During the period up until
1968, the old Federal Bureau of Narcotics only had 30 more people
than it had in 1960. Between 1960 and 1968 the money that was pro-
vided to the old Bureau of Narcotics increased at a rate of less than
1 percent per year, and as you have just said yourself, this is when
the explosion in drug abuse occurred in this country. We are doing
our best right now to catch up with a problem that was ignored for
decades.
Mr. Rangel. Mr. Ingersoll, believe me
Mr. Ingersoll. And I think law enforcement hasn't been given the
opportunity to demonstrate what it can do, given the necessary re-
sources, given the support, and all of the other things to go into effec-
tive law enforcement programs.
.381
-,,, Mr. Rangel. Please, I am not trying to be critical of the efforts, the
terrific efforts and gains that have been made by your limited police
force. My real question is : Is it fair for me to assume that a 1,300- or
1,500-man force, assuming they are split up into tours and duty, will
have any possible deterrence on the importation of drugs into the
United States ?
Mr. Ingersoll. I think that remains to be seen, and I am sure that
a 1,300-man operation by itself will not, but in addition to that, in the
last couple of years we have trained tens of thousands of other police
officers who had absolutely no knowledge of drug control techniques
at all before that. We have assisted governments of other countries, in
their efforts to develop their own domestic and international opera-
tion. What I am trying to say, Mr. Rangel, is that these things have
just started, in fairly recent times, and we are tiying to catch up with
a problem that is practically engulfing us.
Mr. Rangel. What I am trying to say, Mr. Ingersoll, is : the Presi-
dent of the United States has promised in broad terms a national of-
fensive against drugs being imported into these United States.
And certainly the American people are anxious to hear that we do
have a commitment against this.
However, we are restricted in extending credibility to the remarks
made by the President, by your testimony, which indicates that as of
the present time you have no international powers; first of all, that
your agency has the prime responsibility of preventing drugs from
coming into the United States and we all recognize the international
restrictions that your Bureau would have.
Second, that you have a very limited amount of men that are on
duty, 61 in foreign countries, with no powers. You have 1,300 men on
duty in this country and certainly we don't believe that they have the
tools to work with to do any more than just make a dent in the im-
portation of drugs, just make a dent, and it seems to me, and I don't
know whether you agree, that unless we can have more executive
power being used against these nations, that there will not be an all-
out offensive against drugs being imported into the United States.
Mr. Ingersoll. Mr. Rangel, it is fair to say that we could use our
resources and our assets more productively and in a more positive
way, and this is one of the areas that we are presently exploring.
But let me tell you what the 61 men have done so far this year. They
have, with foreign authorities, seized over 2,000 pounds of opium, over
1,500 pounds of morphine base, which is the equivalent of 15,000
pounds of opium, 15,000 pounds of opium, sir, 220 pounds of heroin,
130 pounds of cocaine, 27,000 pounds of marihuana and 7,902 pounds
of hashish. That is what those 61 men have been able to accomplish
in collaborating with foreign police agencies and I say that they
have done a pretty good job.
Mr. Rangel. I would say they have done an outstanding job.
Mr. Ingersoll. In addition to that, in the first 6 months of this year
they participated in the arrest of 113 major international traffickers
outside of the United States.
Mr. Rangel. I am not questioning the tremendous job that is being
done with your limited force. What I am really questioning is whether
or not your agency as it presently exists, with its restricted power
60-296 — 71^pt. 2 4
382
can fulfill the vow made by the President of the United States last
night.
Mr. Ingersoll. I don't think that pledge was made in a vacuum, Mr.
Bangel. I think it was made with the intent to develop the capability
of carrying it out.
Mr. Rangel. But this could not possibly be done with the restric-
tions presently placed on your agency.
Mr. Ingersoll. Let me point out to you, sir, section 503 of Public
Law 91-513, subsection (b) , which says :
When requested by the Attorney General, it shall be the duty of any agency
or Instrumentality of the Federal Government to furnish assistance, including
technical advice, to him for carrying out his functions under this title.
I think that we have the potential in law to get the job done.
Mr. Rangel. That you can enter into an enforceable treaty relation-
ships with offending nations ?
Mr. Ingersoll. We have already negotiated a treaty, a protocol
agreement, with France, at the police level. My agency and the French
Surete have entered into an agreement which was signed respectively
by the Ministerior of Interior of France, and the Attorney General
of the United States, that formalizes a process which has gone on for
years, to exchange information, to exchange personnel, and to cooper-
ate in every possible way.
The protocol defines the authority that our people have in Franco,
the authority their people stationed in the United States will have. I
have the authority to enforce that treaty. This is the first agreement to
my knowledge that has ever been made between law enforcement agen-
cies of two different countries to enforce laws.
Mr. Rangel. Tell me, please, how you could enforce that treaty,
Mr. Ingersoll. How can I enforce the treaty ?
Mr. Rangel. Right.
Mr. Ingersoll. Because the responsibilities or obligations are placed
on both parties, both signatories to the agreement.
Mr. Rangel. If a foreign nation breaches this treaty agreement that
has been entered into by your department and their similar depart-
ment, how do you enforce it ?
Mr. Ingersoll. How do you enforce a breach of any treaty, any
breach of a bilateral treaty ? You complain about it. What can you do
beyond complain? In a bilateral treaty you can't carry it — or perl^aj:)?,
maybe you could carry it — to the International World Court of Jus-
tice, depending upon the provisions used to negotiate treaty infrac-
tions, but this is not my field and I just can't answer your question.
Mr. Rangel. I thought the Congress had the powers to advise and
consent on international
Mr. Ingersoll. This is not that land of a treaty and I can't give
you the technical details oft' the top of my head as to why we didn't
have to go to the Senate, but I know that we were not required to do so.
Mr. Rangel. My last question is that it seems as though there has
been some difficulty in identifying the illicit production of poppy crops
throughout the world. Is there a problem there of identifying these
poppyfields.
Mr. Ingersoll. I am not aware of any difficulty. Tlie poppy, even
before the flower blooms, has a very distinctive color that readily
distinguishes it from other vegetation in the area.
383
, Mr. Rangel, Will your Bureau have information as to where the
major poppyfields are throughout the world ?
Mr. IxGERSOLL. Yes, sir.
Mr. Raxgel. That means that you always did have the information
that Congresman Steele and the rest brought in their dramatic report,
that this information was already within your de-v\rtment.
yir. IxGERSOLL. I think, certainly, the locations of poppy cultivation
have been well-known to the U.S. Government for years. And to the
United Xations, I might add. No question about that.
Mr. Raxgel. I have no further questions.
Chairman Pepper. Mr. Murphy.
Mr. Murphy. Mr. Ingersoll, speaking about the United Nations and
Interpol in particular, do you think that we could gain anything by
contribution to Interpol ? When I was there they had a filing system on
various people who have been arrested and tried. Now, they said they
would like to have the United States contribute more to this and put
the filing system on some kind of IBM computer.
I am just wondering whether you, as a professional policeman, feel
there is anything to that suggestion? Should we be more active? We
dont" even have radio communication with them as other nations do.
Mr. IxGEP^OLL. Well, ]Mr. Murphy, Interpol is, first of all, contrary
to the myths that have developed around it, only an information col-
lecting organization.
Mr. MuPiPHT. Only an information center.
Mr. IxGERSOLL. its techniques are aimed at servicing the least
equipped client countries, and when I first went to Interpol I saw
the same file that you did. I saw their Morse code systems. I suggested
that they use computers and that they use more modern communica-
tions facilities, and the response that I got was, "we can't do that be-
cause then these underdeveloped coimtries won't be able to communi-
cate with us."
So they have persisted in using equipment that is extremely primi-
tive by today's standards. What good a computer would do them, I
don't know,
Mr. ]MuRPHY. Tell me this : Has your Bureau received an^^ informa-
tion from Interpol that has led to an arrest or helped in a conviction
on this international drug traffic ?
Mr. Ix'GERsoLL. Yes, indeed. My office in Paris is the primary liaison
with Interpol, and since we have an office located right next door to
Interpol, this is one of tlie reasons, over the years, why we haven't tied
into the communications system in a large scale. But we, do receive
messages from Interpol which assist our operations, primarily in
Europe.
Mr. Murphy. Mr. Ingersoll, taking Mr. Rangel's line of question-
ing, I think what he was trying to say and what I will try to say in this
question, is that we in the Congress want to know in what way we can
aid your Bureau and yourself in the job you are doing. Wliat can the
Congress do to help in this battle to stem the tide of this heroin
addiction ?
That is our function here. We want to do it and we want to hear from
you if you have any suggestions. We want to be helpful.
Mr. Ingersoll. I know you do, and I know that this was the senti-
ment behind Mr. RangePs cpiestion, but I am afraid at this time I
384
have to give you the same answer I gave Mr. Waldie. I will be very
happy to discuss these matters with you in executive session but as
you well know, I work for the executive branch of the Government and
my activities properly have to be cleared through people that I work
for.
Mr. Murphy. Well, I am of the opinion that this is such an impor-
tant problem in the United States, Mr. Ingersoll, that I say to my col-
leagues and the chairman that I think your position within the Coun-
cils of Government should be raised to a level of almost Cabinet
strength because it is such an important question today. •' ' ■ •
Every time I go home and I know every time Mr. Range! and Mr.
Brasco go home, we are constantly besieged by mothers and people af-
fected by these drugs.
So I think if I have any recommendation, it is that the President,
take this into consideration in his designation of your office and ele-
vate it to the importance it deserves.
Mr. Eangel. I would like to share in tliose remarks. Mr. Chairman,
and I am glad that Mr. Ingersoll did recognize the primary thrust that
I have in that in dealing with the Federal Bureau of Narcotics
Mr. Ingersoll. Narcotics and Dangerous Drugs now, Mr. Rangel,
please.
Mr. Rangel. It appears notwithstanding these newly created treaty
powers that you have, that it is not on that level of Government com-
mitment that it should be on. And, Mr. Chairman, if I could just ask
one question to clear up a question that was asked by Congressman
Sandman, and I will be finished.
There seems to be, in your testimony, a direct connection between
the use of marihuana or the condoninof of marihuana and also the ad-
diction to hard-core drugs, and early in your testimony you indicated
that those of us that either come from or represent inner-cities have
been asking for more national attention to be focused on the druc
problem.
Would you agree that in communities such as Harlem and Bedford-
Stuyvesant that we have not and never did have any major marihuana
problem, but, in fact, it is a hard-core drug community and our drug
addicts don't go through the trips that other communities may have
suffered ?
ISIr. Ingersoll. Well, I think, in sreneral, that is quite accurate and,
of course, I also think that we ought to point out that the problem in
Harlem and Bedford- Stuyvesant issued from different causes and has
been endemic in these areas for manv, many, many years. TNHiat I am
trying to do in contemporary terms is place the problem in its present
perspective. Basicall3^ that is, that if you have a society or a group that
demonstrates its susceptibility to drugs, then you are going to have
people who will exploit those people, and you can't correct this prob-
Ipm bv just going down one avenue of approach. If we haven't learned
this alreadv, we certainly should do it soon, and begin to fully deal
wi*^h the problem on several levels and several fronts.
The CriATRMAN. Mr. Brasr>o, did you have a question ?
Mr. Brasco. Yes; I did have one last question of ISIr. Ingersoll.
385
As I understood you to say before, Mr. Ingersoll, you and your De-
partment have a division which is doing some research work ; is thafj
correct ?
Mr. Ingersoll. That is correct ; sir.
Mr. Brasco. And I understood you also to say that you are working
on some substance that might possibly be used to immunize people
from the effects of na rcotirs.
Mr. Ingersoll. We ai-e in a ^^ery preliminary stage of investigating
that possibility.
Mr. Brasco. You know, listening to the dialog here, and I think
that yon ai-e al)solute]v I'ight, in terms of having to attack this on
various levels, but I kind of suspect that the difficulty that we have
here, controlling the supply and the traffic, is only magnified when we
try to get involved in foreign countries.
I am not saying that we shouldn't do that. But it comes to the
question that has always been disturbing me, as to whether or not
we are doing enough in this research area.
Several witnesses have appeared before this committee and have
touched on the research area with methadone, and briefly in terms of
the fact that there may be in the wind some prospects of getting a
longer lasting drug other than methadone.
Now you talk about immunization, and I am wondering, are we
doing anything in this area of research or is this another one of those
late start areas ?
JNIr. Ingersoll. I think that is correct ; yes, sir.
Mr. Brasco. A late start area.
Mr. Ingersoll. Yes.
Mr. Brasco. Well, let me ask you this, then. It would seem to me
that one of the things that you are talking about, immunization,
should be the star emphasis of this or any other administration. I
am wondering what your resources are to follow that program that
you speak of.
Mr. Ingersoll. It is not really within our sphere of responsibility to
do it. We are just trying to examine the proposition in a preliminary
way to see whether it has any possible merit.
Mr. Brasco. Well, is anyone else doing it that you know of ?
Mr. Ingersoll. Not to my Imowledge.
Mr. Brasco. I am told, by our counsel, that the National Institute of
Mental Health is doing something.
Mr. Ingersoll. I was just told that we are working with one of
their employees — one of their staff people.
Mr. Brasco. Do you have any idea what that budget is, in dollars
and cents ?
Mr. Ingersoll. For this particular project?
Mr. Brasco. Yes.
Mr. Ingersoll. It would be miniscule at this time because again, it
is something we have just started examining in the last month, 2
months.
Mr. Brasco. Let me ask you one other question. Is there a possi-
bility of developing some type of sensor or sensitive equipment that
could pick up drugs as they come across the border?
Mr. Ingersoll. We are working on such a development at this time.
386
Mr. Brasco. But that is another late-start deyelopment? ' T ^A
Mr. IxGERSOLL. It is another late start. !^i"'-i
Mr. Brasco. "With no money.
Mr. IxGERSOLL. No ; I wouldn't say that, sir.
Mr. Brasco. Or little money.
Mr. Ingersoll. We have put quite a bit of money into this. Affain,
we are getting off into an area that I can't discuss openly, primarily
because I don't want to let everybod}^ on the other side know what
we are doing. But it takes time to develop these things. T^nhiether you
put a lot of money in or a little bit of money, you can onh' buy a certain
amount of brainwork, and this is essentially what we are dealing with.
However. I can report that we are in the pilot test phase of one of
these kinds of defaces at this time.
Mr. Brasco. I would think that that would be the saddest situation
of all, if in this country we couldn't — and I just can't believe that we
can't — develop the necessary scientific knowledge to beat this problem.
I know it is difficult to put all the pieces together at one time, find
the necessary brainpower and the necessary money to go headlong
into a crash program to try to come up with something that is more
effective than what we have at the outside now: methadone.
!Mr. IxGERSOLL. I can assure you, Mr. Brasco. that we know wliat
the technology is or the theory is involved in this and we have pro-
duced an instrument. It is being pilot tested now. It has proven to
be very successful. It is a very large thing and we have got to be able
to reduce it, miniaturize it, so it can be a more practical tool.
Mr. Brasco. One last thing. I noticed in your testimony you spoke
about methadone getting into the streets. I wasn't concerned about
the statistics at this point. When it is brought into the street, it is not
used orally, is it; or is it used to shoot up, as one would use heroin?
Mr. IxGERSOLL. It may be used in any way. It depends upon the
form it is in. If it is in tablet form, it will probably be dissolved and
shot.
]Mr. Brasco. That is exactly what I mean. It would seem to me if
one was taking it orally, you don't get the same effect as you do from
taking it intravenously.
Mr. IxGERSOLL. That is right.
Mr. Brasco. And orally would indicate to me an addict wanted to
taper off and that puts him, I would think for practical purposes, in
a much less-harmful position toward society than if he is using it
intravenously. Why can't we just make it in such a form that it can't
be shot up ?
]Mr. IxGERSOLL. Since methadone also has therapeutic utility as an
analgesic, it is manufactured commercially not only for withdrawal or
maintenance programs, but also for other treatment purposes.
Mr. Brasco. So that you are saying we do need the tablets ?
Mr. Ingersoll. May Dr. Lewis respond to that ?
Mr. Brasco. Yes.
Dr. Lewis. I think one of the major manufacturers of methadone has
evolved a tablet which is very difficult to dissolve, so that for injectable
purposes, that particular tablet would not be acceptable to the addict
who wants to inject.
387
Mr. Brasco. Well, as I understand it, Doctor — you stop me if I am
Avrong — the substance that is used to drink, the orange juice, the
oral that you drink, that if you tried to reduce that to liquid it becomes
gummy, so that type you can't shoot up. But it would just seem to me
that the tablet should be able to be produced in the same way if we
even need a tablet.
It seems to me, at this point, the hearings have only indicated to
me that the only need for the tablet is one of convenience, so that
rather than one carrying eight bottles around for an over-the-weekend
supply, they take the tablets.
Now, I am not aware that the tablets are used for any other pur-
pose, other than one of convenience, and if that is the only purpose,
I would think we should do away with them, if that is causing a
problem in the streets.
Mr. Ingersoll. Well, as far as the maintenance programs are con-
cerned, our regulations and FDA's protocol require oral adminis-
tration under close supervision. The use of tablets or liquid that can
be used for injection is not allowed. The methadone being prescribed
by these physicians that I talked about earlier, who are operating
outside the scope of the guidelines can be used for injection.
Their traditional attitude is that the Government can't dictate to
tliem how to treat their patients or how to prescribe to their patients.
Mr. Brasco. Is there a legitimate use for these tablets at this point ?
Can't we just outlaw them or prevent them from being manufactured ?
Mr. Ingersoll. I would like Dr. Lewis, again, to give a medical
clarification on that.
Mr. Brasco. This is one of our problems. We are manufacturing these
things now.
Dr. Lewis. The prime use of methadone has been for analgesia. It is a
milder analgesic than some of the others we have, but it is effective.
It has an antitussive effect to reduce irritative cough, and in sirup
form it is especially good for that. The old-fashioned manufactured
tablet still has some value. It does have insipients in it which, if an
individual dissolves it and injects it, makes him likely to have some
untoward effects.
Mr. Brasco. But wouldn't we be better off — when you measuie the
benefits the tablets have, as opposed to its defects when it goes into
the streets and is shot intravenously — wouldn't we be better off with-
out the tablet ? I mean if it is just used for colds.
Dr. Lewis. I think as far as the street form of the problem is con-
cerned, we w^ould be better off without any form suitable for injection,
whether it is an individual tablet or Tang suspense or lime juice sus-
pense or something of that sort.
Mr. Brasco. But you say we can do that.
Dr. Lewis. Yes.
Mr. Brasco. Get a form that is not capable of being injected?
Dr. Lewis. Or virtually incapable.
Mr. Brasco. Thank you. I have no further questions.
Chairman Pepper. Mr. Ingersoll, just a question or two.
What percentage of the heroin that comes into this country would
you say comes from the laboratories of France ?
388
Mr. Ingeksoll. Well, that is the same kind of question, Mr. Chair-
man, as what percentage comes from Turkey. Again I am going to
say that the overwhelming majority appears to come from that source.
Chairman Pepper. We had testimony this morning that some 1,100
people in the city of New York die every year from heroin. You said
at least a majority of that heroin comes from the laboratories of
France. Now, then, that is almost 100 New York City residents a
month who die from that substance.
Now, if some people with evil minds had some of these movable
rockets that they use over in Vietnam, and they go around over France
and every day shoot some of those rockets, landing in New York City
and kill on an average, let's say, about three or four people a day,
about 1,100 people a year, you can imagine what public opinion in
this country would be demanding of the French Government to stop
that sort of thing.
If they didn't do it, we would see if we couldn't find some way to
stop it, ourselves.
Now, I would like to ask you, in view of your reference to the agree-
ment that has recently been negotiated with the police of France,
how many police, how many law enforcement people are trying to
break up these laboratories from which this heroin comes to the United
States in major supply? How many police officers does the French
Government have committed to doing that, to stopping it?
Mr. Ingersoll. At this time, may I give you a historical perspective ?
Chairman Pepper. Yes.
Mr. Ingersoll. A year and a half or so ago, when I testified before
you the last time, they had, as I recall 16 or 18. Today there are about
100 French police engaged in international traffic control.
Chairman Pepper. One hundred.
Mr. Ingersoll. Practically.
Chairman Pepper. At least that is a step up. They started off with
a lower number. They extended it to 100.
Mr. Ingersoll. It is not quite 100.
Chairman Pepper. Now, France is a big country and a powerful
country and they have a lot of assets. Don't you think we would have
a right to ask a "friendly country like that, from which was coming a
substance that is killing so many of our people and costing us so much
money, that they put more than 100 people to helping us keep these
laboratories from spilling out, spewing out so dangerous a substance
to our country ?
Mr. Ingersoll. We have the right to ask the government in any other
country around the world to do things that we would like them to do.
Chairman Pepper. Well, it would seem to me we would be justified
in being very insistent, if they want to be our friends, that they take
the emergency measures.
Now, the President is talking about an emergency program and we
hope the President is going to implement that, an all-out fight on
trying to do something about heroin to stop the terrible tragedy that
our country is experiencing from heroin, and it would soem to me
that with great earnestness we would have a right to tell the Govern-
ment of France that we expect them, as our friend, to treat this on an
389
emergency basis because it is a very grave danger to the lives of our
people and to the security of our country, and we are just going to
have to ask them, if they treasure our friendship, to take emergency
measures with us to stop this.
Mr. Ingersoll. I don't know that we put it quite in those terms but
they are certainly well aware of the concern we have.
Chairman Pepper. I don't know what favor we are doing the French.
We have been long-time friends.
We are committed to go to a nuclear war if a French city were
attacked by a nuclear power, by any other country, and we are spend-
ing a lot of money to maintain that capability and we expect to live
up to our obligations, and it would certainly seem to me that we would
have a right not only to ask but to demand of them if we are going
to commit ourselves to defend your cities, maybe to the destruction of
our own country, we expect you to help us defend our own people
from an aggression of such a sort that is coming from your country
into us.
Now, the other thing I wanted to ask you : Is your agency, the Bu-
reau of Narcotics and Dangerous Drugs, providing any money for a re-
search program into synthetic drugs or into blockage drugs or im-
munizing drugs?
Mr. Ingersoll. Our research authority is restricted by law, and we
are not investing any substantial amount of money in any of those
areas because that is principally the responsibility of the National
Institute of Mental Health.
Chairman Pepper. Are you providing any money for a national
treatment and rehabilitation program ?
Mr. Ingersoll. No, sir. That is completely out of our sphere.
Chairman Pepper. My last question here is this. You have indicated
here today out of your great knowledge that if we are going to mount
a massive assault on heroin in our country, it has got to have many
facets. We have got to carry on an effective and extensive research pro-
gram, an effective and extensive rehabilitation program, and an exten-
sive law enforcement program, at least those elements must be a part
of any effective all-out fight upon heroin ; must it not ?
Mr. Ingersoll. Yes, sir.
Chairman Pepper. Thank you very much. You are very kind and
very helpful.
Mr. Ingersoll. Thank you very much, Mr. Chairman.
Chairman Pepper. The committee will adjourn until 10 o'clock to-
morrow morning in this room when the first witnesses will be Dr. Ed-
wards and Dr. Gardner.
(Thereupon, at 1 :40 p.m., the committee adjourned, to reconvene
tomorrow, Thursday, June 3, 1971, at 10 a.m.)
NARCOTICS RESEARCH, REHABILITATION, AND
TREATMENT
THUBSDAY, JUNE 3, 1971
House of Representatives,
Select Committee on Crime,
Washington, D.C.
The committee met, pursuant to notice, at 10:15 a.m., in room 2325,
Rayburn House Office Building, the Hon. Chiude Pepper (chau-man)
[jresiding.
Present: Representatives Pepper, Brasco, Mann, Rangel, Wiggins,
Steiger, Sandman, and Keating.
Also present: Paul Perito, cliief counsel; and Michael W. Blommer,
associate chief council.
Chairman Pepper. The committee will come to order please.
The Select Committee on Crime is today continuing its hearings into
various aspects of the heroin addiction crisis. Yesterday we received
valuable testimony from John Ingersoll, Dh'ector of the Federal
Bureau of Narcotics and Dangerous Drugs. What he told us about the
rapidly increasing rate of heroin addiction among soldiers in Vietnam
certainly does not bode well for the future of our country.
In fact, Mr. Ingersoll's testimony on that subject and on the limited
ability of this country to effectively halt heroin srauggling makes all
the more important the testimony we are going to receive today. For
today the committee once again turns its attention to the scientific
aspects of fighting drug addiction. Given our mability to halt or
significantly decrease the flow of heroin into our country, as long as it is
cultivated legally elsewhere, we must concentrate our attention and
our resources on seeking new and creative means of curing drug de-
pendence. After all, it is the drug addict who is the market^ for those
people wdio smuggle heroin into our country.
Our investigations lead me to believe that the creative genius of our
country can be utilized in order to produce new drugs to combat
heroin addiction. If there is a substantial possibility of developing
niore effective and longer lasting blockage drugs or effective nonaddict-
ing antagonistic drugs, then there seems to be no reason for our
Government's failure to expend its energies and resources in the de-
velopment and use of such drugs. Further, if our scientists can possibly
develop a vaccine which could be used to immunize our population
against the euphoria of opiate base drugs, then it is our responsibility
to see that these laudatory projects are properly funded and that
sufficient manpower is committed to the completion of such worthwhile
endeavors.
You heard yesterday Mr. Ingersoll's estimate that some $8)2 billion
to $4 billion may be the total cost of heroin addiction to this country.
(391)
302
Any reasonable amount of money, including even hundreds of millions
of dollars, would be a very wise investment if we can find something
that will be an antagonistic, blocking, or immunizing drug.
The testimony this committee has heard so far ov the use of metha-
done as a maintenance drug indicates that while methadone is far
from perfect, it is a very helpful tool in combating heroin addiction.
Yet methadone maintenance was developed by two New York doctors
working on a shoestring budget. If this maior advance can be accom-
plished with limited financial resources, think of the great progress
that could be made if a massive Federal commitment to research,
adequate research, were undertaken. Considering the enormous cost
of drug abuse to this country in terms of crime, relatively unsuccessful
attempts at law enforcement, and other direct and indirect drug-
related expenditures, such a commitment must indeed be massive.
If we do not move effectively and massively in our attacks against
this problem, we aren't going to accomplish anything very much.
We had testimony in our hearings in New York from competent court
officials that 48 percent of the cases in the courts of general jurisdiction
of the Bronx and New York County were attributable to drugs, and
another 25 percent were related to heroin because they grew out of
people committing crimes in order to get the money to sustain drug
addiction.
So 73 percent of the cases in these courts were related to the drug
problem. In fact, these prosecuting attorneys said that if it were not
for the fact that they take guilty pleas from defendants, the best
plea they can get, theu' court system would absolutely break do-sm.
That shows another one of the ramifications of this drug problem.
Mr. Ingersoll told our committee yesterday that drug abuse costs
the United States in the area of $3}^ to $4 billion annually. This stag-
gering amount is in stark comparison to the relatively small sum
spent by the Government in combating drug abuse. It would be safe
to predict that an allocation of substantial additional funds to combat
the drug problem would amount to an economic saving in the long run,
not to speak of the lives and the careers that would be saved.
What kind of research is underway, what kind of research could be
undertaken if the necessary funds were available, what kind of
results could we expect from a massive Federal commitment to
researcli. These are some of the questions we mil ask today and
tomorrow. We have some of the most responsible people in our
country here to advise and counsel with our committee.
Our first witness this morning is Dr. Charles C. Edwards, Com-
missioner of the Food and Drug Administration.
Following graduation from public schools in Kearney, Nebr.,
he attended Princeton University from 1941 to 1942, and received
his bachelor's and medical degrees from the University of Colorado
in 1945 and 1948. In 1956, he earned a master of science in surgery
degree from the University of Minnesota.
He spent 5 years in the private practice of surgery from 1956 to
1961, and served as a considtant to the Surgeon General, U.S. Public
Health Service, during 1961-62.
Dr. Edwards was director, division of socioeconomic activities,
American Medical Association from 1963 to 1967, and was the AMA's
assistant director for medical education and hospitals in 1962 and 1963.
39,3,
Dr. Edwards held a surgical fellowship at the Mayo Foundation,
1950-56, a teaching fellowship at the University of Minnesota,
1949-50, and hiterned at St. Mary's Hospital in Minneapolis, 1948-49.
Prior to joining the Department of Health, Education, and Welfare
on December 1, 1969, he was vice president and managing officer,
health and medical division, in the firm of Booz, Allen, & Hamilton,
Inc., Chicago, 111.
Appearing with Dr. Edwards is Dr. Elmer A. Gardner, consultant
to the Director of the Bureau of Drugs of the Food and Drug Adminis-
tration, and du'ector of program and evaluation and development of
Milwaukee County Mental Health Services.
Dr. Gardner received his medical education at the State University
of New York College of Medicine at Syracuse. He has served on the
faculties of the University of Rochester and Temple University in
Fliiladelpliia.
He has served as chairman of the American Psychiatric Association
Task Force on Automation and Data Processing in Psychiatry and as
a member of the American Psychiatric Association Task Force on
Standards. He was recently named to the board of the American
Psychiatric Association Journal of Hospital and Community
Psychiatry.
He is also the author of numerous books and articles.
We are also pleased to note that Dr. John Jennings is with us.
Dr. Jennings is Associate Commissioner of the Food and Drug
Administration. We are very much pleased, Dr. Edwards, to have you
and your associates here today.
Mr. Perito, would you examine.
Mr. Perito. Thank you, Mr. Chairman.
Dr. Edwards, you have submitted a prepared text; is that correct?
STATEMENT OE DR. CHAHLES C. EDWAEDS, COMMISSIONEE, POOD
AND DEUG ADMINISTRATION, DEPARTMENT OF HEALTH, EDU-
CATION, AND WELFARE; ACCOMPANIED BY DR. ELMER A.
GARDNER, CONSULTANT TO THE DIRECTOR, BUREAU OF DRUGS;
AND DR. JOHN JENNINGS, ASSOCIATE COMMISSIONER FOR MEDI-
CAL AFFAIRS
Dr. Edwards. That is correct.
Mr. Perito. Would you care to read your prepared text or sum-
marize it, as you wish?
Dr. Edwards. I think I would prefer to read it, if you don't mind,
and then we will be delighted to answer any questions that any of the
committee members might have.
Mr. Perito. With the chairman's permission, you may proceed.
Chairman Pepper. Go right ahead.
Dr. Edwards. Thank you, Mr. Chairman, and members of the com-
mittee. We do appreciate this opportunity to discuss with you current
research in the treatment of narcotic addiction.
As you have pomted out, we are all aware of the extent of the drug
abuse problem and the mcreasing public concern about heroin addic-
tion, in particular. A variety of therapeutic approaches, many with
some partial success, have been utilized over the past several years — -
394
ranging from chronic hospitalization through residential })rograms, to
outpatient ])sychotherapeutic efforts. The time, the manpower, and
the money required in all of these approaches have resulted in only
limited success, making a successful chemical therapeutic agent an
attractive alternative.
This has resulted in a search for a medication that would do the
following: Block the euphoric effect of heroin for addicts, prevent
withdrawal symptoms, be nonaddictive, be effective orally, be long
acting, be free from toxic effects, and compatible with normal per-
formance and reasonable behavior. The addict would have to be freed
of his craving or hunger for heroin.
Methadone, as you know, is currently under study for the mainte-
nance treatment of narcotic addiction. It has been an effective anal-
gesic since it was synthesized at the end of World War II. Although'
for more than a decade it has been known that low oral doses of
methadone would allay withdrawal symptoms, it was not until 1963
that it first was observed that large oral doses could block the euphoric
effects of even high doses or other opiates or synthetic narcotics. Thus,
the current widespread interest in methadone for the maintenance
treatment for heroin addicts.
Methadone is a marketed drug that has been approved through the
new drug procedures of the Food and Drug Administration, for thi*ee
specific uses: As an analgesic, an antitussive, and for treatment of
withdrawal symptoms in heroin addiction. The last refers to the short-
term treatment of the acute symptoms resulting from the withdrawal
of heroin from those who have become physiologically dej^endent.
Maintenance treatment of heroin addiction with methadone is
investigational because substantial evidence of its safety and effec-
tiveness for this use is not yet available. The law defuies "substantial
evidence" as meaning evidence consisting of adequate and well-
controlled investigations, including clinical investigations, by experts
qualified by scientific training and experience to evaluate the effec-
tiveness of the drug. Although there are studies which suggest that
methadone maintenance may be effective for some heroin addicts
over a period of at least months, and perhaps even a few years, we
have no good body of data or well-controlled studies that meet the
required criteria.
We are only now beginnmg to obtain the kmd of mformation which
may eventually permit us to define the place of this drug in the
treatment of heroin addiction.
Because it was available on prescription, the use of methadone for
maintenence therapy became quite widespread following the early
reports of success by Drs. Dole and Nyswander.
In order to collect the type of scientific data needed to support ap-
proval of a new use of a drug, it was necessary that the maintenance
programs follow protocols, protocols which include recordkeeping,
that could in fact yield such data. Investigational studies of methadone
present problems not encountered in studies with other types of drugs
because it is an addicting narcotic with a proven capacity for abuse.
Therefore, to protect the community from the hazards of diversion
and abuse, and to assure the development of valid data, guidelines
for methadone maintenance studies were developed through the co-
operation of the National Institute of Mental Health, the Bureau
395
of Narcotics and Dangerous Drugs, and the Food and Drug Ad-
ministration. These guidehnes were pubhshed in the Federal Register
on April 2, 1971. Prior approval of both the Food and Drug Adminis-
tration and the Bureau of Nai'cotics and Dangerous Drugs is required
before such studies may be initiated.
Heroin addicts do not constitute, as you know, a homogeneous
population and proper treatment requires that we have some knowl-
edge about which addicts may benefit from this treatment approach
in contract to other types of therapy.
Some investigators have reported that 70 to 80 percent of treated
addicts are rehabilitated as judged by reduction in criminal activit}*,
improvement in employment status, or schooling. But most of these
reports have not given adequate consideration to the bias produced
by patient selection. Some idea of the difficulty of interpreting such
studies can be gained from a most recent evaluation of one of the
best known programs. Although the program had a very broad criteria
for admission, more applicants were not admitted, and I emphasize
not, to the study than were admitted.
In general, those patients admitted to the study and remaining
in treatment, when compared to the overall heroin addict population,
tended to be older, more often white, and in better health. This
group, which had an improved employment status and reduced
criminality, was not representative of the total heroin addict popula-
tion. Therefore, this study, as well as others reported to date, cannot
be used to generahze the results for the entire addict population.
^Vliether those not accepted for treatment would have fared as well
as those accepted of course is as yet unanswered. Reports have not
provided the kind of data that enables better patient selection.
Also, data are needed to distinguish the role played by the drug
itself from the role played by the psychological, the social, and the
occupational rehabilitative efforts in such programs; and marked
proliferation of programs may produce many in which only the drug
is used and no rehabilitation is pro^^.ded.
Methadone maintenance treatment may be a valuable therapy in
reducing heroin addiction, but we believe it is wise to proceed cau-
tiously in moving toward its general prescription use for this purpose.
We need better evidence to determine the safety of this treatment.
It is well to bear in mind that methadone maintenance treatment
represents substituting methadone addiction for heroin addiction and
does not represent the absence of drug addiction. One of the hazards
of methadone treatment is that j^oung drug users who are not physio-
logically dependent on heroin might become addicted to methadone
as a result of treatment. Another hazard stems from the possibility
of death if a nonaddict takes the usual maintenance dose of methadone
intravenously or because of the addictive eft'ect, if an addict ''shoots"
methadone while still taking heroin. We do not wish to have a poten-
tially valuable therapy discredited because of its misuse by some
practitioners while its efficacy is being evaluated.
We now have some 257 investigational new drug exemption (IND)
numbers assigned to sponsors representing 277 methadone treatment
programs. Of these, 185 programs are institutional programs. The
remainder are being carried on by private practitioners. However, at
present, no appfication is being approved unless the program can
396
study an adequate number of patients to yield meaningful data
regarding the safety and efficacy of methadone.
We have requested 6-month status reports from these programs
instead of the customary annual reports, in order to obtain adequate
data as soon as we possibly can.
We expect our recently published regulations to serve as a valuable
tool in insuring compliance with existing requirements. In this regard,
we have recentl}^ undertaken a program for the inspection of all
methadone maintenance studies. By mid-July, we will have completed
inspection of an initial 40 to 50 programs throughout the country,
selected on the basis of various criteria.
In addition to achieving correction of any deficiencies, we hope to
stimulate improved practices and better data collecting procedures.
In these inspections, whenever possible, medical officers from our
Bureau of Drugs of the Food and Drug Administration will ac-
compau}^ district field inspectors. All of this will be done in close
cooperation with the Bureau of Narcotics and Dangerous Drugs,
which, in addition, has its own program for surveillance of the
methadone studies.
Preliminary results of these inspections have demonstrated that at
least some programs must be terminated. Action to do so has already
been initiated in some instances.
When necessary, a sponsor will be given a time limit to correct
deficiencies or face loss of his investigational status. However, before
a program is terminated, we will contact local health departments,
medical societies, and other approved methadone maintenance pro-
grams in an effort to insure that continuing treatment for the addicts
is available. A letter has also been sent to all State and local drug
program officials notifying them of our inspection program; I am
submitting a copy of this letter to you for the record.
In addition to review by our own personnel, we have appomted a
committee of outside experts to assist in evaluating data as it accumu-
lates, as well as other aspects of the ongoing programs. The committee
will also be called on to assist in reviewing any new drug applications
for methadone maintenance.
The members of our advisory committee, some of whom have al-
ready appeared before your committee, are Dr. Henry Brill, Dr.
Robert Milliman, Dr. William Bloom, Jr., Dr. Max Fink, and Dr.
Sidne}^ Cohen. In addition, we have contracted with Daniel X.
Freedman, M.D., Dr. E. Leong Way, Ph. D., and Dr. Maurice
Seevers to serve as consultants to this particular committee.
The concept of narcotic blockade has stimulated a search for other
drugs, drugs with no addicting potential, with greater safet}^ and of
longer duration than methadone. Acetyl-methadol promises some hope
in that its duration of action is 72 hours in contrast to the 24 hours
in which methadone remains effective. Thus, an addict could take his
medication even under supervision, on a twice-weekly basis. How
ever, the possible toxicity of acetyl-methadol needs further stud}'.
Cyclazocine is another narcotic antagonist that has been studied
for the treatment of heroin addiction. Its use has been limited, how-
ever, because it has some narcotic actions of its own, it can produce
respiratory depression and it may be addicting.
397
Naloxone, recently approved for marketing as a narcotic antagonist,
has some similarity to cyclazocine but lacks its narcotic actions, and
in particular, does not produce repiratory depression. Naloxone has
no reiDorted addictive potential but its short duration of action, 4 to
6 hours, limits its usefulness. It has also, like cyclazocine, been tested
on a pilot study basis for the treatment of heroin addiction. It is
hoped that similar agents having the properties of naloxone, but a
longer duration of action, can be synthesized.
To reduce the availability of addictive drugs, a variety of agents
are being synthesized and tested to obtain a potent analgesic with
no abuse potential. Four such analgesic agents are currently under
investigation. In addition, the search continues for a safe and effec-
tive blocking agent in the treatment of heroin and other forms of
addiction. Only a limited number of drugs have reached the stage of
animal testing, and a very few have become available for clinical
tests in humans. I can assure you that we at the Food and Drug
Administration are extremely eager to expedite the investigation of
any of these potentially good drugs and are working \\dth various
groups in order that this can be accomplished.
Mr. Chairman, we would be delighted to attempt to answer any
questions that you or any members of the committee might have.
Mr. Perito. Dr. Edwards, you have submitted for the record a
letter dated May 14, 1971, subject, "Investigation of Methadone
Mamtenance Program"; is that correct?
Dr. Edwards. That is correct,
Mr. Perito. Mr. Chairman, at this point I would respectfully offer
for the record this two-page memorandum, mth enclosure, submitted
by Dr. Edwards.
Chairman Pepper. Without objection, it will be received.
(SeeExliibit No. 17(b).)
Chairman Pepper. You may inquire, Mr. Perito.
Mr. Perito. Thank you, Mr. Chairman.
Dr. Edwards, to the best of your knowledge, how many addicts
are presentl}^ being treated in the United States on methadone?
Dr. Edwards. May I ask Dr. Gardner to address liimself to that?
He is in charge of our total program.
Dr. Gardner. I would estimate that about 20,000 to 30,000 are
being treated. At the moment v/e have no really accurate figure, but
this is our estimate based on what we know about some of the NIMH
programs and other programs which have submitted progress reports
to us. Our 6-month annual reports which have started to come in -will
be coming in over the next month or so, and should give us a better
figure. The inspectional programs should also provide a better esti-
mate of the number of addicts under treatment.
Mr. Perito. I take it. Dr. Gardner, when you mention the figure
of 30,000 addicts you are referring to 30,000 persons presently being
treated in methadone maintenance programs; is that a correct
assumption?
Dr. Gardner. That is right.
Mr. Perito. Do you have any idea how manj^ addicts are being
treated throughout the United States on a detoxification basis in
addition to the maintenance basis?
60-296 — 71 — pt. 2-
398
Dr. Gardner. No, I don't. That would be difficult to estimate
because that would be done through all kinds of medical facilities, and
really sporadically rather than through any routine or ongoing
detoxification programs.
Mr. Perito. Any ])racticing physician can dispense methadone for
the alleged purpose of detoxifying an addict?
Dr. Gardner. For withdrawal.
Mr. Perito. For withdrawal or as an analgesic.
Dr. Gardner. That is right.
Mr. Perito. How do you define withdrawal? How long does that
take?
Dr. Gardner. Withdrawal as noted in our labeling for methadone
and also as conducted in medical practice throughout the country
takes from 10 days to 3 weeks. This represents the time for ph3"sical
withdrawal.
Mr. Perito. And if a physician should continue to prescribe
methadone over a 3- or 4-month period, based on your statement,
that wovild be maintenance.
Dr. Gardner. That is right.
Mr. Perito. What if any action can the Food aud Drug Adminis-
tration take hi a situation where it is reported to them that a doctor,
without an IND number, is prescribmg methadone on a long-term
basis rather than for the purpose of detoxifying an addict patient?
Dr. Jennings. Mr. Chairman, the use of a marketed drug for an
indication that is not part of the labeling falls within the purview of
the practice of medicine, and the Food and Drug Administration has
only an indirect control or influence on the practice of medicine. We
are responsible for approving drugs, for marketing, contingent upon
demonstration of safety and efficacy for certain claims.
Methadone happens to be a narcotic with potential for abuse, and
it is, of course, addictive. Therefore, until recently, it came under the
Harrison Narcotic Act and is now subject, although we are in a
transition period, to the provisions of the Comprehensive Drug Abuse
Act, Public Law 91-513. The enforcement of that particular phase
of the law is the responsibility of the Bureau of Narcotics and
Dangerous Drugs.
Traditionally, in the past, the Bureau of Narcotics, and now its
successor, the Bureau of Narcotics and Dangerous Drugs, has main-
tained that prescribing a narcotic substance for the sole purpose of
catering to the habit of an addict was not a legitimate prescri]:)tion and
that a doctor who did this could be subject to ])enalties. I believe that
situation still obtains under the Comprehensive Drug Act.
Therefore, if a private jihysician were to maintain a patient or a
number of patients on methadone maintenance without tiling an
IND, he would not be in violation of an^^ sjx'cific regidation that we
are responsible for. We would feel that he is conducting an investiga-
tion and that he should file what we call an IND; that is, a notice of
claimed exemption from the new drug reguhitions, and that he should
submit data and aniunil reports to us, but we do not have any en-
forcing responsibility or captibility.
We do not s(Mid our agents out to take any action against a. doctor
who might be using tiie cU'ug in this way when it comes to narcotics.
Mr. Perito. Do you recommend action by FBNDD based ui)on
the information and knowledge that comes to vou about a doctor.
399
for example, who might be abusing methadone or allowing his office
or clinic to be used for illicit purposes?
Dr. Jennings. We certainly would bring this to their attention.
Mr. Perito. To the best of your knowledge, how many prosecu-
tions have been brought in the past 5 years of doctors who have
wrongfully abused methadone?
Dr. Jennings. I have no knowledge of that.
Mr. Perito. Do you liave any idea?
Dr. Jennings. I would thmk it would probably be very few.
Mr. Perito. How many instances in the pa^t 5 years has FDA rec-
ommended to BNDD that prosecution be initiated based upon what
your Agency considered and concluded to be wrongful medical
practice?
Dr. Jennings. I don't recall any instance except since our regula-
tions went into effect and that is sometliing that Dr. Gardner can
speak of in detail. We did mention this to the chau^man yesterday.
Dr. Gardner. We have notified the BNDD about the illegal dis-
pensing of methadone at least a few^ times in the last 3 or 4 months.
Mr. Perito. Since the April 2 regulations went mto effect?
Dr. Jennings. Yes.
Dr. Gardner. Even before that, when we heard of one dispensing
methadone illegally we have always informed BNDD about this.
Mr. Perito. Is it fair to say, based upon your knowledge and
understanding, that most of the diversion of methadone into the
so-called black market is originating on the physician level and not the
manufacturing level?
Dr. Gardner. Yes; 1 thhik that is a fair statement.
Dr. Edwards. I think that is correct; yes. At least to the best of our
knowledge it is.
Mr. Perito. I assume that you are receiving continual data from
the 277 methadone maintenance programs; is that correct?
Dr. Edwards. Now that the regulations have been published and
have come into effect, we will be receiving this information on a
twice-a-year basis from each of the programs.
Mr. Perito. Dr. Edwards, if I understood your testimony correctly,
you are investigating methadone to make a determination as to its
safety and efficacy. Is that correct?
Dr. Edwards. Well, this, of course, is why we want to get all of this
information from these various programs to determine its safety and
efficacy.
Mr. Perito. Prior to the promulgation of the regulations on April 2,
1971, were you receiving data from the various methadone mamte-
nance programs?
Dr. Edwards. Do you want to speak specifically to that. Dr.
Gardner?
Dr. Gardner. We received some sporadic data, but nothing very
systematic. Actually many of the programs have been initiated only
during the past year. Usually, an IND holder reports to us on an
annual basis. When we became aware of the abuse in some of the
programs, we decided that seirdannual reporting would be more
appropriate for methadone programs.
My. Perito. Dr. Gardner, when was the first IND permit issued?
Dr. Gardner. The first one was issued to NIMH and that was in
1969. Most of the NIMH programs were not mitiated until 1970.
400
Mr. Perito. Were you getting data from the Dole-Nyswander
program back in 1963, 1964, when they first started experimentation?
Dr. Gardner. No. At that time there was no IND procedure for
this and methadone for the maintenance treatment of heroin addiction
was not specifically precluded or guided by any regulations.
Mr. Perito. Do you now have proper manpower in your agency to
investigate the 277 methadone maintenance programs and protocols
so that your Agency is able to make an informed judgment as to the
safety and efficacy of such treatment programs?
Dr. Edwards. Manpower, as far as we are concerned, is a very
scare commodity. Our inspectors in the field are involved in the food,
product safety, and drug fields of activity. So the real answer to your
question is no, but we have given this a very high priority in the
agency and are expanding special effort in this area.
We consider this one of the major problems that we are confronted
\\dth and have diverted a lot of our manpower into this ])rogram. I
must also say, however, that it takes a person with special training to
really get involved in these programs, in the inspect programs such
as this. Consequently, we are in the process of training some of our
people in the inspectional techniques necessary to inspect these
programs and to give us the kind of information we need at
headquarters.
Mr. Perito. Do you know how many people FBNDD have assigned
to work with you in conjunction with this effort?
Dr. Edwards. Not specifically.
Dr. Jennings. No, sir; but to backtrack a little bit to explain some
of the background that Dr. Gardner referred to, until recently an
investigator of any drug was entitled to begin his investigations as
soon as he had filed with us his notice that he intended to do so. As a
matter of fact, he was entitled to begin the investigations as soon as
he had mailed in his application.
Mr. Perito. In other words, a licensed physician could start
immediately without getting your prior approval?
Dr. Jennings. That is right. About a year ago, for reasons not
dh"ectly related to methadone but to other investigational drugs, we
promulgated a regulation that requu^ed a 30-day waiting period
before he could begin his investigations.
When the methadone regulations went into effect in April, they
contained still another safeguard. That is, that there would have to be
prior approval, not only by the Food and Drug Administration but
by the Bureau of Narcotics and Dangerous Drugs before the studies
could be instituted.
We have now been informed that the Bureau of Narcotics and
Dangerous Drugs is going to make an onsite investigation of each
investigator prior to giving their required approval to the investiga-
tional new drug investigation. The studies that exist now were not
subjected to this sort of scrutiny. Prior to April 2, they were approved
by the Food and Drug Administration in the manner then part of our
procedure; that is, the investigator's qualifications were examined,
his protocol was reviewed, and if there was nothing obvious that
would prevent the application trom being approved, it was permitted
to go into effect in accord with the then current procedure, that is, a
30-day waiting period.
401
Now, because of our attention having been brought to certain
abuses tliat Dr. Gardner can speak of, we have undertaken to examine
these programs that are ah'eady set up. Some of them will be examined
because we have reason to beheve that they may not be measuring
up. Others will be examined on the basis of getting a representative
sampling of institutional and private programs, and as was indicated
by Mr. Ingersoll yesterday, we believe that there will be actions
taken against some of these in the very near future.
Mr. Perito. Prior to the promulgation of the regulations on April 2,
1971, how long did your Agency have under consideration the proposed
regulations?
Dr. Edwards. Quite some time. I think it was about 9 months,
wasn't it?
Dr. Jennings. Yes, sir. The efforts on the part of the Food and
Drug Administration to promulgate these regulations probably go
back for more than a year. I can tell you that the}^ did not initially
meet mth the unqualified approval of the medical commmiity, the
scientific communit}^, and the people who are investigating the drug,
and especially the strong proponents of methadone as a treatment for
heroin addiction.
Mr. Perito. Thank you.
Chan-man Pepper. Mr. Blommer, our associate chief counsel, do
3^ou have any questions?
Mr. Blommer. Yes, Mr. Chairman.
Dr. Edwards, is your agency at this time granting new IND numbers
to invest gate methadone maintenance?
Dr. Edwards. We are not granting any additional IND's for
indi\ndual investigators, single investigators, that aren't part of an
institution.
Mr. Blommer. If I understand your testimony here already, there
are 30,000 individuals being maintained on methadone, is that correct?
Dr. Edwards. That is an estimate, but that is a rough estimate.
Mr. Blommer. And I assume that because you are granting new
numbers, you feel that 30,000 is not a large enough figure or that
there should be more people in methadone maintenance programs?
Dr. Edwards. I don't know if that is really the criteria. We are
Avilling to grant an IND number to anyone that we think is, first of
all, a responsible investigator that can provide the kind of information
we need to fully evaluate the drug.
Now, I can't say whether Vv^e need 30,000 or 60,000 people. I can't
give you a specific answer on what the exact number should be.
Mr. Blommer. Well, Doctor, if you find that methadone mainte-
nance is either not safe or not effective, then you will recommend that
all these methadone programs be closed down, I assume.
Dr. Edwards. That is right.
Mr. Blommer. 1 have no further questions.
Chairman Pepper. Doctor, how many addicts does your agency
estimate there are in the United States?
Dr. Gardner. I think we have the same kind of rough estimate
that anybody has, which is hi the range of a couple of hundred thou-
sand, maybe 100,000, 200,000.
Chairman Pepper. And about 30,000 are on methadone
maintenance.
'402
How many would you say are being treated with other drugs?
Dr. Gardner. At this point in time, a very small number. The
only other drugs that are really being studied A\dth any kind of intensity
are the derivative of methadone, acetyl-methadol, and some blocking
agents as Dr. Edwards mentioned, cyclazocine and naloxone. The
studies involving cyclazocine and naloxone do not include more than
a few hundred patients.
Chairman Pepper. So if there are 200,000 or 300,000 heroin addicts
in the United States, your opinion is that probably less than 50,000
are receiving treatment with some approved drug?
Dr. Edwards. On some apjjroved drug, that is correct; j'^es.
Chairman Pepper. Well, now. Doctor, I would like to have the
record show clearly what the function of the Food and Drug Admin-
istration is. You are not charged with trying to solve the herohi
problem in the country, are you, in the sense of having responsibility
for developing a drug that will block heroin addiction, heroin euphoria?
Dr. Edwards. No; but we do have the responsibility of working
with and encouraging research in this area.
Chairma!! Pepper. Does your agency carry on any research of
its own in this field, to try to find a drug that would be a blockage or
immunizing drug?
Dr. Edwards. No. We are not doing any immediate work ourselves.
Chairman Pepper. That is what I was getthig at. You are not
charged with the responsibility by law of furnishing the funds to carry
on independent research to try to find a drug that will be a blockage
or an immunizing drug for heroin?
Dr. Edwards. We are supplying funds to the Committee on Drug
De])endence.
Chairman Pepper. You are more or less a policing agency to
examine drugs that are projiosed to you and to see whether or not
after projier inquiry is made, they are efficacious and/or safe drugs?
Dr. Edwards. That is correct. Our responsibility is to evaluate
the scientific data obtained from these various programs and to eval-
uate the safety and efficacy of the drugs.
Chairman Pepper. And since submissions to your agency might
be made by another Government agency, or almost anybody who
wants to use a drug, private pharmaceuticals or NIMH, and trying
to carry on an inquiry, trying to develoji a particular type of dnig.
Dr. Edwards. Yes, sir; that is correct.
Chairman Pepper. Does NIMH in your opinion generally
have responsibility in this field as the initiating agency to try and do
something about the drug i)roblem?
Dr. Edwards. I think it has the })rime responsibility in the Federal
Establishment for initiating and stimulating r(>search in this area;
yes.
Chairman Pepper. Well, now, has NIMH submitted to the Food
and Drug Administration any drug and asked for your evaluation of
those di-ugs with res])ect to the treatment of heroin addiction?
Dr. Edwards. For the specifics I would have to ask Dr. Gardner
to answer.
Dr. Gardner. They submitted a|)plications for investigational new
drug status for not only methadone, but for some other drugs, particu-
larl}^ those that are being studied in the Lexington Research Center,
403
and this is only for the investigational phase. Beyond that, of course,
if the}' are to be marketed, that would become part of the responsi-
bility of the pharmaceutical industry.
Chairman Pepper. Well, now, Doctor, one of the things that this
committee is ver}' interested in and very concerned about, is tr^nng
to develop a system by which everything that can be done, shall be
done as quickly as it can be done to do something effective about the
heroin addiction problem in this country.
You know, of course, what it is costing the country in terms of
lost lives and ruined careers and crime and loss of propert}', et cetera.
I know your agency is desirous within the bounds of propriety and
within the limitations of law to be cooperative. We heard here a
little bit ago about a drug, for example, that some doctors have been
using in respect to the heroin addiction that they think blocks the
physical craving for heroin, and it has been used on a number of
people, according to one of the doctor \vitnesses who appeared, and
another doctor had sent some of his patients to receive treatment by
this drug.
Now, vre wouldn't, of course, in any sense of the word suggest or
condone your giving approval when it should not properly be given,
but I think we do have a right to inquire whether or not good leads
that might be developed would have all possible expedition and
consideration by your agency, because this is a matter of great public
interest. I mean, you wouldn't put too much emphasis on the form
and too little upon the substance so as to just take as a matter of
casual day-to-day routine submissions by responsible people of
possible antagonistic or blockage or immunizing drugs for heroin
addiction; would you?
Dr. Edwards. No; we certainly wouldn't. We share your concern
for this problem and, as I mentioned earlier, we do not vrant to
impede progress in trying to develop a meaningful drug in this area.
On the other hand, we do have a responsibiiitj^, first, to assure that
dangerous drugs are not allowed on the market. Second, that the
drugs are not diverted into illicit channels.
Chairman Pepper. And if the National Institute of Mental
Health, which seems to have the primary responsibility by law, told
you they had some leads, and asked your cooperation and inquiring
into the safety and efficacy of those potential drugs, you would
cooperate with them, of course, in every way possible.
Dr. Edwards. Absolutely, and we are doing this right now. All
we w^ant to be sure of is that these studies and these drugs are being
used by people who should be using them. The National Institute of
Mental Health is really the focal point in the United States for testing.
Chairman Pepper. Just one other question. Doctor. Now, is it your
general opinion that methadone is about the best drug that is on the
market so far for dealing with heroin addiction? I mean, even if it
does have its defects and its faults, it has certain advantages m the
treatment of heroin addiction if properly used.
Dr. Edwards. It certainly shows some promise, more so than any-
thing we have currently available.
Chairman Pepper. Well, now, if it were to be used — suppose we
were to recommend to the House of Representatives, and the Congress
should adopt a law and adequate funds should be provided to set up a
404
system of treatment and rehabilitation facilities all over this country,
in every community in America where there was a need for it — would
you suggest that such treatment and rehabilitation programs should be
conducted through clinics where there M'Ould be proper supervision
and the like, rather than permit these drugs to be prescribed by in-
dividual practitioners?
Dr. Edwards. I think a drug with the potential danger — and I
will use the words "potential danger" — of methadone, if it is going to
be used on a widescale basis, it has got to be used through institutional-
type clinical settings. I don't think they can be used through individual
practitioners.
Chairman Pepper. And your regulations have been moving rather
in that direction?
Dr. Edwards. Our regulations are definitely moving in that
direction.
Chairman Pepper. The clinic can require the patient or the recipient
of the treatment to be there in person and receive it when the}' think
it is desirable to do this.
Dr. Edwards. That is right.
Chairman Pepper. And they can give him certain therapeutic and
occupational and other assistance.
Dr. Edwards. That is correct, because there is
Chairman Pepper. Which the doctor doesn't profess to be able to
afford.
Dr. Edwards. I think your point is an extremely good one, that we
need more than just methadone tlierap}-. There is a whole range of
rehabilitative services that have to go into the rehabilitation of any
addict and it is more than just a single drug. You have to have other
forms of therapy as well.
Chairman Pepper. Mr. Brasco?
Mr. Brasco. Yes.
Dr. Edwards, can you tell us how long you have been investigating
the properties of methadone in terms of its safety?
Dr. Edwards. If I might, I would like to have Dr. Gardner answer
that. He is better acquainted with the specifics.
Dr. Gardner. Actuall}^, of course, we haven't been investigating it.
Mr. Brasco. Well, you make a determination as to whether or not
it is a safe drug.
Dr. Gardner. Yes.
Mr. Brasco. Somebody should be investigating it.
Dr. Gardner. I meant we only evaluate the data submitted by the
people who conduct the studies. Most studies have been in progress
for only the past year and insufficient data has been submitted as j^et
to fully evaluate the safety and efficacy of methadone maintenance.
Mr. Brasco. Well, let me ask you this, Dr. Edwards. All of j^our
statement is replete with the fact that there are certain judgment
criteria, and I heard a moment ago that there are approximately
30,000 people in the prograni already. Now, what are you working
toward in terms of getting to a point that you can say whether or not
this is a safe drug or not a safe drug?
Dr. Gardner. Well, first of all, the 30,000 might be on the high side,
but something between 20,000 and 30,000 people are probabh^ in
these programs. In terms of safety we must know about any adverse
405
effects this drug will produce in long-term use. Will it interfere with
normal functioning? How many deaths may occur from the licit or
illicit use of this drug, given the amounts necessary for a maintenance
program. We do need to know how much illicit distribution stems from
the approved program because this, in a sense, affects the safety of this
use of methadone.
We want to know what the possible death rate is, just from the
use of this drug alone. We want to know how much illicit distribution
there is from the progi*ams, because if we were to substitute tliis type
of addiction for another type of addiction, and it would be widespread,
there would be widespread abuse and illicit trade with the drug.
Mr. Brasco. Would that really make a difference in terms of its
safety? I appreciate that most of the drugs that we have on the market
today can be diverted and are diverted into illegal channels. We
haven't stopped manufacturing them. Is that one of the considerations
that is bogging dowm the determination?
Dr. Gardner. No; it is not the only consideration. We do not have
the data submitted to us to permit an adequate evaluation of safety
and eflficacy.
Dr. Edwards, In other words, we do not at this time have the
scientific information available to us that will establish the long-term
or even the short-term safety of this particular drug.
Mr. Brasco. Well, hoAv long has it been under consideration in
terms of years or months?
Dr. Edwards. Well, of course, the drug was considered sometime
ago. Short-term studies were done when the drug was being considered
for its analgesic and its antitussive properties, but at that time, again,
no long-tei-m studies were done. These were short-term studies.
Mr. Brasco. What does that short-term mean? A month, 2 weeks
or a year?
You see, the thing that I am concerned about, and maybe I can
make myself a little more explicit, it seems to me when we get some
of these drugs, and I appreciate that everyone wants to be safe in
making a determination with respect to a drug, but — well, take cycla-
mates, for instance, we found out — I don't knov\^ how long it took to
investigate that — that it has a property that may cause cancer of the
kidneys and I, along -with, other people, have been drinking all of
tliis diet stuff with it.
Now ^ve have got a drug and you have approximately 30,000
people using it in a program. I, myself, have recommended a number
of young people in my o-wn district into the program. They have come
back to my office and people who were in trouble before with the law,
marital problems, are now working, living at home in a family relation-
ship, and I tliink really the important thing is when can your agency
make a determination so we can either say that methadone is not
safe or say it is available for general use?
Dr. Jennings. Well, sii-, I think you have raised questions of both
safety and efficacy.
Mr. Brasco. I am trying to find out from you how long you need.
Dr. Jennings. Yes, sh.
Mr. Brasco. You might study this thing to death. That is what I
am concerned about.
Dr. Jennings. The drug has a long history for relatively short-
term use. It has been studied or used sometimes in a situation that
406
did not permit adequate study for long-term use, for several years.
What we are attempting to determine is whether the drug, given in
rather massive doses, day in and day out, for periods of 3^ears will
produce any adverse effects that would outweight its potential
usefulness.
]\Ir. Brasco. I miderstand all of that, but what I am trying to
find out, do you have any idea of how long that would take in terms
of what you say are criteria that you are using in the statement?
Dr. Jennings. We have only just begun to collect this kind of
data. Until recently these studies were comjileteh^ disorganized.
A'lany of the resources had not bothered to submit IND's because
they felt that the drug was not an mvestigational drug. It required
this regulation, hoj^efully, to bring this home to the jieople who were
using it, and I think that it will take us a matter of many months
before we are able to say that the drug is safe for a certain period of
time, to be administered day in and dQ,j out at high dosage.
The question of efficacy is one that is going to be much more difficult
to resolve. The studies to date have not yielded the kind of control
data necessary to make a determination of efficacy. ¥*"e have anecdotal
and testimonial evidence that in some cases it has aided in the re-
habilitation of well-motivated addicts, but the large population of
heroin addicts in this country is not made up of well-motivated
people.
Mr. Brasco. Let me go on to something else. I don't want to take
all of the time. I see that you really have no idea of how long it will
take. I only suggest, very respectfully, that we do everything we can
to speed up this process because from what I have seen, I think it is
effective. I am not an expert and I don't pretend to be, but there are
going to be some 30,000 people that are taking this stuff now in bad
shape if somebody doesn't make a determination soon, and if it is
something that is effective, then the other, you say, 100,000 to 200,000
drug addicts, should have a crack at it.
But let me get on to something else here, if I might. Now, assuming
that you find that this drug is safe and efficacious, I would assume
then. Dr. Edwards, that you would want the Attorney General to
prevent or to regulate the use of it by doctors.
Dr. Edwards. That is correct.
Mr. Brasco. In other words, you would
Dr. Edwards. Like any other narcotic drugs.
Mr. Brasco (continuing). You would ban it from being used bj^
doctors.
Dr. Edwards. Beg pardon?
Mr. Brasco. A total ban and dispensed only hi clinics or just to
be regulated by the Attorney General.
Dr. Edwards. Well, again, I can't give you the specifics. These
specifics would have to be worked out with the Department. Gcnerafiy
speaking, this drug has to be used in the proper setting, ami 1 ihink
the ])ro])er setting is an institutional one.
Mr. Brasco. Let me ask you this, Dr. Edwards. You have ex-
pressed concern about methadone being diverted into illegal channels,
and we heard that same testimony yesterday from Mr. Ingersoll and
it has also come to this committee's attention, that methadone can be
made in such a Avay that it cannot be used intraveneously.
407
Now, if it is not used intraveneoiisly, then the diversions don't
present the problem that we have today, because otherwise it would
only be used by addicts orally and I would assume they would be
using it to taper off on their habit.
Now, if this can be made into what the experts call a gummy sub-
stance that is incapable of being injected intravenously, why don't we
doit?
Dr. Jennings. I can answer that. We are Avorking closely with the
principal manufacturer to develop just such a formulation. That is, a
large tablet which, when mixed with the limited amount of fluid
which would be used for intravenous use, forms a thick, gummy
substance unsuitable for administering,
\h\ Brasco. That can be done now, as I understand it, unless I am
laboring under a misapi)rehension.
Dr. Jennings. That formulation has not yet been developed to
the
Mr. Brasco. Well, are we talking about the drug companies have
to be convinced or we can't do it? What are we talking about?
Dr. Jennings. We are talking about the efforts of the principal
manufacturer to develop such a formulation having met with some
difficulties which we think are not insurmountable. We think we are
ver}'^ close.
Mr. Brasco. What difficulties would they be? Is it the drug com-
panies resisting?
Dr. Jennings. Technical difficulties.
Mr. Brasco. Then it is not capable of being made into a gummy
substance today?
Dr. Jennings. We expect we are very close to this.
Mr. Brasco. At this point I would like to refer to our counsel who,
I understand, indicated that it can be done.
Mr. Perito. Dr. Jaffe's program.
Mr. Brasco. He uses a gummy substance; is that correct?
Mr. Perito. Dr. Jaffe has advised the staff that he has a method of
distributing methadone, as I understand it, which is not susceptible
to injection.
Dr. Edv.'Ards. We are not aware of that.
Dr. Jennings. I think he is one of the people testing the Lilly
product which consists of the tablet I have described.
One of the problems with this was that, although it had some of the
characteristics that were desirable, that is, when mixed with a small
amount of fluid it formed a thick gummy substance, it was not com-
pletely soluble in some of the solutions that are usually used by the
clinics.
Mr. Brasco. Do you have aiij^ idea of when we might arrive at
that point?
Dr. Jennings. I think we are within weeks of the development.
Mr. Brasco. Of being able to at least do that.
Dr. Jennings. Yes, sir.
Mr. Brasco. May I ask this last question. I see on the chart that
I have here you are under HEW; is that correct?
Dr. Edwards. That is correct; yes.
Mr. Brasco. Now, I see that in 1971 they have an appropriation of
some $17.9 million. Can j^ou tell us what portion of that is for your
agency?
408
Dr. Edwards. No; I wouldn't know what that $17.3 million figure
is. I would have to see how it was broken down.
Mr. Brasco. Well, could you tell us what portion of this money,
if any, is being used to develop new drugs?
Dr. Edwards. Well, of course, I can't speak concerning the de-
velopment of new drugs by the National Institute of Mental Health.
None of our money is going directly into the development of new
drugs.
Mr. Brasco. So you don't have a research budget, as such?
Dr. Edwards. We have a research budget, but not for the de-
velopment of new drugs in this area.
Mr. Brasco. What would that money be for? What would you be
researching?
Dr. Edwards. Oh, we are doing a lot of things. We are dohig a lot of
toxicological research in the heavy metals. We are doing research work
in the pharmaceutical field.
Mr. Brasco. But not hi the area of drugs that could be used in the
problem of drug addiction.
Dr. Edwards. No. Our role is not in new drug development.
Mr. Brasco. I don't want to take all of the time, and I don't,
gentlemen, want it to be understood that I want to appear to be
unfriendly, but I iliink part of the problem that we have here really
is that most of the ]3eople that we have heard from have said that we
don't have adequate statistics as to how many drug addicts we have.
We don't have adecpiote r.tatistics as to how many people are involved
in what programs, and how they are making out. We are talking about
minuscule amounts of moneys used for research development of new
drugs in th^s particular area. We are talking about our mability to
convince the Government of South Vietnam, where we have expended
mone}^ and men, to help us in this problem.
France is a great friend of ours and I think owes us approximately
$7 billion and we can't convince them they ought to do something
about breaking down the laboratories that make heroin.
I think that unless we are all ready, and this is not looking for a
fall guy in anjT- partisan way because I think the only people that are
falling are the American pubhc as a result of this problem, unless we
put together a concentrated effort of research and want to crush and
destroy the sources of this, we are just going to be going around in
circles.
And with that, I thank you, Mr. Chairman.
Chairman Pepper. Thank you.
Mr. Wiggins?
Mr. Wiggins. Yes, Mr. Chairman.
Dr. Edwards. Mr. Chairman, may I make just one comment?
I certainly agree with what you have said. I think that for the fii'st
time, at least since I have been here, this coordinated effort on the
part of all of the Federal agencies, particularly those that are involved
in tliis program, is just beginning to take on a head of steam, and it
came about first with the passage of our new regulations, and I feel,
for the first time, a great deal more optimistic about the total Govern-
ment effort than I have been in the past.
Chairman Pepper. Mr. Wiggins.
409
Mr. Wiggins. Dr. Jennings, does statutory authority exist to
})ermit you to require the manufactiu'e of methadone in a nonin-
jectable form?
Dr. Jennings. I am not sure that I understand your question.
Certainly we have the authority to approve drugs for safety and
efficacy and that approval includes the formulation of the drug, that
is, the physical state in which it is marketed, as well as the labeling
for it, and we have requested the principal manufacturer to develop
the dosage form that we were speaking about for this particular
investigational use. But we haven't extended that particular require-
ment to the currently marketed forms of methadone for its other
indications, that is, as an ordinary analgesic or antitussive.
It may very well be that its hazards or its usefulness in the main-
tenance program would eventually be considered so great that it
would be in the interest of the public welfare to eliminate the dosage
forms.
That is something that certainly could be considered, and because
we do have the authority to make an estimation of the benefit-to-risk
ratio, we could probably require a single nonabusable dosage form if
one could be developed.
Mr. Wiggins. Have you answered my question; yes or no?
Dr. Jennings. I think it is yes; but I think we would have to con-
sult our legal people about it.
Mr. Wiggins. Would you provide a fuller answer if, after con-
sultation, you believe the answer to be no, and even if you believe the
answer to be yes, would you communicate with the committee and
clear that matter up?
Dr. Jennings. Yes; of course.
(The following, in reference to the above request, was received from
M. J. Ryan, Director, Office of Legislative Services, FDA:)
QUESTION
Does statutory authority exist to permit FDA to require the manufacture of
methadone in a noninjectable form?
ANSWER
Yes. Under the terms of the Federal Food, Drug, and Cosmetic Act, a new drug
may not be marketed unless it has been approved as safe and effective by the
Food and Drug Administration. If there is the possibility of safety problems
(which could include problems related to drug abuse) using a particular dosage
form of the drug, approval could be restricted to those dosage forms where this
problem does not exist, or exists to a lesser degree.
Mr. Steiger. Will my colleague yield?
Mr. Wiggins. I will yield if you have a question.
Mr. Steiger. I thank you. I wondered, assuming that we find a
legal basis for this requirement, that methadone only be dispensed in a
nonabusable form, what criteria would you require to arrive at that
decision?
Dr. Jennings. In order to make such a decision we would, first of
all, have to make two decisions. One, that methadone is safe and
effective for the long-term maintenance treatment of heroin, and, two.
that this use was so important vis-a-vis its other uses, that it would
be considered overriding and we would, therefore, eliminate, or at
410
least curtail to some extent, the other uses by having just the one
dosage fonn.
Mr. Wiggins. Does statutor}- authority exist for 30ur agency to
compel that methadone be dispensed onl}' in an institutional setting,
not by private j^hysicians?
Dr. Jennings. At the present time we could invoke that require-
ment for the investigational use. That is, for the maintenance treat-
ment of heroin addiction. We could not do that currently for the
marketed form of methadone which i^ labeled for other uses.
Mr. Wiggins. As to that question as well, would you refer that to
your counsel and then advise the committee precisely as to the extent
of vour statutory authority to do some of the things you think might
be necessary to be done.
(The following was subsequently received from M. J. Ryan, Director,
Office of Legislative Services, FDA:)
QUESTION
Does statutory authority exist for your agency to compel tliat methadone be
dispensed only in an institutional setting, not by private physicians?
ANSWER
Yes. If is is necessary to restrict distribution of a drug in order to assure its safe
and effective use, the Act does provide such authority.
Mr. Wiggins. A.nd then, finally, as an aside, this drug has been
used for maintenance purjioses, at least since 1963, in ro.assive doses
and it is surprising that you are just now accumulating statistics in
1971, because it was used in 1963 with your approval. I am not blaming
anybody, but I am suggesting that the timelag is sufficient for some
sort of determination to be made about it.
Dr. Edwards. It was authorized for certain uses in 1963, not in
terms of the treatment of heroin addiction, however.
Mr. Wiggins. Well, that program started in New York with Drs.
Dole and ?'Tyswander in 1963 for maintenance purposes to relieve the
effects of heroin addiction, and T understand it was done with your
acquiescence. By "your" I mean the Agency's acquiescence.
Dr. Jennings. I am not sure of the exact date of Dr. Dole's filing
an IND. I want to point out, however, that until our recently api)roved
regulations went into effect, or until it became apparent that Me were
going to promulgate such regulations, most of the investigators of
this drug did not consider that they were carrying out an investigation,
but were, on the basis of the published reports of Drs. Dole and
Nyswander, actually treating patients.
It was our contention then, as it is now, that the kind of data and
evidence required by law did not exist and it was only when we were
able to promulgate a definite regulation in conjunction with the
Bureau of Narcotics and Dangerous Drugs that we could begin to
bring these studies luider control.
Our major concern was that we first of all not interrupt any legiti- J
mate investigations and, second, that these all be done in such a m
way that meaningful data could be derived. ■
We are primarily concerned at this point with deriving efficacy data
that will enable us to label the drug as other drugs are labelecl for a
definite patient population that can be tlelined in that label.
411
Penicillin is good for pneumonia but it isn't good for every case of
pneumonia. Methadone is probably good for some cases of addiction
but it isn't good for every case of addiction. When we approve this
drug, if we approve it, the labeling will be such that it will identify,
as far as we are able, the kinds of patients for whom it is effective.
Mr. Wiggins. I commend your efforts in that regard, and I think
it is about time that you started doing that.
I will yield the balance of my time.
Chairman Pepper. Thank 3-ou.
Mr. Mann?
Mr. Mann. Dr. Edwards you mentioned earlier that you did have
a moderate capacit}^ for independent research in the drug field through
certain funding grants. Tell us a little bit more about that, please.
Dr. Edwards. Well, we have a very, veiy modest grant program.
Our funds are used to contract studies in certain specific areas.
For instance, as I mentioned earlier, we are doing contract studies
on a number of the heavy metals. W"e are doing some in-house studies
on such things as saccharine. We have not allocated any specific
funds for the specific development of certain new drugs.
Mr. Mann. If someone came to you and alleged that they had a
breakthrough drug idea, to whom would you refer them for help?
Dr. EovrARDS. Well, we would first of all say, OK, let's see the
data on which you base these claims. If the data was good, w^e would
approve the drug or we might send them to the National Institutes of
Health for additional funding. We certainly wouldn't turn them off.
]\ir. Mann. Well, the testing that 3^ou require is a rather expensive
drawn-out procedure.
Dr. Edwards. That is right.
Mr. ]Mann. The person who has the idea may not ha^'e that capac-
ity. The private drug industry may not be interested or the}^ may
not reach accord.
Dr. Edwards Right.
Mr. Mann. So where does he go for this item that might be of great
public interest? Wliere does he go for the development of that?
Dr. Edwards. I think this depends on the nature of the particular
product involved. I don't think there is a single place to go. I think
we might be able to develop funding. We may go to the National
Institutes of Health for additional funding. There may be private
funds available. I think we have a responsibility to flag any potentially
good ne\^' drugs that haven't adequate funding and try to help them
obtain funding.
\h'. Mann. Well, let's assume that it is a drug that would appear
to have great promise in the heroin blocking area. Where would you
send him?
Dr. Edwards. Probably the National Institute of Mental Health.
They are in the research and development area. They are the lead
agency in this area and that would be the logical place to send them.
If it were a heart drug, we \\'ould send them to the National Heart
and Lung Institute.
Mr. Mann. Do you have any information as to whether or not the
National Institutes of Health have adequate funding or personnel to
proceed with such a project?
412
Dr. Edwards. All 1 know, I can look at their budget, and they have
a budget, but I don't know how much they have earmarked specifically
for this particular purpose.
Mr. Mann. That is all, Mr. Chairman.
Chairman Pepper. Mr. Rangel?
Mr. Rangel. Yes, doctor, is it safe to say that over the 7-3^ear
period methadone has been before your agency, that you have not
been able to determine its safety ^^^.th any degree of accuracy?
Dr. Edwards. No. Its long-term safety has not been established.
Mr. R.ANGEL. Now, v^hy would you continue to give IND numbers
for a drug which you cannot over this period of time determine its
safety?
Dr. Edwards. Well, again, you have got to remember the way it is
being used now, the kind of data and information that we need to
determine safety. We are just beginning to accumulate this right noAV.
Mr. Rangel. You are accumulating. Does your agency have any
jurisdiction to sanction a phj^sician that wants to prescribe methadone
for whatever purpose he wants to prescribe it?
Dr. Edwards. No. If the physician has a narcotics license, he can
fortunately or unfortunately use it any way he wants.
Mr. Rangel. You have no control over this?
Dr. Edwards. We have no control over the individual physicians
practicing medicine; no.
Mr. Rangel. But you have control as to whether or not this drug
can be used by this physician.
Dr. Edwards. Can be marketed; yes.
Mr. Rangel. So, in fact, even though there has been no completion
of the study as far as safety is concerned, any physician can dispense
a narcotic
Dr. Edwards. We are satisfied as to the safety of the drug, accord-
ing to its labeling. In other words, as an analgesic, as an antitussive.
Mr. Rangel. But you can't control how it is actually being used on
the streets.
Dr. Edwards. If the doctor wants to misuse or abuse the drug,
there isn't much we can do about it.
Mr. Rangel. Now, you mentioned in your testimony the bias that
exists in selecting patients who are using methadone, and I assume
you are talking abovit the institutions. Is it safe to say that the civil
rights statutes don't apply as relates to treating drug addicts?
Dr. Edwards. Again, what was that? I didn't get the exact question.
Mr. Rangel. Well, on page 4 of your statement, j^ou indicate that
it is impossible for your agency to determine with any degree of
accuracy the rehabilitative value of the drug because the institutions
are selecting in the main, older people, and in the main, the majority
of the patients are white.
Dr. Edwards. What I said is that the several studies that have been
brought to our attention, and which we reviewed in some depth, have
tended to have a select group of patients in the study. They have
tended to be perhaps better educated, white, and so forth.
Mr. Rangel. Well, my question was, do the civil rights statutes
apply in connection with dispensing methadone to drug addicts?
Dr. Edwards. I would hope so.
413
Mr. R ANGEL. But from the studies that you received, it doesn't.
Dr. Edwards. Well, again, I couldn't make a comment on that
specifically. I would hope that it did. In other words, there are reasons
why patients are selected for a study. I am not being necessarily
critical of the investigators per se, but it may be that for the first
group, they wanted a better educated group to try this on. I don't
know all of the background.
Mr. Rangel. Now, your testimony reveals 257 IND numbers, 277
programs, 185 of these programs are in institutions. How many in-
vestigators do you have to police these IND numbers?
Dr. Edwards. Well, theoretically, we have some 700 inspectors in
the field for general use. At the moment, we are probably using, oh, I
suspect 50 of our inspection al staff for this particular purpose.
Mr. Rangel. Now the 92 that are other, how many of those are
located in New York State?
Dr. Gardner. There are approximately 60 in the New York City
area and about another 20 or so throughout the rest of the State.
Mr. Rangel. How many investigators would be assigned to those
that are located in New York City?
Dr. Gardner. There is a staff of at least 100 in the New York City
regional office but at the moment only a small portion of those people
are assigned to this particular kind of investigation.
Dr. Edwards. At the moment it is a combmed effort between our
headquarters staff and the particular regional staff, wherever the
program might be. Again, as I mentioned earlier, it does take some
specialized traming to be able to properly evaluate some of these
programs, some of the technical aspects of it. I suspect that we have
used off and on in the last several weeks in the New York area probably
25 or 30 different people.
Mr. Rangel. Are you satisfied with the clinical work of the metha-
done clinics that operate on 95th and 97th Streets in the city of New
York, Manhattan?
Dr. Edwards. No; we absolutely are not.
Mr. Rangel. Well, why is it that they are still allowed to, in the
community's opinion, dispense without regulatory sanctions?
Dr. Edwards. We have inspected their operation. If the deficiencies
that were pointed out to them very clearly are not corrected in just a
matter of days, the program will be terminated.
Mr. Rangel. Now, I have contacted your office I think several
months ago. Are we saying that we are now within a couple of days of
reaching a conclusion?
Dr. Edwards. I think that is a fair statement; yes.
Mr. Rangel. Is it true that your Agency has authorized or given
IND numbers to physicians that have been convicted of violating the
Harrison Act?
Dr. Jennings. I don't believe that to be so, sir. I would hope not.
Mr. Rangel. Well, specifically, a doctor from the District of
Columbia. Did he have a con^dction of violating the Federal narcotic
laws when he was issued his IND, after your investigation?
Dr. Jennings. I don't know that, sir. We can check that out for you.
I hate to keep going back to history but only very recently, the re-
quu'ement of prior approval by both the Bureau of Narcotics and
Dangerous Drugs and ourselves was put into effect. It would be pos-
60-296 — 71^pt. 2 6
414
sible for someone to conceal from us certain facts that might have
resulted in his not having been granted a number. So I can't really tell
you the answer to that question. We can check it out and respond to it.
As it stands now, before anybody is approved, he will be checked out
by the Bureau of Narcotics and Dangerous Drugs for just this sort of
thing as well as b}^ the Food and Drug Administration for the scientific
merits of the protocol that he submits.
(^J^hc following information, subsequently received from. M. J.
Ryan, Director, Office of Legislative Services, FDA, was received
for the record :)
QUESTION
Is it true the FDA has authorized or given IND numbers to physicians who have
been convicted of violating the Harrison Act?
ANSWER
We have no knowledge of having given an IND number to a physician con-
victed of violating the Harrison Act. We have checked with the Bureau of Nar-
cotics and Dangerous Drugs, Department of Justice, and they do not know of any
physicians who have been convicted of violations. Investigations have been done
on IND sponsors and adverse findings have subsequently come to light concerning
physicians with IND's for methadone maintenance, flowever, we know of no
Harrison Act convictions. With the new methadone regulations now in effect, the
Bureau of Narcotics and Dangerous Drugs does a background check on each new
applicant, which would prevent this possibility.
Mr. Rangel. But, it is safe to sa}^, notwithstanding the statutory
sanction that your Agency possesses, that any unscrupulous doctor
can feel free to dispense this drug, which you have authorized to be on
the market, without fear of an^^ sanction from your particular Agency.
Dr. Jennings. We have no direct authority over that; tliat is
true.
Mr. Rangel. Has there been any other drug that has been before
the FDA that has been allowed, agreeing that you have not reached
any conclusions as to its safety, to be on the market to be used this
widely for a 7-year period without being certified?
Dr. Edwards. Probably not.
Mr. Rangel. Are there political implications to why you \\'ill not
reach a decision as to whether methadone is safe or not?
Dr. Edwards. There are no political reasons as far as we are
concerned.
Mr. Rangel. I am not talking about Democrat or Republican. I
am talking about the American Medical Association and the phar-
maceutical industry.
Dr. Edwards. No. I am referring only to the decisions we have
made on the drug.
Mr. Rangel. Is it true that your statistical data would indicate
that this drug has been used mainly in treatment of low economic
groups in this Nation?
Dr. Jennings. No. I don't think that is true, sir.
Dr. Gardner. No; that is not true. Certainly it has been used in
treatment of low economic groups, but by no means limited to that.
Mr. Rangel. I don't mean restricted, but isn't it true that the
overwhelming number of addicts being treated by methadone are in
the low-income brackets?
415
Dr. Gardner. Again, we don't have all of the figures but I would
say from what we have, "No."
Mr. Rangel. Let's talk about the cities where you have your major
clinics. Are they not located to service the inner cities?
Dr. Gardner. Many of the progTams are located in the major
cities, but by no means all. At least half of the programs are located
outside of the cities or inner cities.
Mr. Rangel. I am not talking numerically in terms of number of
clinics; I am talking about in terms of the number of patients that
are being treated by methadone. Isn't it a clear fact that the over-
whelming number of the patients that are being treated by methadone
fall into a very low economic bracket?
Dr. Gardner. No; this is not a clear fact, as yet, in many programs,
even those in the inner city, we see large numbers of patients from
middle-income groups and from the suburbs. This is one of the
things that we wanted more, better figures about, you know, why
this is going on and how this can occur. But by no means in the
figures that we have are the bulk of the patients from lower economic
groups, at least to begin with. Of course, if they have been on heroin
for a while that may occur, but by no means ■
Mr. Rangel. How far away can the American public expect the
FDA to give a professional decision as to whether or not methadone
is safe for use on human beings.
Dr. Edwards. I can't give you a specific answer on that. I think it
depends on how our new regulations work, how rapidly we are able
to accumulate meaningful data.
Dr. Jennings. I might add one thing to that, sir, in response to
your question, and in partial response to one Mr. Wiggins raised
earlier. The Dole and Nyswander study, which was the pioneer study,
was published in the open medical literature but it is onh^ within a
matter of the past several months that at our behest, and funded by
the drug companj^, an effort has been made to collect their data in a
form that would permit us to make the kind of decision you are speak-
ing about. I think we could say now, that by the usual measurements
of safety, that methadone in these dosages would be safe for a defini-
tive period of time, for perhaps a matter of a year or two or three.
We have no data on the extended range beyond that, and Dr.
Dole, of course, insists that patients who start on methadone will
persist on it for the rest of their lives.
We need to go very far to find examples of drugs that seem to be
safe for even an extended period of time, but when studies were done
that encompassed, say, perhaps 10 years, adverse effects that were
completely unsuspected began to develop, and we are currently
wrestling with just such a problem in a drug that must be adminis-
tered chronically.
Chairman Pepper. Mr. Sandman?
Mr. Sandman. I only have two questions. Dr. Casriel was here and
testified about a drug that he called Perse. Are you familiar with that
drug?
Dr. Edwards. Yes; we are.
Mr. Sandman. I came here late and if you have already discussed
this, I will withdraw the question.
416
Well, very briefly, does it have the degree of success he claims?
Dr. Gardner. We can't tell that at the moment. Our major concern
has been with the possible toxicity of the drug and we haven't been
able to get the data yet to evaluate that, and we have held up further
studies until we can meet with Dr. Revici and inspect his facilities.
Mr. Sandman. From his claims, I would assume you are going to
do that pretty quickly.
Dr. Gardner. We have scheduled two meetmgs with him already
which have been postponed at his request.
Mr. Sandman. Methadone has been used rather widely in Lexington ;
has it not?
Dr. Edwards. Yes.
Mr. Sandman. You have been using it there ever since 1963, as
far as I know.
Dr. Edwards. No.
Mr. Sandman. You have or have not?
Dr. Edwards. I don't know how long they have been using it
there. I would have to check and provide that information for the
record.
(The following information, in response to the above question, was
received by the committee from FDA :)
QUESTION
When did methadone use begin at Lexington?
ANSWER
Dr. Philhpson (Division of Narcotic Addiction and Drug Abuse, National
Institute of Mental Health) reports that methadone for detoxification of addicts
has been used since the late 1940's. He adds that they have never used methadone
for maintenance at Lexington until this year when they started it under the
NIMH methadone IND on the female ward.
Mr. Sandman. Do you have any statistics at all to provide
the value insofar as your experience at Ijexington is concerned?
Dr. Jennings. 1 haven't.
Mr. Sandman. I am interested only in those cases where it had a
real bad effect, where it did damage. During that period of time, how
many cases do you know of at Lexington, for example, where it had a
real bad effect by using it upon the addict?
Dr. Gardner. To our knowledge, its use there has been largely
short-term use and there hasn't been much
Mr. Sandman. Do you have an}^ deaths, for example, that you can
say were caused by the use of methadone?
Dr. Gardner. JSFo. Not at Lexington that we know of.
Mr. Sandman. Have you had any cases of real bad effects, perma-
nent injury?
Dr. Gardner. No.
Dr. Edwards. You mean at Lexington?
Mr. Sandman. Yes,
Dr. Gardner. No; not that we know of.
Mr. Sandman. Then it would appear from what you have said that
because wc don't have anything better to use at the present
thne, this particular drug probably is the best we can use now; is that
your position';
417
Dr. Edwards. I suspect it at least has as much potential as any
drug we currently have; yes. But, again; I think the important point
for everyone to bear in mind, we are not talking just about safety. We
are trying to determine whether or not this drug is efficacious. Nobody
has really j^et proven that this form of addiction for another foiTa of
addiction is going to solve our problem.
Mr. Sandman. I have no further questions.
Chairman Pepper. Mr. Keating?
Mr. Keating. Yes. Just a couple of brief questions. I am concerned
about the use of methadone by private physicians. Is it your thought
to limit the application or the dispensing of methadone to only clinical
areas and under the clinical environment?
Dr. Edwards. This will iiave to be worked out with the Depart-
ment of Justice. As of the moment, any doctor that obtains a nar-
cotics license can, in fact, use these drugs.
Mr. Keating. I understand.
Dr. Edwards. I think some changes will have to be made.
Mr. Keating. I understand that. Do you intend to seek those
changes that are necessary?
Dr. Edwards. It again would have to come about through the
Department of Justice but it would certainly be my recommendation
that certain changes be made.
Mr. Keating. Recommendations would have to come from you
before they would take any action.
Dr. Edwards. Yes.
Mr. Keating. But yoa intend to make those recommendations?
Dr. Edwards. Yes; in a general way. This has to be done, however,
with caution, because we certainly do not want to obstruct the
conscientious good practicing physician from being able to use metha-
done in a way other than just for methadone maintenance. How you
cut one off and turn one on is a difficult problem.
Mr. Keating. I understand that, but do your statistics indicate
that the greater source of illicit use of methadone is from the clinical
atmosphere, from the private physician or from the manufacturer?
Dr. Edwards. I think currently it is from the small individual
practitioner that is perhaps carrying on a large program in vvhich
he doesn't have adequate facilities or adequate manpower to keep
track of what is going on in the study.
Mr. Keating. Or to make proper reports.
Dr. Edwards. Right. Exactly. Recordkeeping.
Mr. Keating. It seems to me that the use of methadone would
require very strict supervision and investigation to be sure that we
are not creating a nation of addicts by the use of a mamtenance
program.
Dr. Edwards. This is exactly right. This is whj^ we have put
together these regulations. There are going to have to be additional
regulations as we move along. Particularly if the drug is accepted as
safe and efficacious in the treatment of this particular condition.
Mr. Keating. Now, we are talking about maintenance and the
use of methadone. Does it fall within your province to suggest that
methadone be used primarily for withdrawal from the habit, or do
you take a position on that, whether it should be used for maintenance,
418
maybe the rest of their lives, or whether it should be used only for
withdrawal.
Dr. Edwards. Yes. Part of what we approve the drug on are the
indications for the use of the drug and this all goes, of course, in the
labeling for the use of the drug. In other words, what are the specific
indications.
Mr. Keating. I guess what concerns me is that we constantly
center these discussions that we have on maintenance programs and
we don't seem to be talking enough about withdrawal, the withdrawal
and rehabilitation process.
I am not accusing you of this by any matter of means, because
yours is a limited area, I think, as far as this is concerned, but con-
stantly through these hearings I am concerned that one doctor who
is handling the dispensing of methadone says we don't tread into
that area for fear that we will discourage them from participating in
the program at all, and I am a little bit concerned that we may just
be moving in one direction which may be injurious to the national
health of our 3^oung people.
Dr. Edwards. Again, I would say your point is extremely well
taken. I share your concern, and this again is exactly the point we
are trying to make. There are an awful lot of answers we don't have
on this drug, and until we have them, I think it is the responsibility
of the FDA, the National Institute of Mental Health, the Bureau
of Narcotics and Dangerous drugs, to proceed cautiously in allowing
the use of this drug.
Mr. Keating. Well, I know that it is not easy to arrive at a jierfect
solution and I am sure that no amount of investigation will give you
a perfect solution, but I believe that we should be cautious and
should arrive at a goal that protects the country as a whole.
That is all, Mr. Chairman.
Chairman Pepper. Doctor, just two questions. If methadone is
found not to be safe, what happens to the 30,000 methadone addicts
M'ho are now being maintained on it?
Dr. Jennings. I think there has been considerable misunderstand-
ing of what our goals are here. I think if it hasn't alread}^ been done
we might submit for the record a co])y of our regulations governing
the investigation of methadone for mahitenance treatment of heroin
addiction.
These set forth, among other things, a protocol or a plan for the
investigation of methadone which requires that prior to entry into
the program, the subject or i^atient must undergo certain examina-
tions, i>hysical examination and certain laboratory studies, which
must be repeated at intervals. It is, I think, already obvious that we
are not concerned with relatively short-tei-m use of the th'ug but,
rather with extended use such as is envisioned by Dr. Dole and those
who follow his way of thinking. vSo, if it became apparent to us that
some of these routine examinations and hiboratory studies were
showing the development of abnormalities, these wou.ld have to be
weighed against whatever evidence we had for the eflicacy of the
drug.
This is always the case with a potent drug offered for serious
indications, and if the benefits to be derived outweigh the risks, then
with |jro[)er precautions the use could continue.
419
On the other hand, if serious side effects or other adverse develop-
ments showed up during the course of the investigation, it might be
that we would want to terminate the long-term use of the drug.
Chairman Pepper. Let me see if I can summarize what you are
saying. You are saying that you have not yet evaluated what the
effect of the use of methadone over a long period of time is. You are
saying also, as I understand it, that there is no immediate prospect
that you are going to abruptly cut off methadone from these programs
unless the data that comes in to you from these people who are using
the methadone treatment show disturbing effects with respect to
individuals or groups. Is that about it?
Dr. Jennings. That is correct, sir.
Chairman Pepper. Do all the 277 programs that you say you are
now o])erating conform to this protocol?
Dr. Edwards. No. We are in the ]:>rocess right now of going through
and inspecting all of the programs. We started out with the 50 or so
that we suspected probably needed inspection most. There is no
question that there are some deficiencies in a number of these programs
and vre are trying to come to grips with them.
Chairman Pepper. That was going to be my next question. What
are the deficiencies in the clinics which may be closed?
Dr. Edwards. Dr. Gardner has been involved and he can tell you
specifically what the problems are.
Dr. Gardner. Largely, the lack of adequate supervision of those
who are under treatment, lack of adequate screening procedures to de-
termine whether, in fact, somebody is addicted when they come
into the program, the lack of adequate controls of the drug as it is
used, so that it can be obtained for illicit distribution on the streets.
Chairman Pepper. Do I understand your position to be that
you do not recommend or approve the general distribution of metha-
done to every herohi addict, but that there should be an examination
of the individual before he is given methadone; is that your position?
Dr. Gardner. We think it may be useful for many people We
need to find out more about it, because w^e don't know who would do
best on methadone and who would do best with other kinds of
programs.
Chairman Pepper. But you do not recommend that it be given
indiscriminateh' to every heroin addict?
Dr. Edwards. Absolutely not. And again. Dr. Gardner pointed
out, first, we had to be assured that the}' are heroin addicts. We
don't want to make a methadone addict out of someone who isn't a
heroin addict.
Dr. Gardner. I think this is extremely important. If the physician
is going to take on the responsibility of giving a potent drug like this,
then he also has to take on the responsibilitj^ of adequately clinically
following that particular patient and keeping records on him and this
is all we are asking of the medical profession really.
Chairman Pepper. Doctor, we could ask you questions all day
but we have kept you and Dr. Gardner and Dr. Jennings long enough.
Dr. Edwards. Thank you, Mr. Chairman.
(The following material was received for the record:)
420
[Exhibit No. 17(a)]
Statement of John Jennings, M.D., Associate Commissioner for Medical
Affairs, Food and Drug Administration, Department of Health, Educa-
tion, AND Welfare
Mr. Chairman and members of the committee, I am Dr. John Jennings, Asso-
ciate Commissioner for Medical Affairs. The committee has been supphed with a
copy of my education and professional background. Commissioner Edwards has
asked me to extend his regrets that a previous commitment prevents his being here
to discuss with j-ou current research in the treatment of narcotic addiction.
We are all aware of the extent of the drug abuse problem and the increasing
public concern about heroin addiction, in particular. A variety of therapeutic
approaches, many with some partial success, have been utilized over the past
several yesirs — ranging from chronic hospitalization through residential programs
such as Synanon, to outpatient psychotherapeutic efforts. The time, manpower,
and money required in all of these approaches have resulted in only limited success,
making a successful chemical therapeutic agent an attractive alternative.
This has resulted in a search for a medication that would block the euphoric
effect of herion for addicts, prevent withdrawal symptoms, be eJBfective orally, long
acting, free from toxic effects, and compatible with normal performance and
reasonable behavior. The addict would have to be freed of his craving or hunger
for heroin.
Methadone is currently under study for the maintenance treatment of narcotic
addiction. It has been an effective analgesic since it was synthesized at the end of
World War II. Although for more than a decade it has been known that low oral
doses of methadone would allay withdrawal symptoms, not until 1963 was it
first observed that large oral doses could block the euphoric effects of even high
doses of other opiates or synthetic narcotics. Thus, the current widespread interest
in methadone for the maintenance treatment of heroin addicts.
Methadone is a marketed drug that has been approved through the new
drug procedures for three specific uses: As an analgesic, an antitussive, and for
treatment of withdrawal symptoms in heroin addiction. The last refers to the
short-term treatment of the acute symptoms resulting from the withdrawal of
heroin from those who have become physiologicalh^ dependent.
Maintenance treatment of heroin addiction with methadone is investigational
because substantial evidence of its safety and effectiveness for this use is not yet
available. Although there are studies which suggest that methadone maintenance
may be effective for some heroin addicts over a period of at least months, and
perhaps a few years, we are only now beginning to obtain the kind of information
which may eventuall}' permit us to define the place of this drug in the treatment
of heroin addiction.
Because it was available on prescription, the use of methadone for maintenance
therap.y became quite widespread following the early reports of success by Dole
and Nyswander.
In order to collect the type of scientific data needed to support approval of a
new use of a drug, it was necessary that the maintenance programs follow protocols,
including recordkeeping, that could yield such data. Investigational studies of
methadone present problems not encountered in studies with other types of drugs
because it is an addicting narcotic with a proven capacity for abuse.
Therefore, to protect the community from the hazards of diversion and abuse,
and to assure the development of valid data, guidelines for methadone main-
tenance studies were developed tlirough the cooperation of the National Institute
of Mental Health, the Bureau of Narcotics and Dangerous Drugs, and the Food
and Drug Administration. These guidelines were published in the Federal Register
on April 2, 1971. Prior approval of both the Food and Drug Administration and
the Bureau of Narcotics and Dangerous Drugs, Department of Justice, is required
before such studies may be initiated.
Heroin addicts do not constitute a homogeneous population and proper treat-
ment requires that we have some knowledge about which addicts may benefit
from this treatment approach in contrast to other tht^rapy.
Some investigators have reported that 70 to 80 percent of treated addicts are
rehabilitated as judged bj^ reduction in criminal activity, improvement in employ-
ment status, or schooling. Most of these reports, however, have not given adequate
consideration to the bias produced by patient selection. Some idea of the difficulty
of interpreting such studies can be gained from a most recent evaluation of one
421
of the best known programs. Although the program had a very broad criteria for
admission, more applicants were not admitted to the study than were admitted.
In general, those patients admitted to the study and remaining in treatment,
when compared to the overall heroin addict population, tended to be older, more
often white, and in better health. This group, which had an improved employment
status and reduced criminahty, was not representative of the total heroin addict
population. Therefore, this study, as well as others reported to date, cannot be
used to generahze the results to the entire addict population.
Whether those not accepted for treatment would have fared as well as those
accepted is unanswered. Reports have not provided the kind of data that enables
better patient selection. Also, data are needed to distinguish the role played by
the drug itself from the role played by the psychological, social, and occupational
rehabilitative efforts in such programs; a mai'ked proliferation of programs may
produce many in which only the drug is used and no rehabilitation is provided.
Methadone maintenance treatment ma}' be a valuable therapy in reducing
heroin addiction, but we believe it is wise to proceed cautiously in moving toward
its general prescription use for this purpose. We need better evidence to determine
the safet.y of this treatment. One of the hazards of methadone treatment is that
young drug users who are not ph3'siologicall3' dependent on heroin might become
addicted to methadone as a result of treatment. We do not wish to have a poten-
tially valuable therapy discredited because of its misuse by some practitioners
while its efficacy is being evaluated.
We now have 257 investigational new drug exemption (IND) numbers assigned
to sponsors representing 277 methadone treatment programs. We have requested
6-month status reports from these programs instead of the customary annual
reports, in order to obtain adequate data as soon as possible.
We expect our recently published regulations to serve as a valuable tool in
insuring compliance with existing requirements. In this regard, we have recently
undertaken a program for the inspection of all methadone maintenance studies.
By mid-July, we will have completed inspection of an initial 40 to 50 programs
throughout the country, selected on the basis of various criteria.
In addition to achieving correction of any deficiencies, we hope to stimulate
improved practices and better data collecting procedures. In these inspections,
whenever possible, medical officers from our Bureau of Drugs will accompany
district field inspectors. Bj^ the end of the year all programs will have been in-
spected. All of this will be done in close cooperation with the Bureau of Narcotics
and Dangerous Drugs, which in addition has its own program for surveillance of
the methadone studies.
When necessary, a sponsor will be given a time limit to correct deficiencies or
face loss of his investigational status. However, before a program is terminated,
we will contact local health departments, medical societies, and other approved
methadone maintenance programs in an effort to insure that continuing treatment
for the addicts is available.
In addition to review by our own personnel, we have appointed a committee of
outside experts to assist in evaluating data as it accumulates, as well as other
aspects of the ongoing programs. The committee will also be called on to assist
in reviewing any new drug applications for methadone maintenance.
The concept of narcotic blockade has stimulated a search for other drugs, drugs
with no addicting potential, with greater safet.y and of longer duration than
methadone. Acetylmethadol promises some hope in that its duration of action is
72 hours in contrast to the 24 hours in which methadone remains effective. Thus,
an addict could take his medication, even under supervision, on a twice weekly
basis. However, the possible toxicity of acetylmethadol needs further study.
Cyclazocine is another narcotic antagonist that has been studied for the treat-
ment of heroin addiction. Its use has been limited, however, because it has some
narcotic actions of its own, can produce respiratory depression, and may be
addicting.
Naloxone, recently approved for marketing as a narcotic antagonist, has some
similarity to cyclazocine but lacks its narcotic actions, and in particular, does no
produce respiratory depression. Naloxone has no reported addictive potential bu
its short duration of action, 4 to 6 hours, limits its usefulness. It has also, like
cyclazocine, been tested on a pilot study basis for the treatment of heroin addic-
tion. It is hoped that similar agents having the properties of naloxone but a longer
duration of action can be synthesized.
To reduce the availability of addictive drugs, a variety of agents are being
synthesized and tested to obtain a potent analgesic with no abuse potential. Four
422
such analgesic agents are currently under investigation. In addition, the search
continues for a safe and effective iolocking agent in the treatment of heroin and
other forms of addiction. Only a limited number of drugs have reached the stage
of animal testing and a very few have become available for clinical tests in humans.
The FDA is eager to expedite the investigation and ultimate marketing of any
safe, effective agent in this vital area of pharmacology.
[Exhibit No. 17(b)]
Department of Health, Education, and Welfare,
Public Health Service, Food and Drug Administration,
May 1/t, 1971.
TO: State health officers and State and local drug program officials.
FROM: Glenn W. Kilpatrick, director. State services staff, ACFC.
Subject: Investigation of methadone maintenance programs.
Although methadone has shown promise as a pharmacological treatment for
drug addicts, it is still subject to the investigational new drug requirements of
Federal Food, Drug, and Cosmetic Act. It may be dispensed legally for this pur-
pose only through qualified investigators for bona fide investigational use until
adequate evidence for its long-term safety and effectiveness in this treatment is
established. It is also a controlled narcotic subject to the provisions of the Com-
prehensive Drug Abuse Prevention and Control Act of 1970 and has been shown
to have significant potential for abuse. Accordingly, prior approval for methadone
maintenance programs must be obtained from the Bureau of Narcotics and Dan-
gerous Drugs, U.S. Department of Justice, as well as the Food and Drug
Administration.
The Food and Drug Administration and the Bureau of Narcotics and Dan-
gerous Drugs jointly published regulations (copy enclosed) for the investigational
use of methadone as "Conditions for Investigational Use of Methadone for
Maintenance Programs for Narcotic Addicts" (Federal Register, April 2, 1971).
One of the requirements of these regulations is that sponsors of investigational
exemptions for the use of methadone must amend their submissions by June 1,
1971, to bring them into accord with the standard protocol, or to justify any
differences from the standard protocol.
The Food and Drug Administration is investigating a number of sponsors and
investigators to determine if their practices conform to legal requirements. We
have reason to believe that these investigations will result in FDA's requiring
some sponsors and investigators to either amend their procedures or have their
investigational exemptions terminated, to prevent later flagrant abuse and to
avoid having the entire methadone maintenance program discredited.
In the event that there should be terminations of any investigational methadone
maintenance programs or any other action that would result in any significant
number of addicts being left without treatment, FDA and the Bureau of Narcotics
and Dangerous Drugs will take immediate steps to notify appropriate State and
local officials in time for them to take steps to alleviate any problems that might
otherwise arise from the curtailment of the treatment.
Glenn W. Kilpatrick.
Director, State Services Staff,
Office of Assistant Commissioner for Field Coordination.
[Reprinted from Federal Register of April 2. 1971 ; 36 F.R. 6075]
Title 21 — Food and Drugs, Chapter i — 'Food and Drug Administration,
Department of Health, Education, and Welfare, Subchapter C — ^Drth^s
part li'o — new drugs
Conditions for Investigational Use of Methadone for Maintenance Programs
for Narcotic Addicts
A notice was published in the Federal Register of June 1 1, 1970 (3.i F.R. 9014),
proposing establishment (21 CFR lo0.44) of acceptable guidelines for i)rograms
for the investigation of methadone in the maintenance treatment of narcotic
addicts. The guidelines of the Bureau of Narcotics and Dangerous Drugs, Depart-
ment of Justice, were also proposed June 1 1, 1970 (;}"> F.R. 9015).
In response, a substantial number of comments were received from the medical
connnunity through the American Medical Association, Student .American
423
Medical Association, American Psychiatric Association, National Acadeni^^ of
Sciences-National Research Council, known authorities in the treatment of drug
addiction, and from individuals and municipalities currently operating methadone
maintenance programs.
The majority of the comments are in the form of objections to provisions of
the protocol and the regulation, as follows:
1. The criteria in the protocol for the exclusion of subjects from the studies:
Pregnancy, psychosis, serious physical diseases, and persons less than 18 years of
age.
2. The requirement in the protocol that no more than a .3-day supply be given
to a subject at one time.
3. The necessity for making records available to the Food and Drug Adminis-
tration and to the Bureau of Narcotics and Dangerous Drugs and the lack of a
guarantee of confidentiality of patient records.
4. The requirement that one of the objectives of the studies be a return to the
drug-free state.
5. The requirement that the dosage level be limited to 160 milligrams per day.
6. The necessity of obtaining prior approval from the Bureau of Nacrotics and
Dangerous Drugs.
7. The requirements for weeklj" urine analysis and other laboratory tests and
examinations.
8. The classification of the use of methadone in the maintenance treatment of
narcotic addicts as an investigational use.
9. The regulation being overly restrictive and not in the best interest of the
public.
The Commissioner of Food and Drugs, having considered the comments and
having met with representatives of interested groups, associations, and individuals
for further discussion, finds that:
1. The majority of the comments are a result of interested persons interpreting
the proposal as restricting investigators to the suggested protocol. This is a
misinterpretation since the protocol is intended only as a guide to assist the
profession, municipalites, organizations, and other groups who are interested in
sponsoring programs for the investigation of methadone in the maintenance
treatment of narcotic addicts. It is not intended that every methadone program
be confined to the limits of this protocol. Modification of the protocol and com-
pletely different protocols will be accepted, provided they can be justified by the
sponsor. Modifications and completely different protocols consistent with public
welfare and safetj' will be approved.
2. Since the suggested protocol is intended as an aid to those who wish to spon-
sor programs for the investigation of methadone in the maintenance treatment of
narcotic addicts, it is recognized that it would be to the benefit of the Food and
Drug Administration, the Bureau of Narcotics and Dangerous Drugs, and the
sponsors of the investigations to have a suggested protocol that would be ac-
ceptable to the majority of sponsors while satisfying the requirements of the two
aforementioned agencies. Accordingly, the following revisions have been made in
the regulation as adopted below:
a. The provision of the protocol "Criteria for exclusion from the program" has
been changed to "Patients requiring special consideration." Pregnancy, psychosis,
serious physical disease, and being less than 18 years of age are not reasons for
automatic elimination from a program but are conditions that merit special con-
siderations which are detailed.
b. A provison has been added to the protocol to permit the investigator to exceed
the dosage of 160 milligrams per day when the investigator finds it essential to do
so and describes the considerations leading to such dosage levels in his protocol.
c. The requirement for laboratory examinations at 6- month intervals has been
changed to 1-year intervals.
d. The objectives of the study have been clarified.
3. The remaining comments concerning the protocol and not m.entioned above
deal primarily with problems that can be met by submission of a modified protocol
to be judged on individual merit.
4. Regarding the objection that the recordkeeping requirements and the neces-
sity for making records available to the Food and Drug Administration and the
Bureau of Narcotics and Dangerous Drugs could violate the confidential relation-
ship between the patient and the phj^sician: The Federal Food, Drug, and Cosmetic
Act provides for promulgating regulations that require the sponsor of the drug
investigations to maintain adequate records and that these records be made
424
available to authorized personnel of the Food and Drug Administration. These
records must be adequate in the event that followup on adverse reaction informa-
tion requires identification of the patient. The Bureau of Narcotics and Dangerous
Drugs is authorized to have access to these records under the Harrison Narcotic
Act.
.5. Methadone used in the maintenance treatment of narcotic addicts is an
investigational use drug because, despite recent research gains, there remains
inadequate evidence of long-term safety and of long-term effectiveness for this
use to permit general marketability of methadone for maintenance treatment
under the Federal Food, Drug, and Cosmetic Act standards for new drugs.
6. It is necessary that prior approval for methadone maintenance programs be
obtained from the Bureau of Narcotics and Dangerous Drugs as well as the Food
and Drug Administration because of this drug's potential for abuse. The Bureau
of Narcotics and Dangerous Drugs' approval will be based on the existence of
adequate control procedvures to prevent diversion of the drug into illicit channels.
Since the applications will be submitted only to the Food and Drug Administra-
tion and reviewed simultaneously by the two agencies, the inconvenience to the
sponsor and the delay of approval will be minimal .
Therefore, pursuant to provisions of the Federal Food, Drug, and Cosmetic
Act (sees. 505, 701(a), 52 Stat. 1052-53, as amended, 1055; 21 U.S.C. 355, 371(a))
and under authority delegated to the Commissioner (21 CFR 2.120), the follow-
ing new section is added to part 130:
§ 130.44 Conditions for investigational use of methadone for maintenance
programs for narcotic addicts.
(a) There is widespread interest in the use of methadone for the maintenance
treatment of narcotic addicts. Though methadone is a marketed drug approved
through the new-drug procedures for specific indications, its use in the main-
tenance treatment of narcotic addicts is an investigational use for which substan-
tial evidence of long-term safety and effectiveness is not yet available under the
Federal Food, Drug, and Cosmetic Act standards for the general marketability
of new drugs. In addition, methadone is a controlled narcotic subject to the provi-
sions of the Harrison Narcotic Act and has been shown to have significant potential
for abuse. In order to assure that the public interest is adequately protected,
and in view of the uniqueness of this method of treatment, it is necessarj^ that
a methadone maintenance program be closely monitored to prevent diversion
of the drug into illicit channels and to assure the development of scientifically
useful data. Accordingly, the Food and Drug Administration and the Bureau
of Narcotic and Dangerous Drugs conclude that prior to the use of methadone
in the maintenance treatment of narcotic addicts, advance approval of both
agencies is required. The approval will be based on a review of a Notice of Claimed
Investigational Exemption for a New Drug submitted to the Food and Drug
Administration and reviewed concurrently by the Food and Drug Administration
for scientific merit and by the Bureau of Narcotics and Dangerous Drugs for
drug control requirements.
(b) No person may sell, deliver, or otherwise dispose of methadone for use
in the maintenance treatment of narcotic addicts until a study providing for
such use has had the advance approv^al of the Commissioner of Food and Drugs
on the basis of a Notice of Claimed Investigational Exemption for a New Drug
justifying such studies.
(c) An abbreviated Notice of Claimed Investigational Exemption for a New
Drug shall be submitted in four copies to the U.S. Food and Drug Administra-
tion, 5600 Fishers Lane, Rockville, Md. 20852. Forms entitled "Notice of Claimed
Investigational Exemption for Methadone for Use in the Maintenance Treat-
ment of Narcotic Addicts," suitable for such a svibmission may be obtained from
the above address. The submission should be signed by the person in charge of the
maintenance program who will be regarded as the responsible party and sponsor
for the exemption. (If the sponsor is a manufacturer or distributor of the drug,
the regulations as outlined in § 130.3 should be followed, except where the guide-
lines set forth below in this section are appropriate.) The notice shall contain the
following:
(1) Name of sponsor, address, and dale and the name of the investigational
drug, which is methadone.
(2) A description of the form in which the drug is purchased (for example,
bulk powder or tablet or other oral dosage form), the name and address of the
manufacturer or supplier, and a statement that the drug meets the requirements
425
of the United States Pharmacopeia or the National Formulary if recognized
therein. If it is in an oral form designed to minimize its potential for abuse, and
is not recognized in the U.S. P. or N.F., assurance that the drug meets adequate
specifications for its intended use should be provided. This information may be
obtained from the manufacturer. If bulk powder is used, a statement detailing
how it is to be formulated, the name and qualifications of the person formulating
the dosage form, and the address of where the formulating will take place if it is
to take place at any location other than the principal address of the sponsor.
(3) The name, address, and a summary of the scientific training and experience
of each investigator, and all other professional personnel having major responsi-
bility in the research and rehabilitative effort, and individuals charged with
monitoring the progress of the investigation and evaluating the safety and effec-
tiveness of the drug if the monitor is other than a physician-sponsor. An investi-
gator, other than a physicain-sponsor (and investigators immediately responsible
to a physician-sponsor and named in his submission) who has signed a form
FD-1571 or the form entitled "Notice of Claimed Investigational Exemption for
Methadone for Us e in Maintenance Treatment of Narcotic Addicts," is required
to sign a form FD-1573, obtainable from the Food and Drug Administration.
(4) A description of the facilities available to the sponsor to perform the required
tests including the name of any hospital, institution, or clinical laboratory facility
to be employed in connection with the investigations.
(.5) A statement regarding the number of subjects to be included in the program.
(6) A statement of the protocol. The following is an acceptable protocol; how-
ever, it is not to be construed that this protocol must be adhered to in order to
obtain clearance by the Food and Drug Administration and the Bureau of Nar-
cotics and Dangerous Drugs. This protocol is intended primarily as a guide for
investigators who wish guidance in what said agencies consider acceptible. Inves-
gators who wish to do so may submit modifications of this protocol or other
protocols; these will be judged on their merits.
PROTOCOL
A. Objectives. 1. To evaluate the safety of long term methadone administration
at varying dosage.
2. To evaluate the efficacy of oral methadone per se in decreasing the craving
for other narcotic drugs and in minimizing their euphoriant effect.
3. To evaluate the efficacy of methadone as a pharmacological moiety in
facilitating social rehabilitation of narcotic addicts.
4. To determine which addicts are capable of returning to an enduring drug-free
state.
B. Admission criteria. 1. Documented history of physiological dependence on
one or more opiate drugs, the duration of which is to be stated.
2. Confirmed history of one or more failures of treatment for their physio-
logical dependence on opiates.
3. Evidence of current physiological dependence on opiates.
An exception to the third criterion (current physiological dependence on opiates;
is allowable in exceptional circumstances for certain subjects for whom methadone
maintenance may be initiated a short time prior to or upon release from an institu-
tion. This procedure should be justified on the basis of a historj^ of previous
relapses. In these circum.stances, appropriate descriptions of the facilities, pro-
cedures, and qualifications of the personnel of the institution are to be included in
the application filed by the sponsor.
Subjects who wish to do so may be transferred from one approved program to
another.
C. Patients requiring special consideration — 1. Pregnant patients. Safe use of
methadone in pregnancy has not been established. There is limited documented
clinical experience with pregnant patients treated with methadone, and animal
reproduction studies have not been done. It is therefore preferable that pregnant
patients be hospitalized and withdrawn from narcotics. If such a course is not
feasible, pregnant patients may be included provided the patient is informed of
the possible hazard. To minimize the risk of physiological dependence of the new
born, or other complications, pregnant women should be maintained on minimal
dosage. The investigator should promptly report to the Food and Drug Adminis-
tration the condition of each infant born to a mother in a methadone maintenance
program.
2. Patients with serious physical illness. Patients with serious concomitant
physical illness are to be included in methadone maintenance program only when
426
comprehensive medical care is available. Such patients require careful observa-
tion for any adverse effects of methadone and interactions with other medications.
The investigator should promptly report adverse effects and evidence of inter-
actions to the Food and Drug Administration.
3. Psychotic patients. Psychotic patients may be included in methadone main-
tenance programs when adequate psychiatric consultation and care is available.
Administration of concomitant psychotropic agents requires careful observation
for possible drug interaction. Such occurrences should be promptly reported.
Investigators who intend to include in their programs patients in categories 1,
2, and/or 3 above should so state in their protocols and should give assurance of
appropriate precautions.
4. Patients less than 18 years of age. It is imperative that adolescents be afforded
the benefit of other treatment modalities whenever possible and that those with
minimal histories of physiological dependence be excluded from methadone main-
tenance programs. Investigators who wish to include adolescents in the program
are therefore required to submit special protocols for this purpose. These protocols
should state in detail the number of such patients to be treated, the alternative
treatment methods available, the criteria for selection, the screening procedures,
and the ancillary procedures to be employed.
D. Admission evaluation. 1. Recorded history to include age, sex, history of
arrests and convictions, educational level, employment history, and past and
present history of drug abuse of all types.
2. Medical history of significant illnesses.
3. History of prior psychiatric evaluation and/or treatment.
4. Assessment of the degree of physical dependence on and psychic craving
for narcotics and other drugs, and evaluation of the attitudes toward and moti-
vations for participation in the program.
5. Formal psychiatric examination in subjects with a prior history of psychiatric
treatment and in those in whom there is a question of psychosis and/or competence
to give informed consent.
6. Physical examination.
7. Chest X-ray.
8. Laboratory examinations to include complete blood count, routine urinalysis,
liver function studies (including SGOT, alkaline phosphatase, and total protein
and albumin globulin ratio), blood urea nitrogen, and serologic test for syphiilis.
E. Procedure. — 1. Dosage and administration. The methadone is to be adminis-
tered in an oral form so formulated as to minimize misuse by parenteral injection.
The initial dosage is to be low ; for example, 20 milligrams per day. Subsequently,
the dosage is to be adjusted individually, as tolerated and as required, up to 160
milligrams per day. In exceptional cases, investigators may find it essential to
exceed this dosage to obtain the intended effect. If such cases are encountered,
the initial protocol or an amended protocol should include the maximum dosage
to be administered, the number of patients for whom such dosage is required, and
a description of the considerations leading to svich dosage levels. The methadone
is to be administered under the close supervision of the investigator or responsible
persons designated by him. Initially, the subject is to receive the medication under
observation each day. After demonstrating adherence to the program, the subject
may be permitted twice weekly observed medication intake with no more than a
3-day supply rountinel^y allowed in his possession. Additional medication may
])e provided in exce]3tional circumstances, such as illness, family crisis, or necessary
travel, where hardship would result from reciuiring the customary observed
medication intake for the specific period in question.
2. Urinalysis. Urine collection is to be supervised; urine specimens are to be
analyzed for methadone, morphine, quinine, cocaine, barbiturates, and ampheta-
mines; urine specimens are to be pooled or selected randomly for analj'sis at
intervals not exceeding 1 week.
3. Rehabilitative measures. Rehabilitative measures as indicated may include
individual and/or grouj) psychotherapy, counseling, vocational guidance, and job
and educational placement.
4. Abnormalities. There shall be adequate investigation and appropriate
management (including necessary referral and consultation) of any abnormalities
detected on the basis of history, {)liysical examination, or laboratory examination
at the time of admission to the program or subsequently-, including evaluation
and treatment of intercurrent physical illness with observation for complications
which might result from methadone.
427
5. Repeated examinations. Physical examination, chest X-ray, and laboratory
examinations conducted at the time of admission are to be repeated annually.
6. Discontinuation and followup. Consideration is to be given to discontinuing
the drug for participants who have maintained satisfactory adjustment over an
extended period of time. In such cases, followup evaluation is to be obtained
periodically.
7. Records. Adequate records are to be kept for each participant on each aspect
of the treatment jjrogram, including adverse reactions and the treatment thereof.
F. Other special procedures. Within the limitations of personnel, facilities, and
funding available and in the interest of increasing knowledge of the safety and
efficacy of the drug itself, the following procedures are suggested as worthwhile,
to be carried out at baseline and periodically in randomly selected subjects:
EKG, EEG, measures of respiratory, cardiovascular, and renal function, psy-
chological test battery, and simulated driving performance.
G. Voluntary and involuntary terminations. Subjects v/ho have demonstrated
continued frequent abuse of narcotics or other drugs, alcoholism, criminal activity,
or persistent failure to adhere to the requirements of the program are ordinarily to
be terminated and their records should reflect that they are treatment failures.
If they are continued indefinitely in the program, the reasons for so doing should
be sta-ted in the protocol.
H. Results. 1. Evaluation of the safety of the drug administered over prolonged
periods of time is to be based on results of physical examination, laboratory
examinations, adverse reactions, and results of special procedures when these
have been carried out.
2. Evaluation of effectiveness or rehabilitation is to l:>e based on such criteria as:
a. Arrest records.
b. Extent of alcohol abuse.
c. Extent of drug abuse.
d. Occupational adjustment verified by employers or records of earnings.
e. Social adjustment verified whenever possible by family members or other
reliable persons.
f. Withdrawal from methadone and achievement of an enduring drug-free
status.
3. Evaluations are to be recorded at predetermined intervals; for example,
monthly for the first 3 months, at 6 months, and at 6-month intervals thereafter.
I. Evaluation group. Whenever possible, a locally oriented independent evalua-
tion committee of professionally trained and qualified persons not directly involved
in the project nor organized hy the sponsor will inspect facilities, interview
personnel and selected patients, and review individuals' records and the periodic
analysis of the data.
(d) The sponsor shall assure that adequate and accurate records are kept of
all observations and other data pertinent to the investigation on each individual
treated. The sponsor shall make the records available for inspection by authorized
agents of the Food and Drug Administration. The Bureau of Narcotics and
Dangerous Drugs is also authorized to inspect these records under the Harrison
Narcotic Act.
(e) The sponsor is required to maintain adequate records showing the dates,
quantity, and batch or code marks of the drug used. These records must be
retained for the duration of the investigation.
(f) The sponsor shall monitor the progress of the investigations and evaluate
the evidence relating to the safety and effectiveness of the drug. Accurate progress
reports of the investigation and significant findings shall be submitted to the
Food and Drug Administration at intervals not exceeding periods of 1 year. All
reports of the investigation shall be retained for the duration of the investigation.
(g) The sponsor shall promptly notify the Food and Drug Administration of
any findings associated with the use of the drug that maj' suggest significant
hazards, contraindications, side effects, and precautions pertinent to the safety
of the drug.
(h) The phj'sician-sponsor or individual investigators in admitting addicts
to the investigational treatment program are required to give to the addict an
accurate description of the limitations as well as the possible benefits which the
addict may derive from the program.
(i) The physician-sponsor or each individual investigator of this program
shall certify that the drug will be used and administered only to subjects under
his personal supervision or under the supervision of personnel directly respon-
sible to him; a statement to this effect shall be included in the notice. The sign-
428
ing of the form "Notice of Claimed Investigational Exemption for Methadone
for Use in the Maintenance Treatment of Narcotics Addicts" by a physician-
sponsor or the form FD-1573 by an investigator will satisfy this requirement.
(j) The physician-sponsor or each individual investigator shall certify that
all participants will be informed that drugs are being used for investigational
purposes, and will obtain the informed consent of the subjects and shall include
a statement to this effect in the notice. The signing of the forms as indicated in
paragraph (i) of this section will satisfy this requirement.
(k) Failure to conform to the protocol for which approval has been received
from the Food and Drug Administration and the Bureau of Narcotics and Dan-
gerous Drugs will be a basis for termination of the claimed investigational
exemption.
(1) The sponsor of a "Notice of Claimed Investigational Exemption for a
New Drug" already on file with the Food and Drug Administration should
review and amend his submission to bring it into accord with the acceptable
protocol where appropriate within 60 days after the effective date of this sec-
tion. All differences in his protocol from the suggested protocol should be justified.
(m) Provisions under the Harrison Narcotic Act enforced by the Department
of Justice are applicable to this use of methadone.
Elective date. This order is effective upon publication in the Federal Register
(4-2-71).
(Sees. 505, 701(a), 52 Stat. 1052-53, as amended, 1055; 21 U.S.C. 355, 371(a))
Dated: March 25, 1971.
Charles C. Edwards,
Commissioner of Food and Drugs.
Title 26 — Internal Revenue Chapter I — Internal Revenue Service,
Department of the Treasury Subchapter A — Income tax [T.D. 7100]
[Treasury Decision 7076]
PART 151 regulatory TAXES ON NARCOTIC DRUGS ADMINISTERING AND DIS-
PENSING requirements
On June 11, 1970, there was published in the Federal Register, 3.5 F.R. 9015,
9016, a notice of proposed rule making amending §151.411 of Title 26 of the Code
of Federal Regulations in order to make clear the conditions upon which practi-
tioners may administer or dispense narcotic drugs in the course of conducting
clinical investigations in the development of methadone maintenance rehabilita-
tion programs. Essentially, the proposal would require that practitioners obtain
approval prior to the initiation of such an investigation by submission of a Notice
of Claimed Investigational Exemption for a New Drug to the Food and Drug
Administration which would then be reviewed concurrentlj^ by that agenc.v for
scientific merit and by the Bureau of Narcotics and Dangerous Drugs for drug
control requirements.
This proposal was published in conjunction with a notice of proposed rule
making published bv the Commissioner of Food and Drugs for addition of a new
section to Part 130 "of Title 21 of the Code of Federal Regulations. Among other
matters this notice contained acceptable criteria and guidelines agreed upon by
the Food and Drug Administration and the Bureau of Narcotics and Dangerous
Drugs for the conduct of clinical investigations of this nature. Since the original
publication of both of these notices, two extensions of 30 days each have been
granted for the receipt of additional written comments. After extensive review of
the written comments received, both agencies have agreed upon certain altera-
tions in the proposed criteria and guidelines which are designed to facilitate
further research and to accommodate the diverse needs and interest of the
scientific communitv. These changes have been effected bv appropriate modi-
fication of the new "section to be added to Part 130 of Title 21 of the Code of
Federal Regulations published elsewhere in this issue of the Federal Register.
Inasmuch as the bulk of comments received concern the criteria and giiidelines
appearing originally in that proposal, no modifications of the proposed amendment
to §151.411 of Title 26 of the Code of Federal Regulations as published on June 11,
1970, have been undertaken.
As previously set forth, it is recognized that the investigational use of metha-
done, a class "A" narcotic drug requiring the prolonged maintenance of narcotic
dependence as part of a total rehabilitation effort, has shown promise in the man-
429
agement and rehabilitation of selected narcotic addicts. In addition, it is a drug
which has been shown to have a significant potential for abuse. The amendment
which follows is designed to clarify the conditions under which it may be used for
the specific investigational purpose indicated until such time as the results of
present and future clinical investigations may indicate the necessity for reevalua-
tion of current uses and control mechanisms. It does not authorize the prescribing
of narcotic drugs for any such piu-pose, see 26 CFR 151.392. Moreover, it does
not affect any other uses of narcotic drugs, or waive an.y requirements concerning
the control, security, use, transfer, or distribution of narcotic drugs imposed by
other Federal narcotic laws or regulations. The amendment shall become effective
as of date of this publication; however, those practitioners currently engaged in the
operation of a bona fide clinical investigation shall have a period of 6U days in
which to submit or resubmit a Notice of Claimed Investigational Exemption for
approval.
Accordingly, under the authority previously cited in the notice of proposed
rule making published in the Fedekal Register on June 11, 1970, 35 F.R. 9015,
9016, the word "Dispensing" preceding § 151.411 of Part 151 of Title 26 of the
Code of Federal Regulations is hereby deleted and § 151.411 is amended to read
as follows:
§ 151.411 Administering and dispensing.
(a) Practitioners ma.y administer or dispense narcotic drugs to bona fide
patients pursuant to the legitimate practice of their profession without
prescriptions or order forms.
(b) The administering or dispensing of narcotic drugs to narcotic drug dependent
persons for the purpose of continuing their dependence upon such drugs in the
course of conducting an authorized clinical investigation in the development of a
narcotic addict rehabilitation program shall be deemed to fall within the meaning
of the term "in the course of professional practice" in sections 4704(b)(2) and
4705(c)(1) of title 26 of the United States Code: Provided, That approval is
obtained prior to the initiation of such a program by submission of a Notice of
Claimed Investigational Exemption for a New Drug to the Food and Drug
Administration which will be reviewed concurrently by the Food and Drug
Administration for scientific merit and by the Bureau of Narcotics and Dangerous
Drugs for drug control requirements; and provided further that the clinical
investigation thereafter accords v/ith such approval; see 21 CFR 130.44. The
prescribing of narcotic drugs is not authorized for any such piu-poses.
Effective dale. This Treasury decision shall be effective when published in the
Federal Register (4-2-71).
Dated: March 25, 1971.
[seal] John E. Ingersoll,
Director, Bureau of Narcotics and Dangerous Drugs,
Department of Justice.
Randolph W. Thrower,
Commissioner, Internal Revenue Service,
Department of the Treasury.
Approved: March 25, 1971.
Edwin S. Cohen,
Assistant Secretary of the Treasury.
Chairman Pepper. Now we will call Dr. Brown.
Our next witness is both a distinguished doctor and a devoted
public servant, Dr. Bertram S. Brown, Director of the National
Institute of Mental Health, and Assistant Surgeon General of the
U.S. Public tiealth Service. Dr. Brown received his medical educa-
tion at Cornell University Medical College and he also holds a master
of public health degree from the Harvard Universitv School of Public
Health.
Dr. Brown began his career with the Public Health Service in
1960 as a staff psychiatrist with the Mental Health Study Center
and held various positions of increased responsibility before be-
coming Director of NIMH.
60-296— 71— pt. 2-
430
He has served as a consultant to four Presidential commissions,
most recently as Executive Secretarj^ of the President's Task Force
on the Mentally Retarded.
Appearing with Dr. Brown is Dr. Robert van Hoek, Associate
Administrator for 0])erations of the Health Services and Mental
Health Administration.
Who else accompanies you, Dr. Brown?
Dr. Brown. I have to my left Mr. Karst Besteman, Acting Di-
rector of the Division of Narcotics and Drug Abuse, and Dr. WUliam
Martin, Chief, Addiction Research Center, National Institute of
Mental Health, of Lexington, who is scheduled as a witness.
Chairman Pepper. We are glad to have these gentlemen accom-
pany you.
Mr. Perito, you may inquire.
Mr. Perito. Thank you, Mr. Chairman.
Dr. Brown, you have submitted an extensive statement to us with
several attachments. I take it you want to submit your prepared
statement for the record, accompanied by the attachments. I untler-
stand part of your prepared statement contains responses to certain
questions which the chairman directed to you and the secretary for
the record?
STATEMENT OF DR. BEETRAM BROWN, DIRECTOR, NATIONAL IN-
STITUTE or MENTAL HEALTH, HEALTH SERVICES AND MENTAL
HEALTH ADMINISTRATION, DEPARTMENT OF HEALTH, EDUCA-
TION, AND WELFARE; ACCOMPANIED BY DR. ROBERT VAN HOEK.
ASSOCIATE ADMINISTRATOR FOR OPERATIONS OF THE HEALTH
SERVICES AND MENTAL HEALTH ADMINISTRATION: KARST
BESTEMAN, ACTING DIRECTOR OF THE DIVISION OF NARCOTICS
AND DRUG ABUSE ; AND DR. WILLIAM MARTIN, CHIEF. ADDIC-
TION RESEARCH CENTER, LEXINGTON, KY.
Dr. Brown. Yes, sir.
Chairman Pepper. Then, without objection, the full statement
with the enclosures, will be received in the record. You may proceed.
Mr. Perito. I understand you want to read the first part of that
statement; is that correct. Dr. Brown?
Dr. Brown. I would like Dr. van Hoek to make a brief statement
on behalf of the Administrator of Health Services and Mental Health
Administration, the agency in which NI^^-I is located.
Chairman Pepper. Proceed as you will. Doctor.
Dr. van Hoek. Mr. Chairman, because of the time problem —
with your permission, and due to the time problem — I will insert the
opening statement for the record, and let Dr. Brown ])roceed.
Chairman Pepper. Very well. Without o])jection, it will be received.
(The statement referred to follows:)
[Exhibit No. 17(c)]
Statement by Dr. Robert van Hoek, Associate Administrator for Opera-
tions, Health Services and Mental Health Administration, Department
OF Health, Education, and Welfare
Mr. Chairmiin and members of the committee, it i^* a pleasure to appear before
you with Dr. Brown and Dr. Martin to discuss the critical issue of drug abuse.
431
As the agenc.v within HEW which carries the primary respoiLsibiUty for liow
health services are organized and delivered to the American people, the Health
Services and Mental Health Administration performs a wide variety of functions.
These range from supporting basic and applied research — including that in the
area of drug abuse which is our primary focus today, collecting and disseminating
data on health services delivery, to stimulating innovative approaches to the
delivery of health services.
Drug abuse has been a long-term concern of the medical profession and of
public health officials. Opiates were a frequent basic ingredient of widely available
patent medicines prior to the passage in 1914 of the Harrison Narcotic Act.
Attempts to deal with widespread noncriminal addiction through public clinics
during the 1920's were fraught with problems — mostly of inadequate control
over the continued use of drugs. While truly accurate statistics have never been
available, it is generally conceded that the percentage of the American population
addicted to narcotics reached its height in the United States prior to the passage
of the Harrison Narcotic Act, and gradually decreased after 1914. During World
War II traditional sources of supply were cut off, greatly diminishing the e.xtent
of the problem.
By the 1950's, use again increased over prewar levels, mostly concentrated
among minority group members living in ghettos of the large urban centers.
The last decade has witnessed an increase, with some youthful middle class
involvement beginning in the late 1960's. Our best current estimate is that ap-
proximately 250,000 persons are addicted to narcotics. It must be remembered
that no current estimates on the extent of drug abuse are wholly satisfactor\\
Clearly, drug addiction, in addition to being a social, legal, and moral problem
is a major medical and health problem. At the physiological-clinical level not
only does overdosage often lead to tragic deaths — especially among very young
users — but narcotics also pose significant dangers because of the associated
medical problems of serious liver involvement (hepatitis) and other types of
infections deriving from the use of nonsterile needles.
Drug abuse must also be viewed from the standpoint of the mental health
and health services system. How can both the acute and the chronic needs of
these physically and psychologically ill persons be met? The nature, the growth
and the geographical distribution of drug addiction present unusual challenges
to the American health care system.
Physicians — pediatricians, internists, family physicians, and others — need to
rapidly acquire the skills and information needed for them to work effectively
with addicts and other drug abusers. Unless physicians are knowledgeable about
the early signs of drug addiction, about the management of acute crises —
especially withdrawal — and about various treatment methods, there is little hope
that they can provide the leadership which is expected of them.
A wide variety of health and medical comjoonents need to be involved in
community drug abuse activities. These include emergency services, inpatient
units of general hospitals, neighborhood health centers, community mental
health centers. State mental hospitals, and health services in special settings
such as prisons. The necessarj^ arrangements must be developed to insure con-
tinuity of care for patients and the proper coordination of various health services.
We expect that health maintenance organizations, in collaboration with specialized
drug addiction services and with community mental health centers, can take
significant steps to provide emergency and continuing medical treatment for
narcotic addicts. I also anticipate that several of the experimental health services
planning and delivery projects being developed by the Health Services and
Mental Health Administration will include a major drug addiction component.
As you will shortly hear from Dr. Brown and Dr. Martin, Federal research
efforts in the area of drug abuse have grown considerably in recent years. How-
ever, it is also obvious that we are only a small wa.v down the road toward any
complete understanding of the cause, treatment, and prevention of drug abuse.
The Health Services and Mental Health Administration is pleased that one of
its major components, NIMH, is now taking a lead role within the Department,
as well as within the total Federal Government, in inci'easing our knowledge of
the complex problem of drug abuse.
Thank you for providing me with this opportunity to express my enthusiastic
interest in our common endeavor.
432
STATEMENT OP DR. BROWN
Dr. Brown. Mr. Chairman, I would like just to read brief portions
of the statement, not the attachments, and then turn to Dr. Martin,
and I would be more than pleased to return after lunch for additional
questions and answers mth the committee, if you wish.
Chairman Pepper. All right, Doctor, you may proceed. We will
recess at 12:30 and we will receive you back at 1:30, if you will.
Dr. Brown. It is both a pleasure and an honor, Mr. Chairman,
to be here today to testify for the National Institute of Alental
Health, which is the lead agency for the non-law-enforcement aspects
of the drug abuse jiroblem. In addition to sponsoring a broad program
of research into the drug abuse problem, the Institute is also funding
treatment, training, and prevention jirograms through public informa-
tion and education approaches. I recognize that the committee's
primary interest is in the Institute's research programs, but I am
aware that you would also like to have some questions and answers
and discussion on the treatment and rehabilitation scene, and we will
be more than pleased to deal with that. We regard the drug abuse
problem as a unitary one so that I may at times refer to the Institute's
treatment, training, and prevention efforts.
The Institute is sponsoring research regarding each of the five
-categories of commonly abused drugs. They are briefly: (1) Opiate
drugs, also called narcotics; (2) sedative drugs, including barbiturates;
(S) stimulant drugs, including am])lietamines; (4j hallucinogenic
■drugs, including LSD ; and (5) marihuana and related drugs, such as
tetrahydrocannabinol. With regard to each of these drug categories.
Institute research ]>rojects are focused on the follomng topics:
(a) Understanding the mechanism of action of these drugs.
(6) Studying factors which affect the development of tolerance or
physical dependence which, in turn, may lead to addiction.
(c) Studying the effects of these drugs of abuse in animals and
humans.
(d) Developing methods of detecting and quantifying abused drugs
in body tissues and fluids.
(e) Lastly, and perhaps most important, developing treatment
methods.
In order to understand the mechanism of action of abused drugs,
the Institute is funding research on the effects of these drugs at the
most basic cellular and molecular levels as well as on well defined
areas of the brain. In addition, studies are being carried out to deter-
mine how the body metabolizes; that is, how it handles these drugs
.and which breakdown properties of metabolites are responsible for
;their psychoactive effects.
Studies on the ways in which tolerance or physical dependence
'develops focus on biochemical, pharmacological, and behavioral
measures associated with tolerances to narcotic analgesics or pain-
killers, such as morphine. In an efl'ort to understand how addiction
•occurs, these studies are exploring the effects of narcotic analgesics
on brain proteins, RNA, and brain transmitters.
In studying the effects of drugs of abuse in animals and himir.ns,
researchers are exploring both long- and short-term effects and also
the effects of both small and large doses. Studies are concentrating on
the effects of drugs on coordination, thinking, perception, memory,
433
and complex acts such as driving. Research is also being carried out
on the potential genetic and cancer-inducing effects of these drugs,
as well as on their effects on developing fetuses, a most important area.
Research into detecting abused drugs in body tissues and fluids
includes research on opiates, barbiturates, marihuana, amphetamines,
and hallucinogens. Better methods of detection will help those who
are treating drug abusers and should reduce the expense, complexity,
and error involved in screening and monitoring both patients and
prisoners suspected of drug use. Some of these developments will also
be as useful in law enforcement as they \\dll in treatment. More
sophisticated methods for quantifying and differentiating various
types of drugs will also be useful to forensic pathologists and medical
examiners. We have underway a great deal of research to evaluate the
effectiveness of treatment and rehabilitation methods, a topic which
the committee has gone into in great depth. I will not go into great
detail on this because I think it will lend itself more quicklj^ to
questions, but let me review that area briefly.
As of March 1971, the narcotic treatment and rehabilitation pro-
grams supported by the Institute were assisting ap])roximately 2,000
l)atients imder the civil commitment program, of whom 1,300 were in
the aftercare phase of treatment, and apjjroximately 7,000 patients in
the community-based treatment programs supported by Institute
grants. Unfortunately, we cannot at present compare the results of
the civil commitment treatment program, the familiar one that usually
goes from Lexington and Fort Worth into the aftercare phase, ^\Tith
the community treiitment programs because they are treating dif-
ferei'it groups of addicts. However, at a later date it should be possible
to extract matched pairs of ])atients fi'om the two groups and com])are
their degree of benefit. To illustrate the differences in the two groups,
addicts being treated under the civil commitment program are 60
percent white and have an average age in the late twenties; whereas,
the ])atients being treated in the community centers are predominantly
black or chicano and have an average age in the earlj to mid-twenties.
In addition, the two groups are not equivalent in terms of employment
histories, arrest histories, or education. What we can say now, however,
is that 1')oth ])rograms seem to be helping a large percentage of the
])atient populations whom they axe treating.
The exact percentage of i)atients who are being helped depends on
\\'hat measure you use to evaluate the patients improvement. For
example, you can look at the precent of ]:>atients who are working, or
the percent who are staying out of jail, the percent who do not become
readdicted, the percent who have returned to school, and so on. In
the civil commitment program, a study of 1,200 patients w^ho were in
aftercare in 1970 showed that approximately 85 percent were employed,
70 percent were not arrested and spent no time in jail during that
period, 35 percent were in self-hel]3 therajiy, and 33 percent were
pursuing their education. Patients who had been in aftercare for 3
months or more were, on the average, drug-free 80 percent of the time.
A similar statement can be made regarding the heroin use of i)atients
who were in the community treatment programs. As you know, many
patients during the treatment of their addiction may abuse drugs other
than heroin occasionally, such as cocaine, marihuana, amphetamines,
or barbiturates. Of the patients in the civil commitment program who
434
had been in aftercare for 3 months or more, 60 ])ercent were not abus-
ing any (haigs. The same is true of patients who had been in the com-
munity treatment ])rogram for 3 months or more. Of the patients who
are in the civil commitment aftercare phase, we know that 60 ])ercent
do not become readdicted (ku-ing their first year in aftercare. Of the
remaining, 25 i)ercent do abuse some drugs or become readdicted and
require further hospital treatment. About 15 percent were dro])outs.
r will skip over our statement on methadone, since that has been
atiequately discussed earlier today, although I think not all of the
issues were fully brought out in the way you would like.
At this point, I do not know of any conclusive studies which demon-
strate significant differences between the benefits achieved by metha-
done and those benefits achieved by other treatment methods.
Mr. Chairman, our overview of the Institute's research program
would not be complete unless I mentioned three additional activities.
First, the Institute's program of sLii)plying standardized pure prepa-
rations of drugs of abuse to qualified researchers. Originally this
jorogram focused on distributing 1>SD to researchers through the joint
FDA-NIMH Psychotomimetic Agents Advisory Committee. With
the increased use of marihuana and related drugs, the jirogram has
ex|)anded to include a wider spectrum of drugs, including psilocybin,
radioactively tagged and imtagged tetrah^^drocannabinol (THC),
the active ingredient in marihuana, and most recently heroin for
research purposes.
At ]H"esent the Institute is not only sui)plying requests from U.S.
investigators but has established procedures with the Canadian Food
and Drug Directorate and the U.N. Narcotics Laboratory for supply-
ing antl distributing these drugs for research in C-anada and Western
Eiu'ope. Information generated by researcli ])erformed in foreign
countries should help the U.S. research program. The number of
requests for research drugs has doubled in the past year. Since this
program's inception, 650 requests for research drugs have been filled,
250 of them for marihuana or its derivatives.
Secondly, the Institute is currently |)retesting a number of educa-
tional materials including })amphlets, jiosters, workbooks, and films
to determine their usefulness in reaching different groups within the
[population. Some of the materials nud educational nuiterials, which
luive previously been developed through the Natioiuil Clearinghouse
for Drug Abuse Information, have been used in the Institute's training
])rogcam. In fiscal year 1970, this program provided 1- and 2-week
courses on drug abuse for over 1,500 professionals, allied health
workers, Government officials, and members of the public
Lastly, I might mention the i)rogram being conducted at the Addic-
tion Research Center by Dr. William Martin to develop inq)rove(l
methods of determining the abuse potential of drugs before they be-
come problems on the street or in the clinic, and to study pharma-
cological treatments for narcotic addiction. Dr. Martin and his as-
sociates are inve-^tigating the conditions under which animals will self-
administer drugs iuu\ ai'c determining the abuse potential of drugs
before they become |)i'oblems on the street or in the clinic, and to study
pharmacological ti'eatments for narcotic addiction. Dr. Martin and hi.>>
associates also ai'c iiu'cstigating the conditions un(hu' which animals
will self-i'.dminister drugs and ai'c determining to what extent each
435
(Inig induces physical and psychological dependence, behavioral
toxicity, and harmful physiological effects. At this point, I would like
to introduce Dr. William Martin, who can toll you in more detail
abou.t these research [)rograms.
I would like to turn to Dr. Martin wtio will also gi\'e an overview
of the research program at the center.
STATEMENT OE BR. WILLIAM R. MARTIN
Dr. Martin. Thank you, sir. I appreciate this opportunity to a()pear
before 3'ou today, and t would like to read my brief statement.
I am the chief of the NIMH Addiction Research Center. I am a
physician and my particular area of competence is in the area of
clinical and neuroi)sychopharmacology. I have worked the last 13
years on j^roblems related to understanding the process of dependence,
its diagnosis and its treatment.
The Addiction Research Center (ARC) is located in the Clinical
Re?search Center at Lexington, Ky., and is both a basic and clinical
research unit constituted of 56 employees, which includes six physi-
cians and seven professionals at the Ph. D., or master's level, as well
as administrative and supporting staff. The disciplines represented in
the ARC include pharmacology, psychiatry, neuroendocrinology, bio-
chemistry, drug metabolism, neurochemistry, clinical jisychology, and
physiological psychology. Our major areas of interest antl work have
fallen into two categories: (1) Prev^ention, and (2) diagnosis and
treatment of addiction.
The major thrust of the ])revention programs is to understand the
basic modes of action of the different drugs of abuse and in so doing to
develo]) methods for the assessment of their abuse potentiahty. The
ARC has develojjed methods for assessing the abuse jiotentiality of
the narcotic analgesics such as heroin, sedative-hypnotics such as
secobarbital and i^entobarbital, amphetamines such as dexedrine and
speed, and LSD-like hallucinogens, and has conducted extensive
clinical studies of the actions of marihuana and the tetrahydrocan-
nabinols. It has for many years provided advice to the National
Research Council and to the World Health Organization concerning
the abuse potentiality of new strong analgesics.
The most important contributions concerning the diagnosis and
treatment of heroin addiction that have been made are, in my opinion,
(1) the demonstration that the chronic administration of mor])hine
to both nnin and animals is associated with long-persisting abnorniali-
ties following v.ithdrawal and that these physiological abnormalities
are associated with relaj^se of postaddict animals to narcotics and
a])pear to be associated with an overresi:)onsivity to stress; (2) the role
of conditioning in relapse and in drug-seeking behavior has been
explored and in part demonstrated; (3) three narcotic antagonists,
cyclazocine, naloxone and EN-1639A, which is a drug which is very
closel}^ related to naloxone structurallv, have been studied at the ARC,
and their potential utility for the treatment of narcotic addiction has
been demonstrated and suggested. We believe that the narcotic
antagonists may be of use in extinguishing the protracted abstinence
syndrome, as well as conditioned abstinence and drug-seeking behavior.
436
The first drug that we studied with this end in view was cj'chizocine,
which is a very potent drug, but ])roduces some undesirable side effects
Avliich has made it necessary for physicians to be both knowledge-
able of its pharmacology and skilled in its use. The second drug that
was studied was naloxone, which iproved to bo a pure antagonist with-
out imdesirable side effects, but which suffered from the disadvantages
that it was short acting and quite ineffective by the oral route. We have
continued to study other narcotic antagonists and have recently in-
vestigated EN-1639A, which combines the structural features of both
naloxone and c3^clazocine, and have found that this agent is two to
three times more potent than naloxone and cyclazocine and that it
has a longer duration of action than naloxone. We have further found
that we can, for all intents and pur])ose, antagonize both tlie euphoro-
genic and the dejjendence-producing effects of large doses of morphine
with an oral dose level of 50 milligrams per day. Thus, we feel that we
have made substantial progress in finding the ideal narcotic antagonist
which meets the criteria of: (1) Being potent, 10-50 milligrams per
day; (2) having a long duration of action; (3) having no side effects,
being a pure antagonist; (4) being orally effective; and (5) being
suitable for depot administration.
Additional efforts need to be undertaken to develop not only longer
acting pure antagonists, but depots which will allow antagonists and
methadone-like drugs to be administered at 2-week to monthly intervals
and which will provide effective levels of the drug for this period of
time. If we can achieve these goals, I believe that certain motivated
addicts can be benefited by this a])proach. Because the antagonists do
not produce physical dependence and are nontoxic, they may find a
role in the treatment of the juvenile experimenter.
Turning now from the anatgonists to the general problem of drug
dependence, it is my personal, though professional, oi)inion that
mounting an effort to deal effectively with drug abuse problems
specifically and the problem of psychopathy generally should start
Anth the assumptions that we do not have an understanding of the
basic psychopathology or ]:>athophysiology of these disease ])rocesses
and that we do not have effective and nontoxic therapeutic measures
to deal with all except a small proportion of the patients incapacitated
with this disease process.
It is further my conviction that both the size of the problem and its
impact on society will continue to increase until we find definitive
solutions. The reasons for this conviction are: (1) The number of
abusable drugs will increase because of the growth of the chemical and
pharmaceutical industries, (2) the impact of psychopathic behavior
on society will become less tolerable as our society increases in size
and complexity, and (3) the complexity and stabilit}^ of our society
lessens the im})act of social controls on i)sychopathic behavior. Be-
cause of the imminence of the i)roblem, I would recommend that the
following stei)s be taken: (1) Increase our efforts to identify drugs
with an abuse potentiality early and to utilize ap])ropriate control
measures, (2) increase our efl'orts to understand the psychopathology
and pathophysiology of psychopathy and through this efl"ort to ra-
tionally i'ornndiii(» therai)eutic processes, (3) aggressively search for
nontoxic, nonaddicting drugs that may be effective in the treatment
of psychopathy.
Thank you, sir.
437
Chiiirmtin Pepper. Doctor, I think some of my colleagues will
share my curiosity, and want to know what psyclioj)athy is.
Dr. Martin. I guess, in the general sense, we mean people who
manifest criminal types of behavior. Looking at this more from a
behavioral aspect, many of these individuals are characterized by the
fact that the}^ are overl}^ concerned with themselves and overly con-
cerned with the immediate present, which has the implication that they
do things primarily to gratify themselves and think ^ory little about
the future.
Chairman Pepper. Have you anything else you would like to say
until 12:30, or shall we recess now until 1:30?
Dr. Brown. I think this would be an appropriate time to recess.
I just want to add my comment on the term "psycho])athy," which
Dr. Martin has used. Those who have worked in the fields for 10 or
20 years become deeply impressed by some of the behavioral and
other character aspects either caused by or seen as related to serious
drug addiction and drug dependence.
This particular behavior, which we often describe as hedonistic,
self-seeking, or self-serving, is, of course, one of the most troublesome
features, and one of the hallmarks of ^^our committee's charge, that is,
those persons who will violate society's mores, who steal and do other
illegal things.
Dealing with this basic behavior, either as a cause or an effect, is
one of the mos^t important dimensions and one of the reasons we feel
it is so important to extend our research efforts in this area.
Chairman Pepper. In general, is there a certain type of mental, or
whatever you call it, complex that results in such human behavior-
is there some general characteristic that j^ou would find in people
who are the users of heroin, addicts of heroin? Do they come into
certain jjsychiatric categories and have certain general characteristics?
Dr. Brown. Dr. Mai tin has had more direct experience with that.
Again, my information is more based on extensive contact with people
who themselves have worked extensive!}' with addicts, as we would
say, in a scholarly world on secondaiy sources rather than an extensive
primary source. There seems to be some generally central character-
istics along the lines of self-seeking, gratifying, hedonistic aspects.
However, there seem to be many routes into heroin addiction. Many
types of people are involved, and it is my own professional judgment
that it is a complex thing with no simple one-character behavioral
I)ersonality facet. That is my own judgment from the material, but if
you would like to answer the quest^ion that Chairman Pepper gave to
us, it might be useful.
Dr. Martin. Thank you, sir. I think I would agree completely
with what Dr. Brown has said, and perhaps just elaborate a small bit
on it.
When you look at the characteristics of individuals that come to,
for example, our hospital for treatment for drug addiction, they fall
into probnbh- three or four categories which mdicate the complexity of
this problem.
The first is the t3^pe tliat I have called the psychopath, a person who
needs immediate gratification and is not very particular about how
he goes about obtaining this gratification.
438
In addition to this, however, there are a significant number of
people that have other types of problems; for example, depression
and chronic anxiety. This group, perha])s, constitutes 25 percent of
the addict population. And there jirobabl}' is another 25 percent of
the population that we do not understancl very well, but which Dr.
Kolb described man}^ years ago as frank hedonists that have a person-
ality that makes them like to get intoxicated. We know very little
about this group.
Chairman Pepper. This is a little bit out of the area which we
are discussing right now, but it relates to om* ])roblem as a committee
concerned with crime. 1 have heard that the teachers or the ps\^chia-
trists who know something about young peo])le say that it is possible to
determine in the very low grades in the jmblic schools, which students
have a ])redilection toward the khid of conduct in later life, that we
call criminal conduct.
Is there any such discoverable characteristic in children in the first
few grades of public school?
Dr. Brown. There is a serious body of research which has attemi)te(l
to do this, to ])redict which students, say, in the first grade would go
on in teenage and young adult life to criminal careers, and the evidence
is somewhat equivocal at this time.
1 would say, again, we have carefully looked into this and we will
be glad to submit sort of a precis for your committee, but we do not
yet have that hard knowledge to predict which child would turn out
to be a criminal.
(The material referred to above follows:)
The develnpment of efficient prediction and prev^ention efforts to cope with the
problems of dehnquency and crime is greatly needed. However, in view of current
scientific and technological limitations, viz., the lack of accurate and economically
feasible predictive devices, very serious scientific and pul^lic policy problems have
to be considered. The younger the age at which predictions are made, the greater
the technological and social policy problems. P>om a scientific standpoint, the
reliability and accuracy of the predictions remains questionable, e.g., to say at
age six or eight that a particular youngster is definitely headed for serious trouble.
From a public policy standpoint, there are serious problems in labelling a child as
"delinquency-prone" and then intervening in his life — before he has even dis-
played any overt problem behaviors.
It is a statistical and empirical fact that predictions aimed at events whicli have
relativel}" low frequencies (e.g., serious or violent crimes), invariably have rather
high rates of errors. Thus, while devices such as the Glueck Delinquency Pre-
diction Scales do pick out high proportions of youngsters who may actually become
delinquent, the\' do this at the cost of having rather high rates of "false positive"
errors, viz., persons who are ])redicted to l)e delinquent but who do not later
display such behavior. In addition, behavioral and social scientists point to various
other problems and complications which result from giving designations and labels
(e.g., "delinquency-prone") to children who have not yet disi^layed problem Ix'-
haviors. For example, such labels and preventive efforts could lead to "self-
fulfilling prophecies".
In attempting to jjredict and prevent deliTiquency, otlier inii)ort;int fticts need
to be considered. The great majority of youngsters engage in acts which could
bring them into official contact with the law, but most such youthful pranks and
problem behaviors do not come to official attention. P'urtliermore, police statistics
tend to reflect social class and related l)ias(>s in the Imndling of problem behaviors.
Thus, youngsters engaging in delinquent conduct will more likely become a
polic(^ statistic if they come from lower social class and economicaUy and socially
deprived families. Youngsters showing the same behavior but coming from middle
and upper class and more stable families, will not as likely receive official ad-
judication. In other words, officially labelled deliiuiuent behavior does not simply
reflect the i)roblem displayed by the individual, l)ut also reflects the manner in
which the comnnmity and social agencies have responded to that behavior.
439
A large proportion of youngsters adjudicated as delinquent, tend to be involved
in status or minor offenses (e.g., truancy, running away from home, incorrigi-
bility, etc.), rather than in violent crimes. Also, a study which the National
Institute of Mental Health has been supporting indicates that nearly half of the
youths connnitting their tirst offense, do not have further contact with the law,
while an additional o5% of these subjects appear to have stopped engaging in
law-violating behavior following their second offense. Thus, it appears that many
youths go through a phase of adolescent turmoil, engage in disruptive and de-
viant behaviors, and then mature into fairly stable and constructive adults.
In light of these facts, there are both practical and ])()licy questions regarding the
particular point in a youngster's life when the comnuuiity should formally in-
tervene to prevent further misconduct. Given the present limitations of our
predictive devices, as well as the lack of clearly demonstrated success of most
delinquency-prevention programs, it remains questionable whether limited man-
power, resources and efforts should be devoted to starting prevention programs
at the second or third grad(^ levels. At this early age i^roblems inay not yet be
manifested, and whether particular yovmgsters are in fact headed for serious
criminal careers cannot be acciu'ately jjredicted.
Thu.s, there appear to be a number of difficulties associated with atteniptlng to
predict and prevent delinquency at early ages. Until the scientific, techiudogical
and related difficulties have better been addressed, the likelihood of effective and
feasible prevention efforts remains somewhat poor. Given these cou,siderations,
the National lu.stitute of :MentaI Health is continuing its re.searcli efforts to
develop more accurate predictive devices, a.s well as to learn- — through longi-
tudinal studies — about the characteristics of that .small but hard-core group of
youngsters who display early problem behaviors and wdio do in fact g'o on to
more serious criminal careers. The Institute is also involved in research aimed
at improving the intellectual, emotional and interpersonal functioning of such
children and youth, e.g., the development of in.structional progi'ammed materials
designed to enhance academic performance, study skills, and inteniersonal behav-
ior. The National Institute of Mental Health is also supix>rting research to
improve the effectiveness of tho.se social institutions and agencies, such as
parents, families, and school sy.stems, which attempt to socialize children and
youth, and to bring about a more po.sitive reciprocal interaction between parents
and children.
Chairman Pepper. Well, slutll we convene at 1:30? Will yon be
back, then, gentlemen?
Thank you very much.
(Whereupon, the committee recessed at 12:35 j).m. to reconvene
at 1 :30 ]).m. on the same day.)
Afternoon Session
Chairman Pepper. The committee will come to order. We will
resume with Dr. Brown's testimony.
STATEMENT OF DR. BERTRAM BROWN, DIRECTOR, NATIONAL IN:
STITUTE OF MENTAL HEALTH, HEALTH SERVICES AND MENTAL
HEALTH ADMINISTRATION, DEPARTMENT OF HEALTH, EDUCA-
TION, AND WELFARE ; ACCOMPANIED BY DR. ROBERT VAN HOEK,
ASSOCIATE ADMINISTRATOR FOR OPERATIONS, HEALTH SERV-
ICES AND MENTAL HEALTH ADMINISTRATION; KARST BESTE-
MAN, ACTING DIRECTOR OF THE DIVISION OF NARCOTICS AND
DRUG ABUSE; AND DR. WILLIAM MARTIN, CHIEF. ADDICTION
RESEARCH CENTER, LEXINGTON. KY.— Resumed
Chairman Pepper. Have you any estimate as to the nimiber of
heroin addicts in the country that would be different from the 200,000
or 300,000 estimates that we have received?
440
Dr. Brown. Our current estimate is 250,000. We in truth have the
same estimate as you have heard. Several hundred thousand, perhaps
somewhere between 150,000 and 400,000. Our best guess is a quarter
of a milUon.
Chairman Pepper. Now, Dr. Edwards told us today that about
30,000 people are being maintained; that is, are being treated con-
stantly by the use of methadone. Do you generally agree with that
figure?
Dr. Brown. Yes; I think it is a little on the high side, and if I were
asked to give a number, I would have guessed closer to 20,000 than
30,000.
Chairman Pepper. So, to use a maximum figure, of your estimate
of possibly 250,000 heroin addicts in the country, about less than
50,000 of them are being treated by any kinds of drugs?
Dr. Brown. Yes; there is an additional small number that are on
other drugs, mostly experimental ones that you have spoken of.
These include cyclazocine and naloxone, but that additional thousands
that you can count on one hand, so it still falls under 50,000.
Chairman Pepper. So, the maximum number in your opinion, of
heroin addicts in the United States being treated by some kinds of
drugs would be under 50,000?
Dr. Brown. Yes, sir.
Chau-man Pepper. That would leave approximately 200,000
heroin addicts that are to be treated by some other method.
What are the other methods currently used in the treatment of
heroin addiction other than the use of drugs?
Dr. Brown. There are several methods. One is the therapeutic
community, particularly Synanon and other similar models. One is
the comprehensive approach that combines counseling, jobs, voca-
tional referral, and training. This is often called multimodality.
Dr. Jaffe has popularized this phrase.
There is individual treatment that a physician might take on with
an individual patient to see what he can do. There are specific sub-
treatments such as being a member of a halfway house or some other
semi-institutional setting.
This is the range of treatments that I am aware of. Mr. Besteman
might want to expand on a few others.
Mr. Besteman. I think essentially most have been covered. There
are still some treatment programs that go on in the traditional insti-
tution, care away from the home community, and we do know of
crisis treatment centeris that are more related to drug abuse than they
are, say, to addiction.
Chairman Pepper. Those are clinical or institutional approaches;
are they not?
Dr. Brown. Yes.
Chairman Pepper. They require personnel, require trying to put
the person in a proper frame of mind, trying to get him a job, give
him therapeutic treatment that may be necessary and the like. It is
sort of an institutional approach. And also sort of a multiple approach.
Dr. Brown. That is correct.
Chairman Pepper. A psychological as well as physical approach
to the individual.
441
Dr. Brown, what would you say is the state of the art at the present
time in the development of drugs for the treatment of heroin addicts?
Would you give us vour own summary?
Dr. Brown. The state of the art is primitive and promising if I can
put together two words. It is primitive only in the sense that imtil
we understand some of the most basic mechanisms of what the nature
of addiction is, what the nature of dependence is, it will be difficult
to develop drugs tailored specifically to actions you do not fully
understand.
On the other hand, we have promising leads in several areas that
your committee is exploring. These include blocking agents, antag-
onists, and perhaps even other drugs that relieve the secondary effects
such as anxiety, tension, and depression.
These are some of the promising leatls.
Dr. Martin may want to give you an even more thoughtful or
knowledgeable response to that question. I think I would like very
much for him to answer that question.
Chairman Pepper. That is what we would like to get. The doctor
covered it pretty well in his statement, but I want to get in the record
about the present state of the art, as it were, on the development of
blocking or immunizing or antagonistic drugs in respect to the treat-
ments of heroin addicts.
Dr. Martin. I am not the diplomat that Dr. Brown is. I would
say the state of the art is primitive.
I think we have several leads that may in the end prove helpful.
We have the use of the "hair of the dog" ; namely, the methadone- type
of approach, or acetyl-methadol, that may help perhaps 25 percent,
perhaps more of the addict population.
We have the possibility of using, developing
Chairman Pepper. Excuse me. You mean being used for the treat-
ment of that large a percentage or maybe as adapted for use with
respect to that large a percentage of the heroin adtlicted population?'
Dr. Martin. I think that percentage of the total addict population
may very well be amenable to this type of treatment.
I think a smaller percentage, but nevertheless a significant per-
centage, of the addict population would be amenable to the use of
the narcotic antagonists, and I think by eventually finding a way of
administering both the methadone-type of drug and the narcotic
antagonist on an infrequent basis, using a depot, so that the patient
is protected throughout the intervening time, may facilitate very
definitely both treatment modalities or both types of treatment.
I think that our efforts to develop a depth form are something
that should be encouraged and helped and I think it is an effort that
shows great promise. It would, I think, for example, have one very
practical consequence, that it would eliminate diversion.
Chairman Pepper. Eliminate diversion?
Dr. Martin. Diversion, because the patient would carry the drug
with him inside of his body in a way that it could not be easily
extracted.
At the present moment, I think that these are the most promising
leads in the area of chemotherapy, but I do believe that we should
very definitely attempt to set our sights a good deal higher than this.
442
and hopefully develop drugs that could not only helj) the addict but
all other patients that had difficulties that were similar to his, and
I believe in so doing-, avo could not only beneficially affect the addic-
tion pi-obleni but also in all probability reduce other forms of deviant
behavior such as alcoholism and perhaps other types of criminality.
Chairman Pepper. Well, now. Dr. Brown and Dr. Alartin, both
of you have described the state of the art so far and the development
of drugs for effective use in the treatment of lierion addiction as })iini-
itive, but that there are certain leads that do hold hope and promise.
What is being done to develop those leads and who is doing it?
Dr. Brown. We have, as you know, a sizable research program and
that research program has several facets or dimensions to it.
Chairman Pepper. Would you describe it to us and tell us how much
money you have for it? i :io"
Dr. Brown. Yes, I will. The program for research overall for 1971
in this area, the overall drug area, drug-related area, is approximatelv
$17.7 million.
Chairman Pepper. Excuse me if I may interrupt you. Is your
Agency, the National Institute of Mental Health, the Agency pri-
marily charged by law with carrying on research and developing
appropriated drugs in tliis area?
Dr. Brown. Yes. That is our prime responsibility, but due to the
nature of the complexity of the task, we work cooperatively with the
other agencies, specifically, for example, with the rest of NIH, wliich
has promising leads in basic treatment problems, and with the FDA,
so that Ave can work cooperatively. We have the primary responsi-
bility, however, in this research.
Chairman Pepper. You have a budget for 1971 for this area, the
research in this area, of $17.7 million?
Dr. Brown. $17.7 million. And we have a table, as you know,
which spells this out in considerable detail. But I thought it would be
heljiful to point our the different waj's we go about our research
effort.
For example. Dr. Martin is the head of the Addiction Research
Center at Lexington, which has available to it an actual clinical
population, prisoner population, and other human beings, people
to work on, as well as doing more basic pharmacological laboratory
and other studies. It has carried out this research for over 20 years
and has some of its facets, for example, in the screening of new drugs
that have abuse potential. That is one facet of our ])rogram.
A second one is the research we do on the NIH campus m basic
pharmacology, neuroi^hysiology, and, of course, here \\e are very,
very ]iroud that one of our researchers, Dr. Julius Axelrod, received
the Nobel Prize for basically elucidating how the brahi works. This
probably has im])lications for drug treatment and drug prevention.
For example, his research shows promise in nniking available to us
new types of agents that will be liel])ful not only in alcoholism and drug
abuse but conditions as diverse as depression and Parkinson's disease.
This is our basic research eft'ort on the NIH cam])us.
Dr. Axelrod, on his own initiative, has turned his team's attention
to the drugs that concern us here, such as maiihuana, and what hap-
pens to the body and its metabolism hi the body. We are pleased he
is going to focus his very high talents on such an effort.
443
Chairmiui Pepper. Wliat is tlie doctor's name?
Dr. Brown. Julius Axelrod, a recent recipient of the Nobel Prize.
That is the second' facet, the Addiction Research Center, and the
NIH laboratories.
The third aspect is our contract program whi(;h is heavil}^ emphasiz-
ing the marihuana field. The reason that our contract program has so
heavily emphasized the marihuana field was the need for ra])idly
getting answers to some pressing ([uestions. We had to develop con-
tracts to gi'o\\- our own so that we could have a plant with a given
quantity of the active agents, make this extract from the plant, make
it available for animal studies and for clinical studies. We also are
going overseas to find poi)ulations that have used such a drug as
marihuana for 20 or 30 years to see what happens in long-term use,
an interesting analogy, I might say, to the methadone question. We
want to see what happens when you have used a drug for 20 or 30
years and you have to go to i)oi)ulations tliat have really done that.
A fourth facet to oiu- program, which is perhaps our largest, is the
research grants that go out rather typically to universities, community
facilities, and hospitals.
Lastly, of course, we do research and evaluation of our treatment
programs to see which ones are working or not. This is research in the
sense of trying to see whether or not methadone is effective, how
effective the therapeutic community is contrasted with methadone
and to find out what happens to untreated addicts. The evaluation of
the treatment programs would be the last dimension of our research
effort.
Chairman Pepper. Doctor, are you carrying on all the research
autl developing all the leads that you as a scientist, as a man in charge
of this Agency, primarily responsible for this program, would like to
carry on?
Dr. Brown. As a scientist, eager to [)ursue answers to pressing
problems, I have the problem of an uncurbed, untranimeled ap})etite
for research sources beyond what the generosity that, yoiii wordd pro-
vide could make available. ' y * !
Chairman Pepper. I am glad to hear that. You are the kind of
fellow we are looking for. We want to give you some more money.
>.lr. Brasco. Ask us. Ask us.
Chairman Pepper. How much money can we give you? How much
can you use?
Dr. Brown. I must finish my statement. As the Director of an
agency which has a range of problems to consider in other related
areas, schizophrenia, depression, disturbed children, suicidcb, neurosis,
psychosis, a range of very important problems, I have to balance my
desires for this field versus the other problems that come under my
jurisdiction.
Chairman Pepper. We do not. We are not res[)onsible for all those
other subjects. We are right now concerned about trying to do some-
thing about the heroin addiction problem in the United States and we
are looking, with blinders on for the moment, at that particular prob-
lem and we are looking for somebody that can use money wisely in
tleveloping some of these leads that will give us the hope that maybe
instead of the primitive state of the art that you and Dr. Martin have
described, in a short time the genius of America, under your scien-
444
tific leadership, might produce something that would deal adequately
with this challenging and tragic national problem.
I can hardly believe that you have all the personnel and all the
facilities and the ability to implement all the programs that your
scientific mind would like to see implemented and what we are looking
for is something to recommend to the Congress.
If they do not want to do it, this is up to them. The President has
just stated this week that he intends to launch a massive attack upon
the drug problem in this country. Well, what sort of an attack is he
going to mount? What do you mean, a massive program?
We just read in the paper yesterday of two young people found
dead on the steps of a hospital from taking heroin.
So, we are dealing with something that is taking the lives of a lot ot
people in this countr}-, costing our people a lot of money, paralyzing
our courts, and generally it is one of the great tragedies of the country.
What we are looking for is wdiat can be done more than is being
done in the technical research field. What more research can be
carried on wisely? And then the next thing we want to know from j^ou
and others is what kind of treatment and rehabilitation program should
be in effect in every community in America to deal adequately with
this problem, and that is what we are going to recommend to the
House.
Now, if the House does not want to do it, it will not be our fault,
but we want to offer to them what we believe they should do in the
national interest and we want you to tell us what we can recommend.
And do not be modest about it. Do not feel that you are in any way
violating any obligations. We, as a committee of Congress, are just
asking you to give us technical advice. Whether the Bureau of Man-
agement and Budget recommends it, or whether Congress appro-
priates it, is not your business but we are asking you as adviser to the
committee, as a witness here today, to tell us if you were speaking
only as a scientist, not as an administrator limited by other obligations
and responsibilities, if you were advising us as a scientist, what yon
think you could wisely do in the national interest with respect to the
heroin problem in the area of research.
Dr. Brown. I deeplj^ respect your concern and I think it is not so
much a matter of having blinders on so much as focusing on the
problem. I really think it is more — -the best spirit of the latter rather
than putting blinders on as jon describe it.
Indeed, as we described our research efforts in terms of basic
understanding of the brain, some additional resources would be useful
and I think would provide the base for ver}' important answers in
terms of exploring the promising leads that Dr. Martin and others
of your mtnesses have described, such as the blocking agents and the
antagonists.
As you know, Mr. Chairman, I personally explored in some depth
the wisdom of trjdng to see whether we can get an immunizing agent,
a vaccine. This is controversial and difficult. It may or may not pay
off and it has to do with a different approach than having an antago-
nist or blocking agent. It has to do with the fact that the state of the
art is such that we could take a chemical such as heroin or tetrahy-
drocannabinol, or cocaine, link it to a protein, develop antibodies so
that perhaps we could have people protected in the sense that you are
protected from polio.
446
The state of the art is promising. I am not sure how much money,
but perhaps just a small $2 or $3 million effort might pa>' dividends
in 2 or 3 years.
This is worth trying. It is the sort of lead, I think, that is promising.
We would not begin such a program unless we spent
Chairman Pepper. You could even give that to somebody who has
not become an addict to keep him from becoming one; could you not?
Dr. Brown. Well, the problem with an approach as new as this is
that it is fraught, if I can use a fancy word, "loaded" would be a
better word, with ethical and moral difficulties but, on the other hand,
the problem is so severe that I think every lead is worth pursuing.
Chairman Pepper. Well, parents give their children shots to
immunize them against smallpox and typhoid fever and all, and with
the current tendency of young people to take drugs, you might
immunize them against drugs as j^ou go along if you could develop
your immunization product.
Dr. Brown. Well, I do not mean to get at all fight about so serious
and weighty a topic but, for example, just picture the issue we would
have to face if we were to develop such a vaccine against alcohol
and whether or not people would want to immunize against a fifetime
of alcohol. This gives us a sense of the problem, so I think you would
not be immunizing against heroin unless you Avere fairly far down the
social, legal, ethical pike. What I am trying to sa}', resources expended
on this kind of approach might develop new kinds of knowledge that
might be helpful in terms of treatment programs.
The state of the art, and science, is somewhat primitive along the lines
Dr. Martin and I have spoken to. Perhaps, what is really troubling
the committee and the society about the state of the art, about how
to treat this problem, is even more primitive and we do have a case
of just exploring with great difficulty, find out the best treatment
program. Our inability to distinguish the effectiveness of, say, a
methadone program from a multiservice clinic or to distinguish those
who would benefit from methadone from those who would not, are
areas of clinical research or evaluation research that are well worth
exploring and some modest resources in these areas would pay hand-
some dividends.
Lastly, I would like to say that I am pleased and proud that the
President does plan new drug abuse initiatives and that I would
expect that new resources \Adll become available and I am hopeful
that they will be also in the area of research so I think you are on the
same wavelength as the President
Chairman Pepper. How much are you spending now in jour
Department to develop a vaccine drug?
Dr. Brown. Right now we are spending no actual money, sir.
It is just an example of a kind of scientific technological thinking.
Chairman Pepper. Why are you not spending money on that?
Dr. Brown. For several reasons. One is because that is a far-out
promising lead and with the resources we have available, we are
spending the money on the more promising far-out leads.
Chairman Pepper. Well, I guess you are telling us, then, you do
not have enough money to spend on the far-out leads. You are trying
to spend what you have got on the leads that are more profitable and
more probable but you never know when the far-out one, the long
shot, is going to win the race; do you?
60-296 — 71— pt. 2 8
446
Dr. Brown. T notice the ])icture on the back of the wall. There
must be -;everal people there who tried the long shot and looked
awfully sad
Chairman Pepper. So in the public interest, a few more experiments
mio'ht make all the difference. If I recall correctly, up until penicillin
and some of these antil)iotics came along, the thing they had to treat
syphilis with was No. 606, and as I understand it, the reason it has
the name No. 606, is the 606th experiment was the one tliat jn'oved
successful. If they had stoi)i)ed at 605 — if somebody said that is too
far out — we would not have liad any remedy for syphilis until the anti-
biotics came along.
Now, why should a big Nation like this be denie<l the possible fruit-
ful success of something that in your scientific judgment is worth
following as a lead? Is it not in the public interest that you should
have an opjiortunity to })ursue whatever you thhik might lead to a
successful conclusion?
Dr. Brown. My answer to that is yes, sir, and no, sir. By yes, sir
and no, sir, I mean that the resources are provided by the will of the
l)eople through the Congress and I think that is your responsibility.
Our job is to be credible and honest witnesses and to s[)end that which
is made available to us i)rudently and well. The decision about how
much the Nation spends is very much in the hands of the executive
and the legislative. li-itini: I j-
Chairman Pepper. Well, tliat is what we are looking for. We share
that responsibility, Dr. Brown, with the executive. This committee
has to have something to tell the Congress. We cannot say, well, wi>
think you ought to i)rovide $25 million more a year to NI^I^I or $50
million or a $100 million which is a very picayunish sum compared tc^
the expenditures of this Nation and the gravity of this i)roblem and
the cost of this jiroblem to this country. But we have to have some sort
of a factvuil basis.
If we could say that Dr. Brown of NIMH said if he had $25 million
more a year or $50 million more a year, he could follow a lot of promis-
ing leads that might possibly result, in something much better than
what we now have, it would support our recommendation. You and the
other ])eople who have testified here told us about methadone. It is
not appropriate to everybody. In fact. Dr. Dole told us in New York
that it is only adapted really to the hard-core addict and Dr. Edwards
here this morning suggested that everybody should not have metha-
done. You should examine the recii)ient or the prospective recii)ient
before you begin to give it to him. And it is addictive and it may have
certain side effects.
You do not know yet what may be the long-term effects of its use.
So, you have to keei) on trying to refine this product, and maybe,
find others. Do you think, on the whole, methadone is the best thing
we have now?
Dr. Brown. I think it is the most promising practical treatment
that we have available.
Chairman Pepper. All right, Now, then, the |)roblem is to try to
find something better that has less faults or less objectionable attri-
butes, and our curiosity is h(n\' we are going to develop in the national
interest these new products.
447
Lot nie ask you first, is tlic drug industiy coming up with anything
new? Does it look Hke they are hkely to come up with anything that
will be safe and effective in the inunediate future?
Dr. Browx. I think that the drug industry has ex[)ertise in several
promising developments. 1 am not personally expert on this subject.
Again, I do not know whether Dr. Martin has anything to contribute
on this.
Would you care to comment. Dr. Martin, on what j^ou think the
drug industry might be able to provide us on this?
Dr. Martin. It is my personal opinion that, at this time, the drug
industry has not made, and as far as I can see, will not make a heavy
commitment to an effort directed toward the treatment of drug
addicts.
Chairman Pepper. Well, then, I guess the perfectly reasonable and
understandable reason is that they have to make a profit to survive
and they can only i)ut a certain amount of money in research and they
must have some probabilities of return and the like.
The drug houses do have a lot of laboratory facilities and |)ersonnel,
I su[)i)ose, capable of competent research. But some of the needed
research has no profit i)otential
I have been toying with this idea: The Federal Government might
say, all right, we will put up luilf the money or we will j^ut ui) two-
thirds of it with the understanding that if this thing turns out to be
no good, no profit, then you do not repay us but if you ever make a
profit out of this thing, the first profit has to come to us. You have to
l)ay the Government back because we risked capital with you.
Do you suppose that would have any incentive upon the j)rivate
tlrug industry?
Dr. Brown. Yes; I am i)leased that you are ex])loring tliis because
it is a very difficult area that involves patents, ])rofits, and yet the
jiroblem is so serious that the ])otential research capacity of the drug
industry should be exploited, and I mean exploited in the best sense
of that term.
Chairman Pepper. I would like you, as head of NIMH, to have
some money available, to place it with them under pioper restrictions
and safeguards. Say to them, "We will share with you some all-out,
some long-shot projects and programs with the understanding that we
have a ])roper agreement that the first profit you make out of this wdll
repay us for the amount of money that we put in it. The rest of it you
keep. W^e will not insist on the patents or anything like that. We just
want our money back."
Well, noAv, that is one area where we could stimulate competent
research. W^hat about the universities and the colleges? What about
them as a i)ossible source of the development of new leads?
Dr. Brown. Y"es; tliis would be a prime place that one could look
to for study, research, exploration, knowledge, new leads, et cetera.
If you had couched the question in terms of how would you expend x
amount of money, what would you do and what would be the return,
that would be a fair question.
Chairman Pepper. How much money do you now have available
to give by way of encouraging research to the colleges and universities,
in the drug area?
448
Dr. Brown. The total, as I said, is $17.7 million, perhaps of which
$9 to $10 million is available to universities, colleges, and the like.
Chairman Pepper. And you are using that now for that purpose?
Dr. Brown. Yes; we are.
Chairman Pepper. You have how many institutions participating?
Dr. Brown. I do not have the exact number but I am sure it is in
the area of 100 or so and I will be glad to make that figure available.
(The information referred to above follows :)
The number of colleges and universities conducting research with funds from
the National Institute of Mental Health in field of narcotic addiction and drug
abuse is 98.
Chairman Pepper. Are any of them working on this possible
immunizing drug?
Dr. Brown. No.
Chairman Pepper. Because you have not made any grants for that.
Dr. Brown. That is correct.
Chairman Pepper. You not did have the money, as a matter of
fact, I suppose, for that.
Well, we have talked about the drug houses and the colleges and
universities. Now, what other sources are available to help in the
development of these technological leads? Are there other areas?
Dr. Brown. Yes; there are in terms of doing the clinical research,
the actual comparison of treatment methods, all the facilities that do
such things, including State institution and aftercare programs, clinics,
and hospitals. The actual clinical facilities would be promising places
to explore such questions.
Chairman Pepper. In other words, if you had the money to place,
you could look over the country and find what clinics or hospitals you
think would wisely use the money that you might make available in
areas that joii thought were worthy of exploration?
Dr. Brown. That is correct, and then if we are going to look to
what — we might coin a term right now, "the creative far out, not the
foolish far out," one might look to special places for this sort of thing.
For example, there are local community action groups, people's
organizations, in the model cities and HUD and poverty areas where
research might be done in a way that is somewhat unusual. For ex-
ample, they could help us to see which youngsters at ages 14, 15, or 16,
become addicted. No university could get into that community to ask
questions. We would go, in other words, to somewhat unorthodox
places that were seriously responsible, local urban organizations, and
ask them to help get answers to some key research questions. This
would be a little bit more unorthodox but I think it could be very
productive.
Chairman Pepper. While I think of it, Doctor, have you approved
any project or have you in your mind concluded that there are projects
that would be promising which you have not funded because you did
not have the funds under the appropriation that you now have?
Dr. Brown. Yes; there were promising research projects, particu-
larly in the area of narcotic antagonists, that the NIMH was unable
to support because of insufficient funds.
Chairman Pepper. Could you give us the overall figure and make
the details available to us?
Dr. Brown. I would be glad to do that.
449
Chairman Pepper. Do you happen to remember what the overall
figure is?
Dr. Brown. We do not have that at hand at the moment.
('J'he information requested fon:)ws:)
Additional research is sorel.y needed to develop a long-acting narcotic antag-
onist to be used as a tool in treatment. The National Institute of Mental Health
had planned to let contracts for this purpose, but was unable to do so because
of lack of funds. Promising proposals in this area amounted to $360,000 and are
detailed below:
Investigator and descriptive title:
Alpen — Battelle: Implantable slow release matrix — biodegradable ^styear
polymer $75,000
Gray — University of ^"ermont: Preparation of relatively insoluble
salts in aqueous or oil suspension 35, 000
Meloy Laboratories: Polymer — coupled narcotic antagonists for
intramuscular administration 60, 000
Willette- — Connecticut, University of: Long acting forms of exist-
ing antagonists 40, 000
YoUes — Delaware, University of: Sustained release polvmer proc-
ess 1 1 150,000
Total 360, 000
Note.— Subsequent to this hearing, a $67,000,000 budget amendment was submitted to the Congress
jjUd passed by both Houses.
Chairman Pepper. Now, you have described those thi'ee sources,
])harmaceutical houses, colleges and universities, and the institutions,
community and otherwise. Are there others that can be helpful to
you if you could fund them?
■•'Dr. Brown. Well, the only other category that we are doing some
funding with crosses over the other three and I think it is tremendously
important in the drug area. That is, certain ty])os of research that
can be best done or better done overseas in the international arena,
and I think that is an important facet of our research ])rogram.
Chairman Pepper. You are working in collaboration with the
United Nations or otherwise?
Dr. Brown. With the U.N., the World Health Organization, and
other bodies, specifically for example, going to places like India
where you have chronic drug usage, working collaboratively even
with our chapter 480 funding. In the last year I have endeavored
to step up our use of these funds that are already available to increase
our research endeavor at no additional cost to us, so to speak.
Chamiian Pepper. That does not come out of your appropriation?
That is chapter 480 funds?
Dr. Brown. Right; but the other possibilities in overseas research;
for example, in identifying chronic use of, say, amphetamines; to
go to places where this has perhaps happened more than has happened
here. This is analogous to what we are trying to do with marihuana.
The foreign category of research endeavors is another important lead.
There is one other research responsibility that I would like to
put on the table, so to speak, which is, that as bad as the problem is,
we have to anticipate the problems that are coming on us very rapidly,
by which I mean, with the drug industry and science producmg new
drugs, just to stay abreast of screening those drugs with abuse poten-
tial, to liave a so-called early warning system to know which drugs
are not going to be dangerous so that we can perhaps put them in
the right schedule or alert the medical profession — we need increased
450
capacity to do this kind of anticipator}^ and ]3reventive work. That
is another nnsexy, if I may use the term, area and yet terribly im-
portant area where research is needed.
Chairman Pepper. Doctor, we have not gone into the question
as to whether there shouhl be any Umitation on the i)()\ver of anybody
to put on the market in this country something that has a very kirge
abuse potential, even if it has desirable attributes. A good many
things would come into that category.
Dr. Brown. That is correct, but I think the issue then gets to be a
sensible, responsible weighing of the assets and liabilities or the costs
and benefits. If one is dealing with a disease like leukemia, very power-
ful drugs with terrible side effects are used, yet benefiting 90 percent
of the children at the cost of 10 percent serious side effects seems
well worth it. So, this issue of having very jwtent medicines or drugs
for serious diseases is one that has been with us for a long time. I
think it is an approachable i)roblem.
Chairman Pepper. What facilities for research do you have in
your own agency?
Dr. Brown. I mentioned the two i)rimar3^ ones. These are the
Lexington Clinical Research Center, particularly the Adtliction
Research Center that is part of that facility, and the NIH-based
National Institute of Mental Health intramural laboratories.
Chairman Pepper. How many people who are capable of carrA'ing
on research hi promising lead drugs for treating heroin addiction do
you have in NIMH?
Dr. Brown. I would be glad to provide specific figures on the
personnel at Lexington and at the NIMH intramural activity.
(The information referred to follows:)
At the Addiction R,esearch Center, the NIMH facihty for carrying out intra-
mural research in the area of drug aljuse, there are 23 professionals, inchiding
four consultants, capaVjle of conducting research on promising lead drugs for
treating heroin addiction. These professionals are assisted by a supportive staff
of 32 technical and clerical personnel.
Chairman Pepper. But at Lexington it is more clinical in character;
is it not?
Dr. Brown. Yes, sir, and Dr. Martin in his presentation, detailed
very specifically, if I remember, six physicians and seven Ph. D.
scientists and supporting personnel. He gave rather exact figiu'es.
I think he was being modest because those small amounts of the
peoi)le have produced a tremendous gooil for the Nation.
('hairman Pepper. Now, what I am getting at is this. We had wit-
nesses on the third day of these hearings who told us about a drug that
a doctor in New York hail develo))('(l. It is being used experinu'iitally
in the State of New York and the doctor who testified before us
thought it had great ])romise. It has not been ai)j)roved yet by I he
Food and Drug Administration. He said a little vial of it, that cost
a dollar or less, would be enough to treat two ])eoi)lc for a week, at
the eiul of which time, the craving of the boilv for more heroin w ouUl
be eliminated.
Well, it would be phenomenal if we could develop something like
that.
Now, supi)osing somebody does come along, some doctors, some
researchers or j)romoters, and say, we have got something here we
451
want you to take a look at. We want you to see if you can develop
it, see whether it has any potential or not.
Now, what would your facilities be, what would your abilities be
to take a promising drug like that in your own shop, as it were, and
develop it, see if it is cai)able of being developed into a desirable drug?
Dr. Brown. We would have a modest capacity to handle that
kind of situation and, to tell the truth, we would be very cautious
about people who present, you know, the instant miracle thing that
will do something.
Our first approach is to say on what basis do you say that? What is
the data you have? What is the scientific background? What is the
nature of the drug? What of its chemical analysis? Have you tried it
on animals or patients?
Just because a person has deep conviction and sincerity about the
promise of a drug, we have learned to be ske])tical in our business as
you have in yours, and we would assess very carefully. If it looked very
promising on its own basis we would encourage that person to submit
a research grant from a university, from a college, from a clinic or any
other facilities, even as a private investigator.
We might in some cases ask Dr. Martin to look into the drug. He
might think it worthy of testing on animals and otherwise. Our capac-
ity would be cautious and modest to handle such a situation.
Chairman Pepper. Well, now, Doctor, that concerns me a little
bit because I realize that that is the normal and the natural approach.
On the other hand, if an epidemic were beginning to sweep over this
country that was going to take a lot of lives and cost the country a
great deal and soinebody came up with a potential antidote for that
epidemic, a blockage for that epidemic, and the national interest was
very seriously threatened, and I was a Member of Congress or I was
speaking for the Congress, I would want action that was actuated by
a sense of emergency, a search for it, not just saying, well, you have
not proved to us yet that that will do any good. Go on and get up all
your pa])ers and do your homework and bring it in and we will take
a look at it. If you are looking for something to block this national
epidemic, 1 would want an approach other than business as usiuil.
Let me tell you a little story. President Roosevelt once told me,
when he was Assistant Secretary of the Nav}', the}' needed something
to ward off the German submarines and the Navy had not come up
with anything that was that attractive and he or somebody came up
with the idea, well, let us advertise that we are looking for i)eoi)le
that have ideas as to how to protect our ships against submarines,
and the}' brought them all up to New London and got rather a large
dormitory or something and put all these fellows that showed up who
thought they had something, they put them in this dormitory and he
said there were a lot of amusing aspects of it. Each one of them chinked
U]) the keyhole and cracks and everything so nobody could spj' on
what he was doing, and they all went to work.
He said, believe it or not, in a few months they had come up with
something that the Navy could take and develop and it was the best
thing they had to ward off the submarine and that is how it started.
The ingenuit}' of all these people was encouraged and they let them
come up with what they had to offer and then the technicians of the
452
Navy took and developed the best leads and they came up with
somethmg.
Now, that is what I am talking about. The curiosity or openminded-
ness on the part of the Government, not you but the Government,
that is out looking for a fellow with a good idea and wants to help
him develop it, see if it has got any potential, because we have not
come very far, we have not gotten beyond primitive yet in this field.
So, that is the reason that we are perhaps embarrassing you by
suggesting that we would like to have you submit to us in response to
our request an ideal budget if we were the Appropriations Committee
of the House of Representative and asked you, wdth your knowledge
of this problem and the gra^dty of it and the knowledge you have of
the potentials in the field of research what would you offer as an ideal
budget for NIMH.
Would you be embarrassed to submit in response to our request
what you think in the national interest, if you were just asking for
what you thought might wisely be used, an ideal budget for this field?
Dr. Brown. It is within your prerogatives to ask for such a budget
and it is in our responsibilities to respond thoughtfully.
Chairman Pepper. We would request you to do it and we do not
want you to feel any sense of embarrassemnt in doing it because we
are authorized by the House of Representatives to explore this subject
to the fullest and we want to help the House by getting you to help
us with a recommendation.
Would you consider that, Doctor, and submit to us what you think
you could wisely use?
Dr. Brown. Yes, sir. And like Franklin Delano Roosevelt, in this
problem we are all at sea, it is a stormy sea, and we need to get into
the deep waters of submarines to find new and creative answers.
(For information concerning the budget discussed above, see
material received for the record, p. 465.)
, Chairman Pepper. Mr. Rangel?
/Mr. Rangel. Thank you, Mr. Chairman. I have a group that is
interested not only in the drug addiction problem, but also the survival
of communities, and if my colleagues would yield, I certainly would
appreciate it. Thank you.
Doctor, I suppose the Chair has indicated the general thrust of
the feeling of this committee and in studying some of the other
activities which your organization has taken on, it seems abimdantly
clear that the recent attack against narcotic addiction as declared
by the President has not yet reached the point that your institution
would feel the vibrations, and I can understand your reluctance to
come before legislative bodies, especially being appointed by the
Executive, in making positive and affirmative requests for funding.
However, in view of yovu- own admission of the primitive state of
affairs that exists in the ai*ea of drug addiction, it seems to me that
most of tliose who have testified before this committee have restricted
their concern to the methadone program, notwithstanding the fact
that even the head of FDA, who you heartl testify this morning,
declare*] that they have no jurisiliction over the activities of physicians
that are misusing this drug and, in fact, creating methadone addicts
in communities where the}'^ were not addicted Lo anything.
453
In addition to that, there seems to be some rehictance on the part
of all those who have testified from a variety of agencies to suggest
that the American Medical Association assume some of the responsi-
bility in this area, which allows me to believe that the politics that
are being considered involve the pharmaceutical houses, which again
it has been testified, have not taken the leadership in terms of sub-
stitutive drugs. Now, you have the prime responsibility in the area
of research and many of your j^rograms are methatlone related. There
seems to be some contradiction between 3'our testimony and that
which was given earlier as to the economic and ethnic composition
of those who are being studied by your agency as opj^osed to those
groups that allegedly are being studied, investigated, by the FDA.
Dr. Brown. Yes. I was aware and sensitive to that issue as it came
out in your discussion.
Mr. Rangel. What bothers me is that I think it is really unfair to
the American people to listen to witness after witness testif}^ as to
what aspects of research they are involved in. I thhik it is repugnant
to the belief and credibility of any administration when a President
can allege a war is going to be declared when we have before us today
a variety of agencies all of whom are now for the first time becoming
involved in research. We have the law^ enforcement agencies, we have
the Federal Bureau of Narcotics and Dangerous Drugs, we have
HUD, we have Model Cities, we have the Department of Defense as
it relates to the militarv. Of course, vou have heard testimonv from
FDA.
I do not know how many agencies are novv involved in some new,
and some of them superficial, research areas. But I think what the
Chair was asking and what I am begging is, is your agency willing
to assume the responsibility of having a centralized research center
for the pur])oses of finding some cures to drug addiction?
Dr. Brown. The answer to that is an unequivocal "Yes" and we
would hope that the Clinical Research Center at Lexington would
move in that direction and we are planning toward that. We have
been moving toward having an adeqnate addiction research center
for years and hopeful of achieving eminence and contributions in
this area.
Mr. Rangel. But is it outside of your professional realm to suggest
to this committee that you assume the responsibility with all of
those that are now getting into research? I mean, how do you explain
that even though for 7 years a drug has been used in the United
States of America, the FDA has not declared that this drug is safe?
You have the prime responsibility to determine research in this
area, and now State by State, city by city are asking for expansion
of the program without lestrictions on the physician who is misusing
the drugs, and yet there is no word heard from your agency in terms
of suggestions to the Department of Justice. One of my colleagues
asked would you recommend to the Department of Justice restriction,
and he reluctantly said that he would not.
Dr. Brown. You are asking terribly important and diflEicult ques-
tions and I make it a practice not to be unresponsive but to try to
be honestly responsive. The reason for the situation is because the
Avhole country has become aware of the seriousness of this problem.
It is not only that each new agency is becoming involved but organi-
zation after organization from the American Legion to Women's Liber-
454
ation is becoming aware of the problem. Committee after committee
is becoming aware.
Mr. Rangel. Is there any disease, any ailment of a national im-
port, that is being treated like this by the U.S. Government, in such
a ha])hazard, ])iecemeal way?
Dr. Brown. I do not feel I can answer that question. I think this
particular ailment, to use your term, Mr. Rangel, is not the same
ailment, as much as we say it is a disease, as, say, cancer, complex
as it is.
Mr. Rangel. One of the major factors why it is not is because
the larger number of the group historically has been at the lower
economic level.
Dr. Brown. Exactly, and that is exactly the ])oint I was going to
make, that this is an "ailment" that has to do with different cultural
groups, different economic groups, different racial groups. As it has
become more prevalent, the ailment, as I say, of drug abuse has been
moving into middle class and higher socioeconomic areas, we have
begun to see a response and I have often said that this particular
situation, when it was limited to the inner cities, to the ghettos, to
the blacks and the chicanos, was not getting adequate attention. In
fact, we are getting an interesting development, I think, which may
be the right response for the wrong reason, but nevertheless, as the
"ailment," the drug abuse problem, has become more prevalent
and epidemic, we may see assistance, help, community treatment,
clinics and research for the most harmed group, the inner city resident
and the blacks, if you follow the reasoning.
Mr. Rangel. We are begging direction from your particular
profession and I do not know whether it is proper to suggest that we
go into executive session because I do not recognize the sensitivity
and politics that are involved here but there is no question in my mind
that we will be coming to you, or I personally from time to time, for
recommendations as to how the Nation's i)opulation best could be
served and in that direction, I might say that with the return of the
fighting men from Vietnam coming home addicted, and some of the
people being mugged, I agree with you, we should expect a lot of
su])port from Congress and other sectors of the country.
Chairman Pepper. Mr. Brasco.
Mr. Brasco. Dr. Brown, I think that while we are talking about
what further research and developments can be had in the future, I
would like to discuss, as my colleague Mr. Rangel discussed, some of
the immediate problems.
I do not ])rofess to be a great expert in the area but there are some
things that bother me. T am an attorney by occupation and I ]->racticed
criminal law for some 10 years, 5 with legal aid society and then 5 in
the district attorney's office in Brooklyn, N.Y., so that I have had an
op|)ortunity to become familiar with the problem.
T have seen ])eoi)le for a number of years go to Lexington and come
back. I have seen people go to Fort Worth, Tex., and come back, all
in a revolving-door setting. T liave seen people go to Synanon, Day
Top, Phoenix House, your drug-free environments, and all come back.
However, I have been getting a number of peoi)le in my area that
have been asking to become involved in the methadone program and I
think that one of the things that we have to recognize in dealing with
455
the Mfldict is having a program that they themselves, as individuals,
' an fit into.
I had one young man in i)articular who came to me and wanted to
get into a methadone ])rogram and he said he was using $100 a day.
You know, and I know, he was not working for that. And if you start
figuring, he is paying $35,000 plus a year for drugs and knowing some-
thing about the value of ])roperty that is stolen, you find out that an
individual gets, if he is lucky, maybe 10 percent of the value that he
steals. :rO ,.'
Now, this is a guy who, to support that habit, has to steal upward
of $300,000 a year. How many muggings? Stickui)s? Bm-glaries? This
is a one-man crime wave.
He went into that program. He came back several weeks later with
his bottles of orange juice with the methadone mixed in it. He is mar-
ried now and working and not a social or criminal problem.
There are a number of people that want to get a crack at using meth-
adone and the thing that I think is shocking here is that while we are
dohig the further research, we have only 30,000 people involved in the
methadone program. It has been around for 7 3'ears.
I kind of suspect, as you indicate, that it is the best opportunity
we have. It would seem to me that the only reason why it has not ex-
panded to a greater extent so that more people can use it is the business
of the FDA ap])roving it and I would saj' that there is over and above
and beyond what I consider to be tolerable risks that 3'ou spoke about
in leukemia, 90 percent all right and maybe 10 percent the problem, I
think that we have a tolerable risk situation here but assuming we do
not, somebody better make up their minds as to whether or not the
30,000 i)eople who are taking it are in danger or is this the real thing.
I am wondering, could we expect that there are going to be some hard-
core determinations made ver^' soon, after 7 3 ears, as to whether or not
this is a legitimate api)roach?
It is more like a speech than a ciuestion, but this is something that
has been bothering me throughout these hearings and I, just for the
life of me, do not understand why we do not move forward with it.
Now, what is your best estimate of this?
Dr. Brown. Well, one useful suggestion in essence is just to per-
haps further formalize that which you are doing through the hearing
process and to ask for a coordinated report on the efficacy of methadone
from HEW or from the Government in some way, so that this is a
suggestion I am making as a way of, at least, seeing what the state of
the oinnion is if not the state of the art, and that is just perhaps far-
ther than I should go but it is a well-intentioned suggestion for at
least putting together the answers that keep going on and on.
Now, \\\y best estimate of methadone, switching into a different
frame of reference, is that from knowledge, and again this is secondary
knowledge, not primarv knowledge, but considerable experience at
evaluating secondar}^ knowledge, from Dr. Dupont's program in the
District and Dr. Jaffe's program and Drs. Nyswander and Dole and
following the reports very carefully and reading packs of data, ni}^
estimate is that methadone would be a useful treatment with dramatic
crime reducing effects for perhaps as much as a quarter to a third of
the heroin addict population, and this is vs\y estimate of its value.
456
There are, however — as dramatic and important as that sounds,
because we are talking about a bilhon dollars, we are not talking about
a small amount of even crime reduction if you want to take that —
other issues which are sincerely and deeply held, and not by people
who do not want crime to reduce. For example, in the process (if this
treatment being given, how many people are create;! to be methadone
addits who were not addicts at all? This is a terribly sensitive and
important issue.
yir. Brasco. I know, but I suspect, Doctor, that is a strawman.
It would seem to me that anytime you are dealing with drugs of any
sort, you are talking about risks. I remember when sulfa came out, a
younger brother of mine was almost killed by a doctor who w^as
continuall}^ giving him sulfa for some kidney ailment when he should
not have been having sulfa, apparentlv.
So, I do not know why we just cannot develop a procedure to find
out very simj)!}^ before a man enters the program that he is an addict
so we do not get somebody just waltzing in there to become an addict
and I think it is a strawman because the people are out on the streets
getting the drugs with the greatest of ease and more and more addicts
are involved. What we would really be doing is talking about a
significant reduction in crime and what we are really doing is talking
about an opportunity- for people to lead somewhat of a normal life.
I think that we ought to be able to give the American public the
opportunity for this solution because I think that these are tolerable
risks and I am wondering whether or not you think, in dealing with
methadone, from reading all of the reports and making the studies,
that this is an area where we have approached tolerable rislvs, assuming
the great proportion of the drug problem that we have today.
Dr. Brown. I would sa_v that what I would like to see done along
the lines is being done in part here in the District. I, would like to see
in the District, for exam.ple, a major massive pilot experiment where
as large a proportion of the heroin addicts as is feasible or could be
attracted to it, encouraged to use it under safeguards, and then to have
a careful evaluation study. Dr. Dupont's program is approaching
that here, and my figures are not exact, but plans are: to move from
2,000 patients to '4,000 or 5,000 at the end of the next year and funds
are being made available to him from NIMH and LEAA and <i variety
of sources.
Dr. Dupont's estimates are that there are 16,800 addicts and. in
truth, I think that he is somewhat low in his judgment. I would like
to see what happens to crime statistics in one major community if
we make methadone available to closer to 10,000 a^ldicts, as many as
we co\dd possibly see under such a controlled experiment. I think we
are ready for that kind of massive expeiiment. I do not know if we
are ready for that kind of massive ex])eriment nationwide.
Mr. Brasco. Let me just digress for one moment. Doctor, and I
will be finished. Talking about the chug companies, I get the distinct
feeling they sing that song "Your Lips Tell Me No, No, But There
Is Yes, Yes, in Your Eyes" in reverse. I would like to ask you a very
straightforward question. Can you tell me if you think it is in their
best interests not, and I am talking about fiiuincially now, not to en-
gage— as Dr. Martin indicated, they are not doing A'ery much — not to
engage in attempting to find some substance that is useful in the war
457
on drugs? By that I mean, veiy simply, they seem to me to be pro-
ducmg more and more drugs every day. You just turn on a commercial
and they have got Nytol to go to sleep, something to wake up, some-
thing to make you smile in the morning, and it just seems to me that
when they get in that area, they are going to have to make hard
determinations maybe that tliey have been too busy j^roducing too
many drugs that are capable of being abused without any real need
for them, and maybe it is not in their best financial interests to put
their scientific people and research divisions to work in terms of help-
ing to find a cure of this problem. :> ,c/y
Dr. Brown. In terms of clear cut, simple profit motive, I think
this is what Dr. Martin alluded to. It is not clearly going to be a
major profitmaker to develo]) a drug here and if the major motivation
is profitmaking, this is not a high profit sort of thing.
On the other hand, you brought up an issue that I am going to
piggyback on, which is, that unless we look at the heroin problem —
which is the hard-core problem in the drug field — in terms of the
whole drug-using culture v/e are not seeing the Avhole picture. There
are some very startling things happening in our society. Our last
figures showed that close to 20 percent of all the prescriptions in this
country are for mind-altering drugs, mostly antianxiety and antitle-
pressant agents, and that is up from 5 percent just 5 years ago and
the curve is very dramatically up and if you add the over-the-counter
drugs to the prescription drugs, you are movmg forward to a period
maybe 3 years from now, maybe 8 years, I am not sure, in the foresee-
able future wliere half the drugs being used will be foi mind-altering
or mood-altering purposes and that is a major massive phenomena in
the context of which you have to see the drug problem.
The inteiTelationshi}) is mighty comj^lex.
Mr. Br.\sco. There m.ay be a question of profit for them and if
this is outside of your realm, I guess it is for the Congress, but I
think we ought to put our foot down and tell them they had better get
out of this thing no matter how much profit there is for them because
it is really affecting the American public.
The last question. One thing that always concerned me. Doctor,
and I am wondering if jou are doing any research on the problem.
It is a known fact that a woman who is pregnant and is an addict,
and gives birth to a child during that stage, he is born as an addict,
so to speak.
Dr. Brown. Yes.
Mr. Brasco. Now, what do we do in that particular situation, be-
cause I think that is something that has been given very little attention
and 3^ou liear it everj once in a while.
Dr. Brown. Yes. We have a few studies. For many years, two or
three decades, we have been aware of the new born child addicted to
morpliine and heroin and who has to be treated very carefully or
pediatrically having to be withdrawn during the first 2 weeks in life
which is always a dangerous period.
What one would do there is to alert the medical, pediatric, and
obstetrical profession to this particular problem. Now, that is very
difficult to do when j^ou have a big city hospital which has two-thu'ds
of its babies delivered when the mother has had no prior medical
attention and the doctors hardly have time to diagnose the fact that
458
the mother is an addict befoi'e the baby is born, and then the actual
facihties for caring for the baby over the next day or two or week are
inadequate from the medical pediatric point of view.
Mr. Brasco. What you are sajang is we are reall3' doing nothing in
that area.
Dr. Brown. Practically speaking, I think aside from being aware of
it, it is not being handled in an}- big league way which is what 30U are
implying.
Mr. Brasco. There is another area, I guess that your Agenc}', with
the right resources, can get deeper into.
Dr. Brown. Again, this is one where I would like to be able to pro-
vide for the record, the state of the art again in terms of this particular
problem you are raising, which is heartrending.
(The following information was received from Dr. Brown for the
record :)
It has been known for many years that neonates born to opiate addicted mothers
could exhibit addiction and withdrawal symptoms but the full significance of
this phenomenon has not been determined.
Some of the early studies report rather high mortalitj' rates for these infants
but more recent reports have shown either low or no mortality in those instances
where the syndrome was recognized and adequately treated. A complication in
understanding the role of the opiate addiction in infant mortality and morbidity
comes from the fact that there is a high incidence of prematurity and low birth
weight found in these infants. These conditions place the child in a high risk
group whether the mother has been addicted or not. Although these two conditions
are frequently found in babies born to opiate addicted mothers, a causal connection
cannot be drawn at this time because manj^ of these mothers also have mal-
nutrition, poor standards of self care, inadequate prenatal care and come from a
low socio-economic background. All of these factors in varying degrees have
independently been associated with low birth weight and increased incidence of
neonatal complications in populations of nonaddicted mothers.
Generally, if the neonatal addiction is recognized and adequately treated it
does not appear to present a severe problem. Symptoms fotmd in the newborn
such as tremors, shrill cry, hyper-irrital)ility, myoclonic jerks, and gastrointestinal
disturbances are not specific for the withdrawal syndrome. Therefore, it is im-
portant for the physician to be aware of the possibility of this condition and to
maintain a high index of suspicion particularly in the case of mothers who come
from groups that have a high incidence of opiate addiction.
There seems to be no standard treatment regimen at present, bvit the following
drugs appear to be commonly tised: phenol)arbital, chlorpromazine, Demerol,
morphine, methadone, and paregoric. Generally morphine, methadone, and
Demerol are used only in more severe cases which do not respond to sedation with
phenobarbital or chlorpromazine or treatment with paregoric. In addition, sup-
portive measures maj' he important, such as intravenous fluids in the case of
gastrointestinal disturbances.
The eff'ect of neonatal opiate addiction on long-term physical, personality, and
cognitive development is imknown. The presence of other factors such as low
birth weight and prematurity in many of these children may affect their develop-
ment, making it very difficult to assess the role, if any, of the neonatal addiction
in long term growth and development.
With the increased use of methadone treatment programs for addicts it has
become more important to investigate the incidence and severity of neonatal
])roblems in methadone treated mothers. Early studies have reported that when
the mother has bc-en detoxified with methadone prior to delivery, tlu^ infants
show fewer signs of withdrawal. Infants of mothers on methadone maintenance
seem to have fewer signs of addiction. As the number of patients treated in
methadone programs increases and the period of observation lengthens, furtlier
opportunity will be provided to assess the effects of methodone on infants born
to addicted mothers.
Mr. Brasco. J do not want to take all the lime. 1 just want to thank
you. I concur with the chairman antl my colleagues and I thmk what
459
\\ e are basically saying, in order to solve this problem, notwithstanding
the reluctance of the agency heads who are appointed by the Execu-
tive to put themselves in an embarrassing situation. However, the
])roblem is of snch magnitude that somebody's feet have to be to
the fire and as the chairman said, let us give it to the Congress. If you
tell us wdiat j^ou need and what you want, we will put our feet to the
fire, so to speak, in an effort to come up Avith some viable solutions to
this problem.
Thank 3'ou.
Chairman Pepper. Mr. Steiger.
Mr. Steiger. Yes, Mr. Chairman, thank you.
Doctor, do you know of any drug that in your experience or to your
knowledge, was tested over a period in excess of 5 years on over 1,000
people without receivmg some kind of a judgment as to its efl&cacy,
safety, et cetera, that was within the purview of FDA and your
organization?
Dr. Brown. Not off the top of my head. I may say, although it
might not be what you are lookhig for in the way of an answer, several
drugs oral antidiabetics used for as long as 10 years, that might not
be as effective as injectable ones, and there are many examples of
drugs in use by tens of thousands of peoj^le where the real impact,
its efficacy, did not become clear even though organized research
efforts were made toward it. In that sense I do not think methadone
stands alone, you know, in terms of being used for tens of thousands of
people for over 5 years, without having the answers to questions of
effectiveness. It is not that much a loner as perhaps you would imply.
Mr. Steiger. Are you sayin.g that the oral diabetic drugs were in
this state of limbo for 10 years and used on thousands of people or
were approved and then 10 years later were found to be not as effi-
cacious as was originally thought to be?
Dr. Brown. I am perhaps leading.
Mr. Steiger. I see what you are saying.
Dr. Brow N. Yes.
Mr. Steiger. Mistakes have been m.ade as to the efficacy of drugs.
Dr. Brown. Yes. There have been many drugs that have been
approved as safe and efficacious with research over a 10-year period.
Another example is that well-known one, the birth control pills,
w^here the answers are still being sought as to their long-term impact
when used over a period of 5 or 10 years.
Mr. Steiger. But none of these failed to receive the FDA approval
over this period of time.
Dr. Brown. As far as I know, they must have received the FDA
approval.
Mr. Steiger. In your own mind now, we have got somewhere
between 20,000 and 30,000 people over a period of something in excess
of 5 3"ears. We have been exposed to this. We have gone through the
animal i)rocesses and whatever else is required. Now you are talking
about upping the ante to another 4,000 or 5,000.
How many people are we going to have to try this on and for how
long before somebody is willing to say it is OK or it is not OK? I
find it very difficult to accept your rationale up to now.
Dr. Brown. The answer that I give to a question like that, and I
think both your question and my answer are sincere in trying to cope
460
with the problem, not evading; the problem, is that the cost of re-
search as General vSarnoff said, is the cost of going from here to there.
I think until we have matched patients to compare with methadone-
treated patients we will not have the results we need.
1 think one could get good answers in a year or two and I think
there is a promise that within the next year that we wdll have more
definitive answers about the efficacy of methadone.
Mr. Steiger. By definitive answers I get the feeling you are
talking about crime figures. With all due respect, it seems to me that
your responsibility is to see, one, that it is safe, and, two, that it
apparently will work under the conditions which you prescribe.
Now you tell me it is going to take you another year or two to make
that judgment. Are you waiting to make a judgment which includes
the crime statistics, or are you only concerned with the physiological
aspects of this?
Dr. Brown. From my ]ierspective — again, it is in our opening
statement — that one must look at the physiology, whether or not
the person is working, whether he gives up antisocial behavior or
not, whether he is motivated enough to educate himself, whether he
lives with his family, the nature of his mental health, et cetera. All
of these are very important criteria. We are not limited to just whether
or not it has some bad effects on the body or his heart goes bad after
4 years. We are concerned Vvith the whole range. I do not like to
see it when the antisocial behavior is the only criteria. I do not think
that is adequate but I think it is terribly important.
Mr. Steiger. You see. Doctor, our problem is that this is not an
inner-city problem anj" longer. It is obvious our concern is because
now it is our ox that is being gored. I have got a problem in Flagstaff,
Ariz., and you never heard of Flagstaff", Aiiz., but the ]:)oint is that
I honestly believe after listening to weeks of testimony from people
as sincere as yourself, the normal caution that goes with, one, the
scientists; two, the bureaucratic administrator; and three, anybody
in the public light, this is working to the detriment of the Nation
in this instance. I think the most valid evaluation of methadone
was made by yourself, that it is probably effective in a quarter to a
third of the cases of addiction.
Great. All right. Draw some guidelines. Tell us to go use it because
what is happening is you are creating a black market by some doctors
who are not motivated by the profit motive, and by others who are
clearly unscrupulous. You are creating a new artificial illegal situa-
tion and you are dohig it because everybody points to 3'ou. The
buck seems to always end up in yoiu* lap. Wliether it is there proi)erly
or not, it seems to me the time has come to stop saying let us wait
and see.
It is my firm belief that you have the statutory authority to make
this judgment now. If I am WTong, I hope you will correct me. And
I just think that you are scriousl}' shirking yoiu" responsibility if
indeed this is only valid in 10 jiercent of the cases because we have
nowhere else to go at this point and we are playing games with Lex-
ington. We are playing games with the well-intentioned but techni-
cally inadequate peoj)le who arc attempting to solve the problem.
I have got a guy who plays Beethoven in stereo as a means of
treating addicts. I should not say that. It ma}^ work. But the point is
461
that this is the extent to which communities are grasping for this
thing. And I know that you know all these things and yet I wonder at
your ability to say, well, we are going to put another 4,000 here in
the District on it and see what happens, because I can tell you what is
going to happen. You are going to get a 20-percent increase in addic-
tion across the United States this next year without it, period, and
you may still get that 20-percent increase, but at least you will be
controlling ])art of it if we are in a situation in which we are dispensing
it under prescribed regulations.
One other point. If you had a drug that had been used on 1,700
people, recommended by two or three acceptable medical authorities,
and FDA said it had never been tried on dogs and cats and rats and
mice or whatever they have got to do, would you have the budgetary —
and assuming it passed your superficial criteria — -could you find the
rats and mice and whatever to test it on? I am talking about Perse,
which, I understand, you are aware of and to us la3^men it sounds
wonderful and I am willing to concede that it may be as bad as
Beethoven, but the point is that here we are talking about some
monkeys and some dogs and some rats and the fellow who has it has
not got the monkeys and dogs and rats.
Can you give it to monkeys, dogs, and rats to the point that the
FDA can at least give out an IND number on the thing?
Dr. Brown. Yes. We could take the drug and do work on it.
Mr. Steiger. Would you?
Dr. Brown. After we went through the painful process that Chair-
man Pepper said that he was not in good spirits with, of looking care-
fully at the papers and seeing whether it was worth doing with the
limited capacities we have.
Mr. Steiger. All right. If you will stipulate that 1,700 people have
taken this thing over a year, that there are — -we will give you the
testimony. I am sure the chairman will be happy to pro^dde it.
Dr. Brown. We would be glad to explore it in depth and give you
our best answer.
Mr. Steiger. The point is that you are talking about help not
only for the addict but for people who drink too much. You could
have an impact that would fairly exceed the addiction problem.
You could be heroes nationally, not just to the addict population.
The point is that we do not understand all of your problems ob-
viously, and we do not make any pretense that we do, but we have
some very specific things here that it seems to us that need to be done ;
you are the people who have to accomphsh them and you are not
accomplishing them.
Now, that is the way it looks to us. That may be very unfair but
there it is, at least to me. I cannot speak for the balance of my col-
leagues, but I think you should be aware of this and it should not be
just a polite situation.
Would you respond to that, Doctor? Would you give us a commit-
ment to look into Perse? I think that would make us feel good.
Dr. Brown. We have already and we will be glad to do a very
thorough evaluation and get an answer back to you.
Mr. Steiger. Tell me, in your preliminary examination you ap-
parently have not been impressed with it; is that correct?
Dr. Brown. Mr. Besteman has been involved du-ectly.
60-296 — 71 — pt. 2 9
462
Mr. Besteman. The man on my staff who is a pharmacologist has
been scheduled twice to meet \\dth Dr. Revici and the FDA in the
Parklawn building and two meetings have been canceled. We have
asked for written material and we have pursued it from our side.
It is a matter of waiting for the data to come to us but we are in the
position that if the claims are substantiated, tliis is something we
cannot ignore and we have actively gone after the data. We do not
have it.
I understand there has been some illness involved and this has been
one of the problems.
Mr. Steiger. Doctor, are you aware that we had testimony here
from two physicians who have used tliis?
Mr. Besteman. Yes.
Mr. Steiger. Would not their experience be of some value to jou
in evaluating this?
Mr. Besteman. Yes, it would be; but we have to start even more
basically than that because they are talking about the drug and once
you start at that level and Avork forward — 3'ou do not start from testi-
monials and work backward. There are many things that chnicians,
and I have been one, believe in.
Mr. Steiger. Oh, I know.
]\lr. Besteman. And they even work because I believe in them and
I get the people who work with me to believe in them and we are
both happier, but then the next fellow down the block cannot do that,
and this information from the clinical setting alone is not enough.
Dr. Brown. What we are saying is we have pursued and made
ourselves available and I think Commissioner Edwards said the same
thing. We are ready, willing, and aware.
Mr. Steiger. OK. I A\ill just explain this to you, then. We are well
aware that Dr. Revici is not the conventional physician, scientist,
et cetera. Fine. And what he has may or may not be of value. But
on the other hand, while it has not been trietl on the rats and mice,
there are 1,700 people who have taken it and they are fine, or better
than they were.
It seems to me that we have an obhgation here that you have got
$17,700,000 to spend and you are the people — it seems to me that you
have to be more aggressive than simph^ establishing an appointment
that the guy does not keep and then if he does not keep it, ergo, your
responsibility is ended. It may be protocolwise or professionally that
is all you should do but that is not going to help us, and again, we
are in a situation where the barn is burning and everybody is standing
around explaining why they cannot put out the fire, picking a few
dandelions off the lawn but the barn in the meanthne is burning down.
Dr. Brown. I think we have been more than just waiting. We have
asked for the materials. Now, we really are at it. You must under-
stand that whenever the barn seems to be burning, there is this
feeling— let me go back to an earl}^ implication of yom* question. There
was similar feeling, I think, 7 or 8 years ago that has occurred again
about cancer, a terrible thing. Once you get involved in the cancer
situation it is heartrending. It hits almost every famil3\ A large pro-
gram to screen every possible drug that might have an effect on
cancer was approached. Everything that might help ought to be
screened through thousands and millions of rats and mice. That
approach tried and ditl not pay off.
463
We could go into the drug area and say this is so important we had
better try leads of anj^ sort and have that kind of desj)erate approach.
1 do not think it is mse. So, that we have had experience with a
sense of urgenc}' and people dying. You know how many people die
of cancer each year and we find that we must proceed somewhat
thoughtfully clinically. If you had the real feeling that we just were
pushing off the man I think you would be right.
One of the problems we feel is most interesting and difficult is
that mau}^ of the most miportant research advances would have
come from men who could not get a research grant from us because it
would have been such an unconventional idea. It is very difficult,
m3^stifying. How do you deal ^^dth the problem that it quite often
is the unconventional idea? We do not yet have the mechanism to see
wliich ones of dozens and hundreds of thousands of unconventional
ideas are going to be the payoff. We do know, however, from the
nature of people who have unconventional ideas that pay off, they
all were terribly persistent. The}^ all kept at it. They all bootlegged,
bootstrapped their research. They got money from elsewhere. People
who are creative with an unconventional idea do not give up easily
even if they cannot get a research grant.
Mr. Brasco. Would the gentleman yield? I think in this particular
case this is what Dr. Revici is doing, because if he has some 1,700
people that have had contact with this drug of his in a program,
and if he is obviously not getting any help from us, then he is
going out and doing it on his own.
But the real observation I wanted to make, Doctor, is this. It would
seem to me from the testimony that I hear in connection with all
the research that is going on, and with the great difficulty of the
different agencies, and I am not talking about you now, but you have
been here for some of the testimony, to recall what they are doing
in research, what their budgets are and who is doing what and to
whom, so to speak, might it be a better approach inline A^dth your
own testimony that you have a number of obligations, leukemia
being one, several of the others — cancer being another, and there
are several others, Parkinson's disease that you mentioned — that
should we not have under your jurisdiction maybe a separate division
that does not have to divide its resources, that can just zero in on
this one particular problem, so that we can have a unified concen-
trated effort under one roof, and we can always be abreast of what
is going on and maybe it might be wise in your approach to consider
it.
Dr. Brown. We will be glad to have some organizational ob-
servations as to the budget, if you so desire, if you couch the question
to include that.
Mr. Brasco. I think that would be most helpful.
Thank you.
Mr. Steiger. I have no further questions, >.Ir. Chairman.
Chairman Pepper. Just before my colleague, Mr. Mann, I would
just like to say this for the record. I understand that Dr. Revici has
been ill and that is the reason that he has not kept the appointments.
Dr. Brown, ies; that is what he said.
Chairman Pepper. I am sure we are very much interested in your
thoroughly examining Perse to see whether it has any potential or not.
Mr. Mann?
464
Mr. Mann. No questions, Mr. Chairniaii.
Chairman Pepper. Doctor, we are interested in two thinp:s. We have
already been over the research aspects of it. We want to develo[) the
best possible drugs for use in combating heroin addiction.
Now, the other thing is to establish the necessary treatment and
rehabilitation facilities that deal with the heroin addicts in the
country.
Wlien we held hearings in San Francisco in 1969, one of the doctors'.
Dr. Roger Smith, who was in charge of a clinic in Haight-Ashbury, as
I recall, testified before our conmiittee that the thing he thought most
desirable was to establish a clinic in each community, in each area of
a city. It need not be large and need not be [)ublic. It could be an
approved private clinic. But to establish a treatment and rehabilita-
tion facility in almost every community where there was a drug
problem so as to make it easily accessible to the drug addict.
Now, what we would like to do is to get a blueprint from somebotly
who could give us one of what would be the desirable pattern for
treatment and rehabilitation facilities in this country if we were tr^dng
to set up what was necessary and desirable in the public interest.
Could you, or any of the gentlemen associated with you, tell us
what facihties are now available and then tell us what you think
would be desirable if we were adequately to meet the ])roblem?
Dr. Brown. Yes. We would be glad to develop such a thoughtful
document that would lay out a blueprint. I do think the fact that
available health resources, and I am ushig the most general term,
ought to be available in every community for the drug problem — this
is clearly a beginning. I start from that premise that one ought to be
able to get help somewhere near home. This has been our blueprint
with considerable effectiveness in the mental health area, generally,
with the community mental health centers. We hope to have a net-
work of 2,000 centers in every local community. So far wo have such
centers covering about a quarter of the country and we made consider-
able progress with many a hard-nosed criteria. I do think a parallel or
analogous network of services is needed in the drug area.
Chairman Pepper. That sounds like a good analogy. That is what
we are looking for, an adequate program.
As I understand it now, how many treatment and rehabilitation
programs are there, so far as you know, in tlie country today?
Dr. Brown. We know those that we have funded, which is roughly
23 such community centers throughout the country. We do know of
perha])s 100 additional treatment centers that might range from free
clinics like the one in Haight-Ashbury, drop-in centers and other
partial therapeutic houses, halfway houses, bits and pieces as we call
them, as important as they are.
Chairman Pepper. If you are funding 23, that is less than oue for
half of the States of the coimtry. Now, in Miami, in ray home, the
people there who have been trying to provide treatment and rehabili-
tation facilities have had a terrible ordeal to get the money. In one
instance the Bishop of the Diocese of Miami, the Catholic Church,
provided the only mouey that was available for a methadone clinic. It
was operated by a Dr. Ben Sliepard. You know about that. Then there
is one now operated by Father O'Sidlivan. Tlieu there is another one
up in North Miami, I believe it is, and then there was some sort of a
465
program that was i)ut into Jackson Memorial Hospital. But the
jjeople who have been struggling with the j^roblems just have not had
the money. The county has not had the money. The cities have not
had the money. They have not been able to raise enough by charity.
They got a little — Self-Help, I know, got a little money, $20,000 I
believe — through the State from the Federal program. But other
communities in the country must be having the same problem. My
colleagues probably have similar problems in their States. With all
the mone}' the State of New York has put up, I dare say you do not
have nearly enough and in other States you probably have the same
]>robleni. You do not have enough facilities.
Mr. Brasco. No. And if I might. Doctor, I do not know whether
or not you were trying to make a point that went over our heads but
it is something that happens all the time when you talk about local
centers, and I think that is going to be basicallj' our problem because
I found this in my area as well as every other area that people say,
yes, we have a problem, 3-es, we want somebody to do something about
it, but when it comes time to put up a local drug rehabilitation center,
they say put it in somebody else's neighborhood.
Is that what you were driving at? If so, I think that you are right.
This is our problem and we have got to sell it and we will. What we
want is that blueprhit because we just cannot go any more the way
\N'e are.
Dr. Brown. I think that is fair.
Chairman Pepper. Thank you. We thank you very much. We will
look forward to that. Give us a blueprint of what should be the ideal
treatment and rehabilitation program for the countr}- .
(The following was received in response to the above rec^uest:)
During the hearings, you requested a bhieprint and a professional judgment
budget in the field of narcotic addiction and drug abuse. As you know, the Presi-
dent has recently announced a significant new initiative and thrust in this area
and we are currently assisting the White House Special Action Office in designing a
blueprint of a service program for the President. It would, therefore, be inappro-
priate for me to provide either a blueprint or professional judgment budget to
the Committee at this time.
Chairman Pepper. Now, Mr. Perito, did you have any fiu'ther
cjuestions?
Mr. Perito. A couple of questions, Mr. Chairman, if I ndght.
Dr. Brown, if I understood your testimony correctly before another
bod}", you mentioned that there were no federalh" assisted treatment
and rehabilitation programs for people under the age of 18. Is that
correct?
Dr. Brown. I do not recall having said that in those terms, Mr.
Perito. You must be referring to some dimension of perhaps the
methadone regulations which do not permit treatment under the IND
for i^ersons imder 18. I think that may be what you are referring to.
Mr. Perito. Do you know of smj federalh^ assisted programs where
they have a broad multimodality apjjroach for children under the age
of 18? In the 23 community-based treatment programs which are
supported b}^ Federal funds?
Dr. Brown. Yes. Several of them have programs that treat young
adolescents. They may not use methadone which is perhaps specifically
what you had in mind, and again, the nature of the question is inter-
esting enough that I would like a chance to respond for the record by
466
saying how many or what proportion of the people in federally
assisted programs are under 18. That would give us the sharp question
to which we then could tr}^ to provide hopefully, a responsive answer.
Mr. Perito. If you could provide that, it would be very helpful.
Dr. Brown. Be glad to.
(The information to be provided follows:)
Nineteen percent of individuals being treated under NIMH programs (includ-
ing NARA and the community programs) are under age 21. (We do not have the
exact percentage of such individuals under age 18.)
Under NARA (the Narcotic Addiction Rehabilitation Act of 1966, Titles I and
III), 13 percent of all individuals currently being treated are under age 21.
Of those individuals being treated in community-based programs, 21 percent
are under age 21. A further breakdown of individuals treated in the community
programs indicates that 19 percent of these individuals fall within ages 16-20 and
2 percent are 15 or younger.
Mr. Perito. Do you have any criteria or are there criteria set up for
the treatment of young addicts? Do you know of any?
Dr. Brown. Not per se. I know that is part of the primitive art
of treatm^ent which we are talking about. This gets to be, shall we
say, undeveloped, primitive when you get to the young, which is
really a quite op])ressing and difficult problem.
Mr. Perito. One of the problem^s that we have been having in
trying to gather together information is statistics on evaluation. Do
you know of any statistics or any evaluative study as to the efiicacy
of the drug-free approach programs insofar as crime reduction is
concerned?
Dr. Brown. Again, we presented in our testimony our experience
under the NARA program, including crime statistics. We will in the
very near future, within the next few months, be able to take the
drug-free versus the methadone, to do the important thing of matching
for age, sex, employment, social background, to give definitive answers
on that comparative basis as well as the crime, social, educational,
and physiological paramicters. We are pursuing that as rapidly as
we can.
Mr. Perito. That would be very, very helpful.
Chairman Pepper. Excuse me just a minute. We would be very
much interested in that. Can you give any overall judgmients as to
whether or not adequate treatment and rehabilitation facilities made
available in the communities of the country would effectively, and
if so, to what degree, reduce crime? Could you hazard any estimate?
Dr. Brown. Well, what we could do is in laying out what our best
program would be for the total heroin addict j)opalation, 250,000,
with what we now know about its effectiveness, what impact that
would have on the crime rate. We could do the logical steps to give
you an answer to that question.
Cliairman Pepper. That is what I am getthig at. If we api)Hed
the skill and knowledge and substances that we now have available
in an adequate degree, what impact would that have, in j^our best
judgment?
Dr. Brown. We could follow out that thouglit process.
Mr. Brasco. Dr. Brown, not to comijlicate this blueprint any
further — —
Dr. Brown. It is a rainbow print by now.
467
Mr. Brasco. Possibly. However, we look to you for some of these
answers. Obvioiislj^, we do not have them and I am aware that you
do not have all the answers, but I do not know that there are any
programs for the rehabilitation of those addicted to amphetamines
and barbiturates, and these addicts are much greater in numbers
than heroin addicts.
Might we include them in your blueprint?
Dr. Brown. The answer is yes, but let me just expand on it for a
moment. The Comprehensive Drug Abuse Act changed our authority.
Prior to the act, we were limited with our Federal funds for, say,
community centers, to only opium addiction. Now, the act permits
those funds to go also for treatment of amphetamines and barbiturates
and other drugs of abuse so that we now can have community drug
abuse treatment programs, and our recently funded programs now
cover more than just the heroin problem. So, in that sense we do have
new efforts and new authority to deal mth the problem.
If our data are weak on the heroin, they are going to be, of course,
weaker on the amphetamines and barbiturates, as you know.
Mr. Brasco. But you can include in this blueprint recommenda-
tions to cover that area, too.
Dr. Brown. Yes, we can.
Mr. Brasco. Because it would seem to me to be ludicrous to get
into the area of heroin addiction and leave the others out.
Dr. Brown. Mr. Besteman?
Mr. Besteman. There is another important point. Maybe 10 or
15 years ago we talked about a person being a heroin addict and that
would be his drug of choice and it might be his only drug. I tliink
today in our community-based treatment centers we are seeing
multiple drug users and people shifting in a historical sense from
one set of drugs to another for a whole variety of reasons, and so we
are getting experience with these other drug abusers without even
trying. They are coming into a drug abuse center and nobody is
asking — you know, what is the drug is not the first question. The
first question is what do you need? How can we help?
Mr. Rangel. Your experiences are probably unique in any given
community that you are going in but, of course, the thrust in my
community has been whether you are a heroin addict or methadone
addict. Is that true?
Mr. Besteman. It varies in
Mr. Rangel. I mean, you do not ask anj^body in central Harlem
whether they are on pot or whether they are taking pills, you know.
It is just, are you taking heroin or methadone?
Mr. Perito. Dr. Brown, the 91st Congress passed the Compre-
hensive Drug Abuse Prevention and Control Act. Wliat new research
money was provided and authorized for your Agency under that act?
Dr. Brown. The act itself did not authorize any new ceiling in
research funds since that comes under a general authorization. It
did provide new authorizations in the treatment and rehabilitation
and education area. It did not provide new authorizations per se
since we essentially have an open ended congressional authorization
situation.
Our research efforts, again provided in that table, just for a per-
spective, read from 1968 to 1972, which is the w&j, reads $13, $14,
468
$15, $17, and $19 million, just to give you a sense of some modest
increase in the research efforts.
Mr. Perito. If I understand it correctly, in fiscal 1971, $7,987,000
was spent directly by NIMH on drug abuse research; is that correct?
Dr. Brown. Yes.
:\Ir. Perito. And in 1972, $9,325,000 will be spent?
Dr. Brown. I do not know which subfigures j^ou are adding. One
of the issues, Mr. Perito, is that we spend approximately — the figures
you said — $6 or $7 million in drug abuse, that is on the amphetamines
and barbiturates, heroin, cocaine, et cetera. We do have a very im-
portant psychopharmacolog}^ research program that looks at all
drug use and enhances our research endeavors, that $9.8 million, so
Avhen we give you the figure of $17 or $19 million and that is why we
broke it doM'n, one must distinguish between the subportion, roughh'
a third, that is, on drug abuse, clearly drugs of abuse, as opposed to
psA'chopharmacolog}^ or drug use. So, the relationships from the
research point of view, I am sure are clear to you.
Mr. Perito. Two final questions. What was the demand for funds
this past year for research in the area of narcotic antagonist?
Dr. Brown. I do not know the answer for that. Dr. Martin, is that
something you are aware of?
Dr. Martin. No.
Dr. Brown. There was slightly more demand than we had resources
for. That I can say, but not a heck of a lot.
Mr. Perito. So, you turned down some requests for research in the
area of antagonists?
Dr. Brown. Not for antagonists per se. In relation to the antagonists
we funded all the research that has come to us or that we could find.
Mr. Perito. One final question for Dr. Martin. Dr. Martin, I take
it from your testimony, that the resources available to private hidustry,
insofar as laboratory facilities capable of jjerforming toxicity studies
are concerned, far exceed anj'thing our Government has available to it.
Is that a fair statement?
Dr. Martin. Yes; I think so.
Mr. Perito. In your professional judgment, would it be worthwhile
for our Government to greatly exj^and its laboratory facilities to do
toxicity testing insofar as narcotics research is concerned?
Dr. Martin. Yes; I think this woidd be most helpful and most
necessary.
Mr. Perito. Thank you. Mr. Chairman.
Chairman Pepper. Mr. Blommer?
Mr. Blommer. I have just one comment, Mr. Chau'man, to enlighten
our record and maybe Dr. Brown. Dr. Revici has no facilities for
following up on the 1,700 people he has given Perse except for tht^ 2
Aveeks he is in direct contact ^\ ith them. So, I tliink that Congressman
Steiger was a little bit misstating a point to saj^ that they are fine. But
I would add a note of hope and that is that the assistant coroner of
New York (^ity has never heard Dr. Revici's name.
That is all I have.
Chairman Pepper. The last comment — that suggests the ])ossi-
bility that if you had somebody like Dr. Revici, who might not be very
good at recordkeeping, not very good in kee])ing his files and the
written data, would it be within the scope of your authority to help
469
him, arrange to get somebody else to help hhn to perfect his records so
that you \vould be able to evaluate the })roduct that he proi)oses?
Dr. Brown. Yes. We offer this type of technical assistance quite
often.
Chairman Pepper. That is good. I think when we go into that with
you, which we want to do, then we can see what it would be — whether
any help to him would be in the public interest or not.
Well, any other questions, gentlemen?
Doctor, we thank you very much, and Dr. Martin and the other
gentlemen who have been with you. You have been very helpful to us
and we will look forward to the receipt of the material that you have
been kind enough to offer to furnish.
Dr. Brown. Thank you very much.
Chairman Pepper. We will adjourn until 10 o'clock tomorrow morn-
ing, here.
(The following material, previously referred to, was received for the
record :)
[Exhibit No. 17(d)]
Prepared Statement of Dr. Bertram S. Brown, Director, National Insti-
tute OF Mental Health, Health Services and Mental Health Admin-
istration, U.S. Department of Health, Education, and Welfare
Mr. Chairman and members of the committee, I appreciate this opportunity to
appear before you today as Director of the Government agency which has primary
responsibility within the Department of Health, Education, and Welfare for the
non-law-enforcement aspects of the drug-abuse problem. In addition to sponsor-
ing a broad program of research into the drug-abuse problem, the Institute is also
funding treatment, training, and prevention programs through public information
and education approaches. I recognize that the committee's primary interest is in
the Institute's research programs, and I will concentrate on this in my testimony.
Since we regard the drug-abuse problem as a unitary one, however, I may at times
refer to the Institute's treatment, training, and prevention efforts. I have prepared
detailed responses to the questions submitted by the committee and will be happy
to submit them for the record. Instead of reading these responses, I thought I
might present the committee with an overview of the Institute's research program.
I have with me Dr. William Martin, Chief of the Addiction Research Center,
Lexington, Ky., who will provide the committee with more detailed 'material on
the Institute's research program into determining the abuse potential of drugs
and experimenting with pharmacological methods of treating narcotic addiction.
research in drug abuse
The Institute is sponsoring research regarding each of the five categories of
commonly abused drugs: (1) Opiate drugs, also called narcotics; (2) sedative drugs,
including barbiturates; (3) stimulant drugs, including amphetamines; (4) hallu-
cinogenic drugs, including LSD; and (5) marihuana and related drugs, such as
tetrahydrocannabinol. With regard to each of these drug categories, Institute
research projects are focused on the following topics:
(a) Understanding the mechanism of action of these drugs.
(b) Studying factors which affect the development of tolerance or physical de-
pendence which may lead to addiction.
(c) Studying the effects of these drugs of abuse in animals and humans.
(d) Developing methods of detecting and quantifying abused drugs in body
tissues and fluids.
(e) Developing treatment methods.
In order to understand the mechanism of action of abused drugs, the Institute
is funding research on the effects of these drugs at the cellular and molecular levels
as well as on well-defined areas of the brain. In addition, studies are being carried
out to determine how the body metabilizes these drugs and which metabolites
are responsible for their psj^choactive effects.
470
Studies on the waj^s in which tolerance or physical dependence develops focus
on biochemical, pharmacological, and behavioral measures associated with toler-
ance to narcotic analgesics such as morphine. In an eflfort to understand how ad-
diction occurs, these studies are exploring the effects of narcotic analgesics on
brain proteins, R,NA, and brain transmitters.
In studjang the effects of drugs of abuse in animals and humans, researchers
are exploring both long- and short-term effects and effects of both small and
large doses. Studies are concentrating on the effects of drugs on coordination,
thinking, perception, memory, and complex acts such as driving. Research is also
being carried out on the potential genetic and carcinogenic effects of these drugs,
as well as on their effects on developing fetuses.
Research into detecting abused drugs in body tissues and fluids includes re-
search on opiates, barbiturates, marihuana, amphetamines, and hallucinogens.
Better methods of detection will help those who are treating drug abusers and
should reduce the expense, complexitj', and error involved in screening and
monitoring both i^atients and prisoner suspected of drug use. More sophisticated
methods for quantifying and differentiating various types of drugs will also be
useful to forensic pathologists and medical examiners.
Much research is now underway to evaluate the effectiveness of treatment
and rehabilitation methods in the field of narcotic addiction. We are evaluating
both pharmacological approaches, such as the narcotic antagonists and metha-
done, and nonpharmacoiogical methods such as therapeutic communities, compre-
hensive centers, and desensitization techniques. As members of the conmiittee
lasiy know, the Institute supports the treatment of addicts both under the civil
commitment program of the Narcotic Addict Rehabilitation Act and under a grant
program to establish community-based treatment centers, of which approximateh-
16 are now operating and another seven have been funded and are getting under-
way. In addition, under Public Law 91-513, the Institute is now authorized to
fund individual treatment services such as detoxification centers, partial hospi-
talization, or emergency care.
Both the civil commitment program and the community-based comprehensive
treatment centers empio.y pharmacological and nonpharmacoiogical methods
of treatment, and data is being gathered to evaluate the relative efficacy of
these methods.
I should stress that we believe that no one method of treating narcotic addicts
is "the answer." Addicts differ in their needs and in the kinds of therapy which
are most helpful to them. As a result, it is necessary to evaluate a variety of
treatment modalities.
As of March 1971, the narcotic treatment and rehabilitation programs sup-
ported by the Institute were assisting approximately 2,000 patients under the
civil commitment program, of whom 1,300 were in the aftercare phase of treat-
ment, and approximately 7,000 patients in the community-based treatment
programs supported by Institute grants. Unfortunately, we cannot at present
compare the results of the civil commitment treatment program and the com-
munity treatment programs because the}^ are treating different groups of addicts.
However, at a later date it should be possible to extract matched pairs of patients
from the two groups and compare their degree of benefit. To illustrate the differ-
ences in the two groups, addicts being treated under the civil commitment pro-
gram are 60 percent white and have an average age in the late twenties; whereas,
the patients being treated in the community centers are over two-thirds black
or Chicano and have an average age in the early to midtwenties. Moreover,
the two groups are not equivalent in terms of employment histories, arrest histor-
ies, or education. What we can say now, however, is that both programs seem
to be helping a large percentage of the patient populations whom they are trenting.
The exact percentage of patients who are being helped depends on what measure
3^ou use to evaluate the patients' improvement. For example, you can look at
the percent of patients who are working, or the percent who are staying out of
jail, the percent who do not become readdictcd, the percent who have returned to
school, and so on. In the civil commitment program, a study of 1,200 patients who
were in aftercare in 1970 showed that approximately So percent wei-e enii)loy('ti,
70 percent wore not nrrestod and spent no time in jail during that jxn-iod, 3.")
percent wore in self-help therapy, and 33 percent were pursuing their education.
In addition, SO percent of the patients who had been in aftercare for 3 months
or more were completely free of heroin use. A similar statement can be made
regarding the heroin use of patients who were in the community tr(^atnient
programs. As you know, many patients during the treatment of their addiction
may abuse drugs other than heroin occasionally, such as cocaine, marihuana,
471
ainpheta.mines, or barbiturates. Of the patients in the civil commitment program
who had been in aftercare for 3 months or more, 60 percent were not abusing any
drugs. The same is true of patients who had been in the community treatment
program for 3 months or more. Of the patients who are in the civil comtmitment
aftercare phase, we know that 60 percent do not become readdicted during their
first year in aftercare. Of the remaining, 25 percent do abuse some drugs or become
readdicted and require further hospital treatment. The remaining 15 percent
drop out of the program.
There is a great deal of public interest currently in methadone maintenance
treatment for narcotic addiction. Many claims and counterclaims are being
made regarding its effectiveness. How effective is methadone maintenance
treatment? The answer I am about to give you is a cautious one, but I believe
represents the state of our knowledge at this time. The Food and Drug Adminis-
tration, which has responsibility for determining the degi-ee of safety and efficacy
of drugs, has determined that the exact degree of safety and efficacy of methadone
maintenance treatment in unknown at this time. Many groups, including groups
in New York City, Illinois, and here in Washington, D.C., are evaluating metha-
done maintenance. The National Institute of Mental Health is currentlj' spon-
soring the use of methadone in both its civil commitment treatment program and
its community-based treatment in-ograms under carefully controlled conditions
so that we can generate data to help determine methadone's safety and efficacy.
With regard to comparing methadone and other treatment modalities, I must
again point out that the patients who are being treated with methadone differ
in many characteristics from the patients who are being treated with other
modalities. For example, they differ in age, sex, race, length of addiction, history
of criminal behavior, and so on. Lastly, I might again say that comparisons of
efficacy depend on which measures or benefits one looks at — employment,
arrest records, drug abuse, or pursuit of education. At the present time I do not
know of any conclusive studies which demonstrate significant differences between
the benefits achieved by methadone patients compared with the benefits achieved
by patients treated in other waj's.
It might be good to mention here that we are studying other narcotic sub-
stitutes which ma}^ be longer acting than methadone. One drug we are testing is
L-alpha-acetyl-methadol, whose effects last for 48 to 72 hours, and if successful,
wall mean that patients could come in from treatment only two to three times
a week rather than every day. This would greatly decrease the cost of a mainte-
nance program and allow the patient to live a more normal life. We are also support-
ing research into tiie development of a nontoxic removable implant which can
deliver an antagonist drug slowly into the patient's system over a period of time
so that the need for repeated medication would be markedly reduced. A fully
safe and effective antagonist, however, has not yet been developed.
Mr. Chairman, my overview of the Intsitute's research program would not be
complete unless I mentioned three additional activities. First, the Institute's
program of supplying standardized pure preparations of drugs of abuse to qualified
researchers. Originally this program focused on distributing LSD to researchers
through the joint FDA-NIMH Psychotomimetric Agents Advisory Committee.
With the increased use of marihuana and related drugs, the program has expanded
to include a wider spectrum of drugs, including psilocybin, radioactively tagged
and untagged tetrahydrocannabinol (Delta-8 and Delta-9 THC), a uniform
standard grade of marihuana leaf, and most recentlj- heroin for research purposes.
At present the Institute is not only supplying requests from the U.S. investi-
gators but has estabhshed procedures with the Canadian Food and Drug
Directorate and the United Nations Narcotics Laboratory for supplying and
distributing these drugs for research in Canada and Western Europe. Information
generated by research performed in foreign countries should help the U.S. research
program. The number of requests for research drugs has doubled in the past year.
Since this program's inception, 650 requests for research drugs have been filled,
250 of them for marihuana or its derivatives.
Second, the Institute is currently pretesting a number of educational materials
including pamphlets, posters, workbooks, and films to determine their usefulness
in reaching different groups within the population. Materials which pass this
pretesting phase will be ready for release in the fall of this year. Some of the
materials and educational materials which have previously been developed through
the National Clearinghouse for Drug Abuse Information have been used in the
Institute's training program, which in fiscal j^ear 1970 provided 1- and 2- week
courses on drug abuse for over 1,500 professionals, allied health workers, Govern-
ment officials, and members of the public.
472
Lastly, I might mention the program being conducted at the Addiction
Research Center b.v Dr. WilHam Martin to develop improved methods of deter-
mining the abuse potential of drugs before they become problems on the street or
in the clinic, and to study pharmacological treatments for narcotic addiction.
Dr. Martin and his associates are inv^estigating the conditions vmder which animals
will self-administer drugs and are determining to what extent each drug induces
physical and psychological dependence, behavioral toxicity, and harmful physio-
logical effects. At this point, I would like to introduce Dr. William Martin, who
can tell you in more detail about these research programs.
Question 1. What is the total amount of money that has been spent on narcotic
addiction and drug abuse research from 1968 through 1971 and what is the projection
for fiscal 19721
Answer. The total amounts spent on narcotic addiction and drug abuse research
within the Division of Narcotic Addiction and Drug Abuse, and related projects
funded by other divisions, from 1968 through 1970, and the projections for 1971
and 1972 are itemized as follows:
Thousands of dollars
1. Research grants:
DNADA
Other divisions.. .
2. Contracts (marihuana study)
3. Intramural research (addiction research center)
Lexington, Ky
4. Other dir operations (operating costs within Divi-
sion of Narcotic Addiction and Drug Abuse)
Total Institute, drug abuse research activities
1968
1969
1970
1971
estimate
1972
estimate
$2, 506
1 9, 523
466
$2,614
1 10, 131
600
$3, 650
• 9, 800
956
$5, 600
1 9, 800
1,138
$6, 549
' 9, 828
1,495
770
752
769
841
866
187
200
396
408
415
13, 452
14. 297
15,571
17,787
19, 153
' Represents those NliVlH research grants which are not funded by the Division of Narcotics Addiction and Drug Abuse;
they include projects whxh are directly relevant to drug abuse research and some which are indirectly related. For ex-
ample, they include projects which deal with drug research mi'ithodology, drug synthesis, the mechanisms of action in
drugs, metabolic effects, and psychological effects. Even research on drugs which are not abused often produce basic new
knowledge which is useful in drug abuse research
Question 2. How much money has been spent on grants, how much on contracts?
Answer. Within the Institute the amounts spent for research grants compared
with the amounts spent for contracts (all of which are for studies on marihuana)
are as follows:
[In thousand of dollars)
1968
1969
1970
1971
estimate
1972
estimate
Research grants:
DNADA.
Other divisions '
Contracts..
2,506
2,614
3,650
5.600
6.549
9,523
10,131
9,800
9,800
9,828
466
600
956
1,138
1.495
' Represents those NIMH research grants which are not funded by the Division of Narcotic Addiction and Drug Abuse;
they include projects whicn are directly relevant to drug abuse research and some which are indirectly related. For example
they include projects which deal with drug research methodology, drug synthesis, the mechanisms of action in drugs,
metabolic effects, and psychological effects. Even research on drugs which are not abused often produces basic new l<now-
ledge which is useful in drug abuse research.
Question 3. How is the budget for such research determined? (Do budget requests
filter up from the research project and scientific levels to the Office of Management
and Budget or does the Budget Office issue lump sums to be divided ot lotver levels?)
Answer. Budgets for all Institute programs arc developed in a process which
involves the accommodation of program requirements to dollar ceilings. These
budget ceilings are originally announced by the Office of JNIanagement and Budget,
and are intended to cover very large program areas. The OfBee of the Secretar\',
DHEW, subdivides these ceilings among agencies, and, to a certain extent, by
program activity within each agency.
473
In the meantime, the Institute develops its own estimate of budgetary require-
ments based on estimates made at the Division (scientific) levels. A major factor
in the development of these estimates is the amount required to continue specific
projects which have been initiated in previous years.
When the ceiling for the Institute is initially amiounced, our estimate of require-
ments is compared to the ceiling. There are opportimities for discussion of alter-
natives and options, and appeals for revision and additional funds are entertained
by the Department. During this process, the need for additional research is
weighed against otlier requirements, such as additional manpower programs and
the need to provide community-based services. Within the general area of research
and the ceiling and earmarlvings which are ultimately placed upon it, the Institute
has fle.xibility with respect to determing those priority programs in v/hich uncom-
mitted funds will be utilized for program growth.
Question 4- Hoio is the total budget for drug abuse research allocated? What are the
'priorities?
Answer. D\iring the past 3 years, the administration has earmarked specific
funds for marihuana research in response to growing public interest in deter-
mining the health consequences of marihuana use and as a result of specific
congressional directives on this subject. Other research priorities include: (1)
Evaluating drug abuse prevention, treatment, and rehabilitation services; (2)
developing effective chemotherapeutic approaches, such as narcotic antagonists
and long-acting narcotic substitutes, to treating narcotic addicts; (3) carrying
out basic physiological and behavioral research on the abuse potential and effects
of drugs; and (4) carrying on epidemiological studies of patterns of drug use and
abuse.
Question 5. Where are the policy decisions made as to which types of research
shall be funded and which areas of drug research need to be funded?
Answer. Within the overall resources available to it for drug research, the
NIMH establishes general priorities as described in the response to question 4.
Under the guidance of the Office of the Director, NIMH, the Institute utilizes
the following advisory mechanisms:
(a) Once a 3'ear, outside experts in drug abuse research come together to review
the research program of the Institute and to make recommendations regarding
priorities, emphases, and directions that the research program should take, both
long range and short range.
(b) Three times a year, a group of non-Federal experts come together to review
specific research proposals. In their deliberations, this group is guided, not only
by the Vi'ork of the policymaking bodj^, but also by the nature and quality of the
research proposals. The job of this committee is to insure that the research
proposed in a given priority area is scientifically sound.
(c) Four times a j'ear the National Advisor}' jMental Health Council, composed
of both professional and la.y members, meets to review general NIMH policy
issues and particular grant applications. In the course of these meetings, drug
research policy and grant proposals are considered. No grant may be funded
by the NIMH without approval of both the initial review group of non-Federal
experts and the National Advisory Mental Health Council.
This system insures that two types of decisions are made in an appropriate
manner: (1) Broad policy decisions regarding priorities, and (2) decisions
regarding particular research protocols intended to further our knowledge within
priority areas.
Question 6. What arc the roles of the NIMH National Advisory Mental Health
Council, the Narcotic Addiction and Drug Abuse Review Committee and the Division
of Narcotic Addiction and Drug Abuse in determining the funding priorities of drug
abuse research?
Answer. The Division of Narcotic Addiction and Drug Abuse is charged with
administering drug abuse research program within overall NIMH priorities. It
develops policy regarding funding priorities and assumes final responsibility for
implementing these priorities through the grant and contract mechanisms. The
Division obtains the advice of nationally recognized consultants in the field of
narcotic addiction and drug abuse, as well as panels which come together to advise
it on the progress being made in our re.search program and what future directions
it should take.
474
The Narcotic Addiction and Drug Abase Review Committee carries out the
responsibility of (3valiuiting specific research proposals and making recommenda-
tions to the Division as to the scientific quality of the work to be done and as to the
advisability of funding a specific proposal. In carrying out this activity, the
Review Committee is cognizant of the priorities established by the NIMH and
takes these into account as they review specific proposals.
The National Advisory Mental Health Council reviews the research policies of
the NIMH in the area of narcotic addiction and drug abuse and makes recommen-
dations regarding the program. In addition, the Council examines the recommen-
dations of the Review Committee regarding specific proposals and makes a final
determination as to the disposition of these proposals for funding.
The final step in the process rests with the Division. Having received the recom-
mendations of the Review Committee and the approval of the Advisory Council,
the Division must then determine, in light of available funds and the research
priorities of the Division's program, which of the approved research projects will
receive funding.
Question 7. How are drug abuse contracts used? Who is responsible for decisions
on the types of contracts to be issued?
Answer. Contracts are utihzcd b.y the NIMH when it is important that the
Government define precisely what needs to be done, how it shall be done, and what
the product will be. Contracts are now being used for the production of the various
forms of marihuana to be used in research, the toxicological and the pharmaco-
logical assays of marihuana, as well as other aspects of our intensive marihuana
research program. The contract mechanism is also being utilized in education,
public information, and treatment (NARA) programs.
Responsibility for decisions on the use of contracts and the types of contracts
to be issued rests with the Division. In executing this responsibility, the Division
utilizes consultants. In most instances, the contracts constitute one mechanism
to carrj' out a part of the priority system established for the research program.
Wherever possible, contracts are placed on open bid. Panels of experts review the
various proposals in much the same way as the Narcotic Addiction and Drug
Abuse Review Committee evaluates proposals for research grant funding.
Question 8. What areas of research show the most promise for cures of narcotic ad-
diction, for treatment of narcotic addiction, and in prevention of drug abuse?
Answer. Much research is now underway to evaluate the effectiveness of treat-
ment and rehabilitation methods in the field of narcotic addiction. We are eval-
uating both pharmacological approaches, such as the narcotic antagonists and
methadone, and nonpharmacological methods such as therapeutic communities,
comprehensive centers, and desensitization techniques. As members of the com-
mittee may know, the Institute supports the treatment of addicts both under
the civil commitment program of the Narcotic Addict Rehabilitation Act and
under a grant program to estaljlish community-based treatment centers of which
approximately 16 are now operating and another seven have been funded and are
getting underway. In addition, under Public Law 91-513, the Institute is now
authorized to fund individual treatment services such as detoxification centers,
partial hospitalization, or emergency care.
Both the civil commitment program and the community-based comprehensive
treatment centers employ pliarmacological and nonpharmacological methods of
treatment, and data is being gathered to evaluate the relative efficacy of these
methods.
I should stress that we believe that no one method of treating narcotic addicts
is "the answer." Addicts differ in their needs and in the kinds of therapy which
are most helpful to them. As a result, it is necessary to evaluate a variety of treat-
ment modalities.
As of October 1970, the narcotic treatment and rehabihtation programs sup-
ported by the Institute were assisting approximatel}^ 1,800 patients under the
civil commitment program, of whom 1,200 were in the aftercare phase of treatment,
and approximately 5,300 patients in the community-based treatment programs
supported by Institute grants. Unfortunately, we cannot at present compare the
results of the civil commitments treatment program and the community treatment
programs becau.sc they arc treating different groups of addicts. However, at a
later date it should be possible to extract matched pairs of patients from the two
groups and compare their degree of benefit. To illustrate the differences in the two
groups, addicts being treated under the civil commitment program are 60 percent
white and have an average age in the late twenties; whereas, the patients being
475
treated in the community centers are over two-thirds black or Chicano and have
an average age in the early- to mid-twenties. Moreover, the two groups are not
equivalent in terms of employment histories, arrest histories, or education. What
we can say now, however, is that both programs seem to be helping a large per-
centage of the patient populations whom they are treating.
The exact percentage of patients who are being helped depends on what measure
you use to evaluate the patients' improvement. For example, you can look at the
"percent of patients who are working, or the percent who are staying out of jail,
the percent who do not become re-addicted, the percent who have returned to
school, and so on. In the civil commitment program, a study of 1,200 patients who
were in aftercare in 1970 showed that approximately 8.5 percent were employed, 70
percent were not arrested and spent no time in jail during that period, 3.5 percent
were in self-help therapy, and 33 percent were pursuing their education. In addi-
tion, 80 percent of the patients who had been in aftercare for 3 months or more
were completely free of heroin use. A similar statement can be made regarding the
heroin use of patients who were in the community treatment programs. As you
know, manj?- patients during the treatment of their addiction may abuse drugs
other than heroin occasionally, such as marihuana, amphetamines, or barbiturates.
Of the patients in the civil commitment program who had been in aftercare for 3
months or more, 60 percent were not abusing any drugs. The same is true of patients
who had been in the community treatment program for 3 months or more. If the
patients who are in the civil commitment aftercare phase, we know that 60 percent
do not become re-addicted during their first j^ear in aftercare. Of the remaining,
25 percent do abuse some drugs or become re-addicted and require further hospital
treatment. The remaining 15 percent drop out of the program.
As the committee is well aware, there is a great deal of public interest currently
in methadone maintenance treatment for narcotic addiction. Many claims and
counterclaims are being made regarding its effectiveness. How effective is metha-
done maintenance treatment? The answer I am about to give you is a cautious
one, but I beUeve represents the state of our knowledge at this time. The Food and
Drug Administration, which has responsibility for determining the degree of
safety and efiicacj^ of drugs, has determined that the exact degree of safety and
efficacy of methadone maintenance treatment is unknown at this time. Many
groups, including groups in New York City, Illinois, and here in Washington,
D.C., are evaluating methadone maintenance. The National Institute of Mental
Health is currently sponsoring the use of methadone in both its civil commitment
treatment program and its community-based treatment programs under carefully
controlled conditions so that we can generate data to help determine methadone's
safety and efficacy.
With regard to comparing methadone and other treatment modalities, I must
again point out that the patients who are being treated with methadone differ
in many characteristics from the patients who are being treated with other
modailities. For example, they differ in age, sex, race, length of addiction, history
of criminal behavior, and so on. Lastly, I might again say that comparisons of
efficacy depend on which measures or benefits one looks at — employment, arrest
records, drug abuse, or pursuit of education. Although the results I am about to
give you have to be viewed in the light of differences in the groups being compared,
it appears that there are no large differences between the benefits achieved by
methadone patients compared with the benefits achieved by patients treated in
other ways. For example, more than 70 percent of both methadone and non-
methadoiie patients in the civil commitment program were not arrested and spent
no time in jail during 1970. Approximately equal percentages of the two groups,
that is about one-third, were engaged in educational activities. Although it would
appear that more methadone patients were working than nonmethadone patients,
that is 87 percent of methadone patients versus 65 percent of nonmethadone
patients, this figure is misleading since in some programs methadone patients are
required to be employed before they can be admitted into treatment. The one
exception to the generally comparable results between methadone and non-
methadone treatments is that in the community treatment program a larger
percentage of patients treated with methadone remain in the program longer than
the patients treated with other modalities.
In addition to evaluating methadone maintenance, therapeutic communities
and comprehensive centers which offer these treatments as well as emergency
care, partial hospitalization, and consultation and education, the Institute is also
476
sponsoring the developinent and evaluation of narcotic antagonists, such as
cj'Clazocine and naloxone, and longer-acting narcotic substitutes such as L-alpha-
acetyl-methadol. A longer acting narcotic substitute would greatl.y decrease the
cost of a maintenance program and allow the patient to live a more normal life.
We are also supporting research into the development of a nontoxic removable
implant which can deliver an antagonist drug such as cyclazocine slowly into the
patient's system over a period of time so that the need for repeated medication
would be markedly reduced. While these treatment approaches are promising, it
is far too early to assess their ultimate safety and efficacy.
With regard to prevention of drug abuse, the Institute together with other
Federal agencies is sponsoring a public information and education eiTort. Infor-
mation and education alone, however, will not be sufficient to prevent drug abuse.
In many instances, drug abuse stems from motives and social conditions which
are not readily affected b}" education. Prevention efforts must include, therefore,
broad programs of social reform and psychological help to allow meaningful,
satisfying lives for adolescents as well as adults. Prevention efforts must, of
course, also include efforts to limit the suppl}' of illicit drugs and the diversion
of legal drugs into illicit channels.
Question 9. Would more money for research in these areas hasten the discovery
of effective cures and treatment?
Answer. Yes; it is highly probable that additional funds would have this
resvilt.
In recent years there have been two major developments which increase the
likelihood of "payoff" in the treatment area from additional research. The first
of these is that an increasing number of competent scientists are now available
to vmdertake research in the drug abuse area. In the past, few skilled investi-
gators were available to undertake studies in this area.
Second, recent research work in several basic fields now has increased the
likelihood of significant breakthroughs in the near future that may well have
substantial implications for treatment programs. For example, the work of
Dr. Julius Axelrod, the Nobel laureate, in the NIMH intramural research
laboratories, on Dopamine; and that of Dr. William ^Martin at the NIMH Addic-
tion Research Center in Lexington, Ky., on tryptamine, represent significant
progress in our understanding of basic neurological processes underlying narcotic
addiction.
Question 10. What role in research do you believe should be played by private
industry and private scientific organizations such as the National Academy of Sciences
Research Council?
Answer. Apart from the research efforts of pharmaceutical companies, which
are for the most part focused on commercially feasible compounds, roles for
private industry in drug abuse research are only beginning to emerge. The NIMH
would encourage the participation of private industry in this area.
Several private foundations have expressed interest regarding roles they
might play in narcotic addiction and drug abuse research. On May 26 Secretary
Richardson and representatives of other Federal agencies will be meeting with
foundation executives to explore this matter in greater detail.
Staff of the NIMH have initiated discussions with the Division of Behavioral
Sciences of the National Academy of Sciences regarding a role for the Academy
in evaluating the impact of the NIMH drug information and education program.
The Academy has expressed interest in this project but no formal agreements
have as yet been reached. In addition, the National Academy of Sciences re-
cently brought together a panel of experts in drug abuse research to advise it
on possible roles for the Academy regarding heroin and related drugs. The Acad-
emy is considering undertaking activities through its Divisions of Medical
Sciences and Behavioral Sciences but has not as yet reached linal decision re-
garding these activities and has not made them public.
Question 11. What system have you developed to prevent a recurrence of the problems
that now exist with regard to the lack of information on marihuana? We understand
that so little is known about marihiiana that it has been necessary to increase the
fimding in marihuana research from $1.5 million in 1969 to $3 .3 million in 1971 while
477
research on narcotics in the same period has merely increased from $3.2 million to
$3.9 million?
An.swer. Budget increases have been specifically earmarked for marihuana re-
search during the past 3 j'ears. The administration has earmarked these funds in
response to growing public interest in determining the health consequences of
marihuana use and as a result of specific congressional directives on this subject.
The estimated expenditure for fiscal j-ear 1971 is $2.8 million rather than $3.3
million.
Initial work in the marihuana research program concentrated on developing
technicjues to produce natural and synthetic material of known composition and
strength. Only by knowing the dose administered can researchers draw meaningful
interpretations from their results.
The marihuana contract program has established a system of production and
supply of both natural and synthetic material with high qualitj- control. The
availability of material of known potency has stimulated a large number of
studies. In fiscal year 1971, research was focused on the effects of synthetic and
natural marihuana in animals, and important advances have been made in de-
termining the fate of marihuana compounds in animals and man.
The primary metabolic products of the two presently known active constituents
of marihuana, delta-8 and delta-9 tetrahydrocannabinal, have been identified,
isolated, and their molecular structures described.
Studies of the effects of marihuana on perception, cognition, and motor per-
formance are underway and have begim to clarify the consequences of actxte
marihuana use, as described in the Secretary's report to the Congress recently.
The biochemistry and mechanism of action of marihtiana are also under investi-
gation with a variety of tools, and the potential impact of marihuana use on driving,
memory, and attention are being carefully investigated. Perhaps the most im-
portant question concerning marihuana is the effect of long-term use at low and
moderate dosage levels. Two controlled studies are underway in foreign popula-
tions to determine what impact chronic u-e may have upon health, occupational,
social, and illness variables. In this country, careful studies are underway to
determine tolerance to marihuana, cross-tolerance between marihuana and alco-
hol, opiates and hallunciogens, and synergism with other psychoa^-tive drugs.
The effects of marihuana on reproductive processes are under scrutiny, with both
neurological and behavioral exannnations of successive generations of animals
exposed to marihuana leaf and synthetic materials.
To avoid a recurrence of the knowledge gap problem associated with mari-
huana, the Department is actively assessing the abuse potential of new drugs that
come on the market. In addition, community and health surveys now enable us at
an early stage to s.ystematically studj^ the health and social consequences of various
substances that are being used.
There are two additional steps that could be taken to obtain information as
early as possible about new drugs of abuse : The first step would be to expand our
capabilities to evaluate the abuse potential of drugs being produced; the second
step would be to establish drug surveillance in the streets that would enable us to
become quickly aware of what drugs are starting to be abused and to take appro-
priate steps to coimter such abuse. These steps would give us warning and hope-
fully lead time. However, research into the genetic, carcinogenic, and other ])hys-
iological and behavioral effects of drugs alwaj's take some time and cannot be
accomplished instantaneously.
Question 12. How much money has been spent on research into narcotics, into
marihuana, into central nervous system stimulants, and into narcotic antagonists,
over the last 4 years?
Answer. Table I gives the requested information for fiscal year 1969. Note
that all NIMH research activities are included in this table. Tables II (a) and (b)
present similar data for fiscal year 1970. The detailed presentation for fiscal year
1970 also deals with the NIMH grants program in drug abuse as funded by the
Division of Narcotic and Drug Abuse (top row of figures) and other units of NIMH
(second row of figures). The final amounts to be spent out of the fiscal year 1971
budget for these various categories are not j-et known. (Data is not available for
fiscal year 1968.)
60^96 — 71 — pt. 2 10
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TABLE 11(b).— NIMH RESEARCH GRANTS RELEVANT TO METHADONE AND OTHER NARCOTIC ANTAGONISTS IN-
CLUDING CYCLAZOCINE, NALORPHINE, NALOXONE, AND LEVALLORPHAN
lAwarded from 1970 funds)
Number of
Grants
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prorated
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Amount of
award not
prorated
Grants re methadone
Grants re methadone and other narcotic antagonists.
Grants re other narcotic antagonists
Total
12
$207, 597
72, 637
103, 547
383, 781
$255, 327
290, 547
120, 007
665,881
'These amounts are figured as that portion prorated to narcotic drugs where grants are relevant to multiple drug
categories.
[Exhibit No. 17(e)]
Department of Health, Education, and Welfare,
Surgeon General of The Public Health Service,
\f ashington, B.C., Jane 21, 1971.
Hon. Claude Pepper,
Chairman, Select Committee on Crime,
House of Representatives, W ashington, D.C.
Dear Mr. Chairman: This repUe.s to rout letter dated June 8 requesting my
comments on two matters related to opium.
I beheve that it is desirable for the U.S. Government to advocate and negotiate
toward the total eradication of opium cultivation in all nations of the world. It
will take some time to achieve the desired goal but we should start now. As U.S.
delegate to the 24th World Health Assembly I recommended last month that
the Director General of the World Health Organization be requested to appoint
an international panel of experts to consider and report on the feasibility of re-
placing opiates with synthetic drugs. Such a study, I believe, would be necessary
before we would be able to secure the concurrences of the several producing
and the many consuming nations with a complete ban on opium production.
I believe also that it will require some time to prepare for a ban on the licit
importation of opium and morphine into the United States. Opium derivatives,
including morphine, are widely used in the legitimate practice of medicine in
this country. It would not be feasible in my judgment to bring about suddenl}^
the significant changes in the practice of medicine that would be required if
Congress should outlaw the licit use of opium and its derivatives. Stvidies indicate
that synthetic substitutes are available for the several purposes for which opium
and its derivatives are employed in medicine, and I would favor educational
measures on. the part of the Government and organized medicine looking toward
a di-astic curtailment of the licit use of opium and its derivatives with a view to
eventual elimination of opium production.
Further, I believe that continued research is desirable to develop more effective
substitutes for the various derivatives of opium which hopefully would show less
addictive potential.
With kindest regards.
Sincerely yours,
Jesse L. Steinfeld, M.D.
(Whereupon, at 3:40 p.m., the hearing was adjourned, to reconvene
at 10 a.m., Friday, June 4, 1971.)
NARCOTICS RESEARCH, REHABILITATION, AND
TREATMENT
FRIDAY, JUNE 4, 1971
House of Representatives,
Select Committee on Crime,
Washington, D.C.
The committee met, pursuant to notice, at 10:10 a.m., in room 2325,
Rayburn House Office Building-, the Honorable Claude Pepper
(chairman) , presiding.
Present: Representatives Pepper, Brasco, Mann, ]\Iurphy, Steiger,
Winn, and Keating.
Also present: Paul Perito, chief counsel; and Michael W. Blommer,
associate chief counsel.
Chairman Pepper. The committee will come to order, please.
As I have said before, the Crime Committee is primarily concerned
with substantially reducing crime in this country.
We have had evidence from Dr. Robert Dupont, who is the head of
the Narcotics Treatment Administration of the District of Columbia,
that 50 percent of the homicides in the District of CV)lumbia are
are attributable to the use of narcotics and about 50 percent of the
crime generally is also attributable to the use of heroin.
Dr. Dupont testified last year before our committee that in the
District of Columbia it was his observation that each heroin addict
got illegal possession of about $50,000 worth of property a year, by
murder, or mugging, or burglary, or robbery, or theft, or some illegal
way.
We have had estimates here from knowledgeable public officials that
there are some 250,000 heroin adtlicts in the United States. If Dr.
Dupont's estimate that each addict is responsible for getting illegal
possession of about $50,000 worth of property per year, and you
multiply that by 250,000 addicts, you get the figure of $12.5 billion
worth of i)ro])erty that we can anticipate the heroin addicts will take
from the people of this country annually.
Now, it was estimated here by Mr. IngersoU, that probably the
cost of heroin was $3^2 to $4 billion a year. I think he primarily
meant how much it cost in trying to stop it and other costs, but when
you take into account the number of homicides, the amount of illegal
acquisition of property, court delay and court costs, you can see why
the Crime Committee is very much concerned about heroin addiction
m the United States.
Today, the Select Committee on Crime continues, a part of its
continuing investigation into heroin addiction in the United States.
(481)
482
In past hearings we have concentrated on the multiple problems of
the heroin supply and efforts to halt heroin smuggling and vre have
been told, 3^ou recall, that onh^ about 20 percent of the heroin smug-
gled into this country is seized in spite of all the efforts of our Govern-
ment officials. We have also concentrated on curbing the availability
of materials used to dilute and package heroin, what we call para-
phernalia, and we have introduced legislation for a model law on that
subject in the District of Columbia, and we are bringing such legis-
lation as we propose to the attention of the attorneys general of the
several States in the Union.
In this week's hearings, we have been inquiring into what scientists
have been doing to combat addiction, and what the}' could do if they
had more funds. We have examined in depth the use of methadone as
a maintenance drug, and the majorit}" of the testimony we have
received clearly indicates that it can be effective in reducing crime
and helping an addict to lead a more normal life.'' •t-
But as Dr. Bertram Brown, Director of the National Institute of
Mental Health, told us yesterday, it is valuable treatment only for,
perhaps, one-fourth to one-third of the addict population. Clearly,
then, we must find some way of treating the majority' of addicts who
are not, in Dr. Brown's estimate, amenable to methadone maintenance
treatment.
Yesterday we had testimony that less than 35,000 people out of
an estimated 250,000 heroin addicts in the United States are being
treated by methadone and only a few hundred, or a few thousand, are
being treated by other drugs. So, you see that even the drugs that we
have are not being made available to more than a very small percent-
age out of an addict population of 250,000. So, you can see the magni-
tude of the problem with which we have to deal.
It also seems clear to me that not enough money is being spent to
find treatment modalities that will be effective for those addicts not
amenable to treatment with methadone. I certainly commend the
President on his proposed program to make an effective attack upon
this heroin problem, but with all respect, it is my opinion that if we
are going to do it, it has to be done on a large scale. I hope the attack
will not be a piddling one or will be so relatively insignificant that
we have not come anjrwhere near adequately to grips with the magni-
tufle of the problem.
Dr. Brown told us that the state of our knowledge of addiction and
means of curing it must still be called primitive. Now, he is talking
about the United States of America. I think we have the greatest
volume of scientific know-how and the greatest wealth of an}- nation
in the world, and yet the top official in this field described what we
have accomplished and done so far as primitive.
This is no reflection, of course, on the ability of the dedicated men
working in this field, but rather a result of the inadequate funding,
and Congress must bear its share of responsibility, and lack of urgency
attached to the problem in the past by all branches of the Government.
We can no longer afford to seek remedies to this scourge upon our
Nation using primitive methods and scant resources. We have the
ability to develop highly soi)histicated techniques to combat drug
addiction, but the main obstacle standing in the way of that sophistica-
tion is inadequate funding.
If drug abuse costs the Nation $3^ to $4 billion a year, surely we
ought to spend more than the $17.7 million a year that we are now
483
spending for research through NIMH. It seems to me that a major
investment in research that will produce effective drugs to combat
addiction and mtII yield dividends far in excess of the investment.
If, for example, Congress were to direct NIMH to conduct a crash
research program funded at a billion dollais a year to find a drug that
would immunize a person against addiction, we could probabh" find
this drug within a few years. And if we did it, we could reduce crime
in the United States, including homicide, according to the evidence
we have, by 50 percent. And if we did, then the almost $4 billion a
j^ear we now spend in direct and indirect costs might become an item
of the past.
To show you the economy of this research, Dr. Dole, as has been
pointed out here, testified before our committee in New York, that
he developed methadone on a financial shoestring, and yet it is the
best drug we have, the only relatively effective drug we have today.
You see what an enormous profit we have obtained upon that meager
financial investment.
It seems to me that both economics and human decency dictate a
national commitment to finding a cure for addiction.
Today we are going to hear about some of the drugs now being used
on an experimental basis by scientists not associated with the Federal
Government. We want them to tell us of their successes, and how we
can help them m their important and lifesaving work.
Our first witness today is Dr. Julian E. Villarreal, associate professor
in pharmacology at the University of Michigan Medical School.
Dr. Villarreal holds a bachelor of science degree and a doctor of
medicine degree from National University in Mexico City, Mexico,
and a Ph. D. in pharniacology from the University of Michigan.
Dr. Villarreal has authored or coauthored over a score of articles
on narcotics and synthetic analgesics. He is a member of the American
Academy of Clinical Toxicology and its Committee on Drug Depend-
ence; the Society for Neuroscience; and the Society for Behavioral
Pharmacology.
Dr. VillaiTeal is m charge of the University of Michigan's program
for testing new^ morphinelike compounds, which is sponsored by the
Drug Dependence Committee of the National Research Council. He
is an expert on laboratory research, on analgesics, and narcotic
antagonists.
Dr. VillaiTcal, we are very much jileased to have you ^\ith us today
and will listen with great interest to your description of your im.portant
work.
Chau-man Pepper. Mr. Perito, will you inquu-e?
Mr. Perito. Thank you, Mr. Chairman.
Dr. VillaiTeal, would j^ou care to proceed? I understand you have a
statement; is that coirect?
STATEMENT OF DR. JULIAN E. VILLAEREAL, ASSOCIATE PROFES-
SOR OF PHARMACOLOGY, UNIVERSITY OF MICHIGAN MEDICAL
SCHOOL
Dr. Villarreal. Yes.
Mr. Perito. Would you prefer to read your prepared statement
and use your slides in conjunction with it?
484
Dr. ViLLARREAL. I would prefer to speak for about 5 minutes and
then show some of the sUdes.
Mr. Perito. Mr. Chairman, may Dr. ViUarreal's statement be
incorporated in the record?
Chairman Pepper. Without objection, so ordered.
Mr. Perito. Please ])rocee(l, Doctor.
Dr. ViLLARREAL. Thank you, Mr. Chairman. It is an honor to be
here today speakino; before your committee. The main purpose of
my presentation today is to describe to you the current status of the
research in the field of drug dependence and to give you an idea of
the possibilities for its future contributions to the solution of the prob-
blem of human drug dependence.
I am convinced, and many others that work in the field are also
convinced, that we have a very strong giij) on the nature of the
problem of drug dependence and that if the efforts are spent and the
necessary funds and thinking are invested in the problem, we could
within a short period of time come up ^vith very effective agents for
the management, or jjerhaps cure, of human opiate de])endence.
I would like to start by saying that for the last 10 years, I have
worked with monkeys, doing objective investigations on narcotic
dependence in tliis species. This experience with monkeys creates a
very i^eculiar perspective on the nature of the problem of drug depend-
ence.
Many people like to think that drug dependence is a peculiarly
human jiroblem, that it is related to existential problems of man and
to issues that are peculiar to the psychology of man.
We see drug dependence created every day on a routine basis in
monkeys that do not have Oedipus complexes, do not have existential
problems and do not have despairs about the evils of the society. We,
therefore, believe that the nature, the main core, of the problem of
l)sychological as well as physical dependence to the major drugs of
dependence in the human involves phj^siological processes that are
primarily behavioral in nature; automatic, rather than existential or
social.
Psychological or social issues come into the picture in inducing
people to begin experimenting with drugs and in maintaining condi-
tions in which drugs are widelv available and conditions in which there
are little alternative channels of behavior for the human addict that
wants to rehabilitate himself.
To review the field briefly, I want to note that laboratory work has
first of all produced already several thousand com])ounds, morphine
analgesics and morphine antagonists. You have had testifying before
you, Dr. Nathan B. Eddy, who has been a tremendous force in this
field. The tlevelopment of many of these compounds is due to his
encouragement and to his direction and his leadership.
The S3"nthesis of all these compounds has produced an enormous
body of knowledge. We have several thousand m(»r[)hineliko drugs. We
also have several hundred narcotic antagonists. We know how to make
long-acting drugs, short-acting drugs, jjotent antagonists, weak
antagonists, antagonists with a little bit of morphinelike activity,
antagonists with morphinelike properties. But all of these drugs have
])een develojiod primarily for the i)ossibility of using them in the
treatment of pain.
485
There has been no concerted serious effort, except latel}^, to develop
compounds that may be specifically used in the treatment of drug-
dependence. As you know, Dr. Martin, in isolation, started working
with cyclazocine in the middle 1960's. The groups of Dr. Fink and Dr.
Freedman has done work with cyclazocine and naloxone. However,
all of these have been isolated instances of efforts in the direction that
we are interested toda}'.
We have a problem of leadership and we have a problem with the
drug industry, which has been relatively uninterested in working
along the lines of developing products for treatment of drug depend-
ence. I know only of one drug firm that has a program on antidejiend-
ence drugs.
Mr. Perito. Doctor, why does that situation exist? Why has not
the drug industry done something more about develo])ing a drug
such as this?
Dr. ViLLARREAL. 1 cau only guess, of course. There is, first of all,
the fact that no one thought about this before. Misconceptions on the
nature of psychological dependence precluded idtas that drugs could
be used for the treatment of dependence, loi the production of a
psychophysiological condition in which there is a reduced drive to
seek for drugs.
Other factors which may play a role here may be related to the fact
that drug firms tend to be conservative and that they do not anticipate
sufficient profits from this type of research. Drug firms may also
anticipate controvers}' and risks of getting some bad publicity if there
is debate which affects them negativel3\ Again, these are only my
guesses.
Chairman Pepper. The committee will contact the drug companies
concerning this subject (See exhibit No. 32.)
Mr. Perito. On the basis of your experience, could you estimate
what it would cost for a commitment by a drug house to develop an
antagonist?
Dr. ViLLARREAL. Well, again, this can only be a guess based on
average figures from industry, but the development of a drug — once
you have selected a drug to be developed — costs on the average $5
million. Industry also has to consider the fact that once a drug comes
into the market, there are other companies that may come into the
field and compete with their drug. They anticipate that on the average
a drug has a half life in the market of about 5 j^ears. So, they need to
get a return of at least $5 million in 5 years.
Most drug companies do not like to deal with drugs which have
such small markets. They need to get more return to cover the basic
research which led to the identification of the drug that was developed.
Mr. Brasco. Doctor, if I might on this point, in connection Nvith the
drug companies, I think that they have a particularly callous point of
view with respect to their refusal to get involved in the research area,
but I am concerned about another thing.
I consider them to be a prime offender in this drug abuse area be-
cause of the fact that they seem to have an inexhaustible supply of
mind-altering drugs that they continually produce and with all kinds
of advertisements and newspaper advertisements that these drugs are
being sold to the American public for what I consider to be rather
minor ailments. I am wondering whether or not you agree with that
or disagree with it.
486
Dr. ViLLARREAL. Well, it may be one of the factors that leads people
to experiment with drugs of dependence. However, I must point out
that there are many mind-altering drugs that do not produce depend-
ence. There is a large class of tranquilizers that are used for treatment
of psj^chotic individuals. Physicians have a very hard time keeping
people taking those pills. The evidence is overwhelming that there are
only a few drug classes that generate this overwhelming impulse to
repeat the drug experience: Heroin, cocaine, amphetamines, barbitu-
rates, and to a lesser extent, alcohol.
Mr. Brasco. Well, they just seem to me to be setting up an atmos-
phere for people to take pills and this begins as you indicated and
agreed with a moment ago, the atmosphere for wanting to start to
experiment with drugs further. I tliink they are off on a completely
wrong track in the grab for profit.
Dr. ViLLARREAL. I would sa}^ some of the major drug houses have
already started programs for screening their new compounds to screen
out those that have psj^chological dependence potential.
Mr. Brasco. For instance, they have even resisted moves to
properly label those drugs which are harmful in terms of the fact that
they come up with the fact that it is too expensive or the}" have color
codes of their own. They are producing harmful drugs in man}- cases
that are look-alike drugs. One maj" be a barbiturate and looks like
aspirin and they refuse to mark them clearly, so that unless one has
them in the proper prescription vial, no one even knows what the
true ingredients are and it seems to me their whole attitude is callous
and indifferent.
Thank you. I do not Mant to take any more time.
Mr. Perito. Dr. Villarreal, would j'OU explain briefly for the
committee, the type of activity, the type of reaction, you observe in
your monke^^s once you give them opiate drugs, heroin, morphine?
Dr. ViLLARREAL. Perhaps I should get into my slides and go quickly
through them to give you an idea.
Mr. Perito. Please.
Dr. ViLLARREAL. If I may show some of them.
[Slide]
Dr. ViLLARREAL. All this work has been done at the laboratory
founded by Dr. Maurice Seavers, who was a ^^^tness before this
committee a few weeks ago. It has been established that the monkev
responds to narcotics and to stimulants of the cocaine-type very
much like man does. The monkeys shown in this slide are monkeys
that were given a low dose of morphine. They had typical responses
that are also observed in the human.
These are monkeys that were given a small dose of morphine. They
respond very much like man. The}' are totally unconcerned about
human experimenters coming around. These animals are wild. They
do not ever let people get close to them. This is just to show that the
response of the monkey is very close to the response of man to these
types of drugs.
■ [Shde]
Dr. ViLLARREAL. The main experiments that I want to describe to
you today are the experiments in which monkeys are made or allowed
to become psychologically dependent on narcotics. These monkeys
are surgically prepared with an interavenous polyethylene tube and
487
it is left in one of their veins permanently. The tube comes out of the
back of the monkey between the shoulder blades and through a
metal arm goes into the back of a cubicle where there is an automatic
syringe.
^ [Shde]
Dr. ViLLARREAL. The cubicle is also equipped with a microswitch
bar-press deAdce that the monkey can operate to deUver into his own
bloodstream an injection of drug.
The graph does not show very well, but I will describe it to you.
The points represent the number of injections that an animal gives
himself every day. Each point is the number of injections per day.
Wlien we had physiological saline solution in the automatic injector,
this monkey did not press for it. The moment we put Profadol in the
automatic smnge which is a morphine-like compound, a new syn-
thetic compound, the monkey immediately started taking injections,
about 350 a day. Then he cut do^vn to about ISO and he maintained
that rate of self -injections for about 15 days.
When we SA\4tched him from the drug back to saline he quit bar
pressing. We put him back on the drug, at the extreme right, and the
animal went back to taking about 350 or 200 injections a day.
This is basically the picture we find wdth all drugs of dependence
Monkeys take all the drugs that are abused b}^ man. They do not
take the drugs that are not known to be compulsively taken by humans.
Mr. Perito. And what drugs would those be, basically?
Dr. ViLLARREAL. Pheuothiazines, for example. Also the narcotic
antagonist cvclazocine.
[Shde]
Dr. ViLLARREAL. This is the same thing, with morphine, the time
course of the development of psychological dependence in three
monkeys that are given access to morphine.
I must point out that these monkeys are not coerced in any way.
They take morphine and increase their daily intake progressively in
the course of a month to the point where they take some 70 in-
jections every day.
Mr. Blommer. Excuse me, Doctor. Could you explain a little
more clearly how these monkeys can give themselves drugs?
Dr. ViLLARREAL. Yes. There is a little bar in the cubicle and when
the monkey hits that bar — he has to press with some force — there is
a circuit that activates an automatic syringe that injects into the
bloodstream of the monkey a dose of the drug.
Chairman Pepper. So, he gives it to himself periodically.
Dr. ViLLARREAL. Ycs, sir. He does not have to and he does not
know when the drugs that are put in the syringe are not of the
dependence-producing type.
[Slide]
Dr. ViLLARREAL. This is with methadone. Methadone intrave-
nously is not any different from morphine, or for that matter from
heroin, and it is just the same thing. The shde shows the time course
of dependence over successive days, from the beginning of the ex-
periment. The animals take a progressively greater number of in-
jections of drugs per day.
488
Mr. Perito. Doctor, given the choice betAveen methadone and her-
oin which drug does the monkey prefer?
Dr. ViLLARREAL. It is vcrj difficult to answer that ciuestion be-
cause experimentally it is very complicated.
Mr. Brasco. Doctor, you indicated when you start back with the
saline solution that the monkey does not inject himself. Is that correct?
Dr. ViLLLARREAL. That is right.
Mr. Brasco. Well, does he go through withdrawal symptoms,
as a human would?
Dr. ViLLARREAL. Ycs; they do go into withdrawal symptoms just
like a human. The monkey was initially used because the withdrawal
symptoms are so much like man.
Mr. Brasco Would he then stay away from the bar until he is
injected with an addictive substance again?
Dr. ViLLARREAL. Not necessaril}^.
Mr. Brasco. But you would first have to give him that first injec-
tion and then he would go back to the bar.
Dr. ViLLARREAL. No. You do not have to do anything. Just give
him the opportunity to do it himself.
Mr. Brasco. In other words, what you are saying is he will keep
going to the bar periodically until he gets what he considers to be the
light stuff.
Dr. ViLLARREAL. That is correct; yes. The first few trials, of course,
are accidental trials. The monke}^ may be exploring his environment
until he happens to hit the lever or the bar that delivers that injection.
Mr. Brasco. I was trying to clear that \\\) — now it is cleared uj) —
because I was wondering how he got back to the bar again after you
gave him the saline solution. But, apparently, he keeps going to that
bar periotlically checking for the stufi".
Dr. ViLLARREAL. That is right.
Mr. Brasco. Fine Thank you.
[Slide]
Dr. ViLLARREAL. Thcse are records of monkeys that were taking
morphine. The n]iper graph shows the performance of a monkey over
a period of 27 weeks. It is like with a human addict. Monkeys given
access to morphine injections, or methadone injections, take the drug
very regularly, day after day, for very prolonged periods of time.
Like the human, the monkey responds differently to the cocaine,
amphetamine-type stimulants. It a is very irregular kind of drug self-
administration. There are a few days of very heavy drug taking fol-
lowed by periods of spontaneous abstinence and followed by another
period of very heavy drug taking, and so on, just as many human
users of cocaine and amphetamhie.
[Slide]
Dr. ViLLARREAL. We can make the monkeys work very hard for the
drug. Instead of requiring that they bar press just once, you can
increase the requirement for drug injection. And they nniy be required
to bar ])ress 30 times to get an injection, and with some of the stronger
drugs, like cocaine, morphine, heroin, wv can have a monkey bar
press two or 3,000 times to get an injection. This is very strong
evidence of the power of these drugs to rei)rogram tlie brain, if you
want, to lead the animals to seek drugs in the same way they Avonld
normally seek food or water or sex or some other strong biological
stimuli.
489
I do not think I should explain the details of these records but
these records are records of animals that are working very hard bar
pressing 30 times for each one of the injections of the drugs shown,
codeine, cocaine, methadone, morphine.
[Slide]
Dr. ViLLARREAL. Now, this is a newer drug, pentazocine. This is
an analgesic that is in the market, has been in the market for about
3 years. This animal was given access to this drug in cycles, alternat-
ing the drug with a saline, which is inert, and for those of 3'ou who
can read the slide, you can see that every time the animal was given
access to the drug the number of self-injections went up and every
time the animal was switched back to the inert physiological saline
the bar pressing went all the wa}" down.
Th.e rationale for the use of antagonists in this type of situation is
that the antagonists are tlrugs whicli ver}' effectively block, abolish,
the effects of narcotics. These narcotic antagonists are some of the
most powerful drugs that we have in all of pharmacology and medi-
cine. And as some of the members of the committee have heard
alread}", there are some antagonists that are pure antagonists; they
have no other actions except the actions that block the effect of
narcotics. There are other antagonists, like cyclazocine, that have side
effects, central depressing effects.
Mr. Perito. Doctor, could you just briefly describe for the com-
mittee the distinction between a blockage drug like methadone and
an antagonistic drug like cyclazocine?
Dr. ViLLARREAL. Methadone, of course, is a special kind of
morphine-like drug and morphine-like drugs have the characteristics
of jiroducing tolerance very rapi^Uv. So, large doses of morphine or
methadone or heroin will produce a reduction in the sensitivity of
the subject to the effects of the drug that is being taken, and you
will also have cross-tolerance. In other words, a subject that is tolerant
to morphine will also be tolerant to methadone or to heroin.
Methadone can be and has been given, as you know, by Dr. Dole
in very large doses, doses that pro .luce tolerance to all the narcotics,
and the doses of methadone have been large enough so that the effects
of large doses of heroin are blocked. But methadone has all the prop-
erties of mor[)hiiie, produce physical dependence, and so on.
The pure antagonists such as naloxone have no other properties
except that of antagonizing and blocking the effects of narcotics.
Mr. Perito. And they would be nonaddictive; is that correct?
Dr. ViLLARREAL. Nouaddictive; that is right. Cyclazocine has some
sedative effects of its own and has some unpleasant effects, as you
know.
Mr. Perito. Thank you, Doctor.
[Slide]
Dr. ViLLARREAL. Now, tliesc are experiments on a monkey that
was taking cocaine and codeine on alternate dates. He is working in a
schedule in which he had to bar press 30 times to get the drug and you
can see that his behavior — I do not want to explain the record but
each time that the animal bar pressed, the pen of the record went up
so that those ramps indicate the animal did a lot of bar pressing — some
1,000 responses in each one of those panels — to get some 30 injections
of each one of the druos show^i there.
490
In the lower two graphs are ilhistrated experiments in which the
animal ^^ as taking codeine alone, to your left, in which he made about
a thousand bar presses to get 30 injections of codeine, and then his
behavior in 1 day in which he was pre treated with an injection of
naloxone. When he was pre treated with naloxone he bar pressed a
few times, about 50 times, and quit immediately. There was no more
bar pressing in spite of the fact the drug was available to him.
Mr. Brasco. Doctor, naloxone is not a substance upon which one
becomes dependent?
Dr. ViLLARREAL. That is correct.
Mr. Brasco. In the case of this monkey, after he was given a dose
of naloxone, he did not bar press.
Dr. ViLLARREAL. That is right.
Mr. Brasco. Now, how did he come to bar press again when you
took the naloxone away? I do not understand that. If you are not
dependent on naloxone it would seem to me that that would be a
successful treatment for taking someone off drugs and havmg them
drug free. I do not get the relationship of his bar pressing again.
Dr. ViLLARREAL. Perhaps I can answer jour question this way.
When the animal is switched from any drug to an inert substance, to
saline, just physiological solution, the animal quits bar pressing. And
what we have done with the pre treatment of naloxone is to render
codeine totally ineffective so that the self-injections of codeine are
like self -injections of physiological saline. There is no longer an Al-
thing m the syringe.
Mr. Brasco. So, he does not bar press at all.
Dr. ViLLARREAL. He probes a little bit as you saw at the beginning
of the session, because he has all this drive but when there is no
effect, he quits.
Mr. Brasco. Then, how does he go back to bar pressing again,
because the apparatus gives him another shot of an addictive sub-
stance or does he do that by accident?
Dr. ViLLARREAL. He will do that by accident or by the strength of
the habit of bar pressing behavior.
[Slide]
Dr. ViLLARREAL. These few slides that come next mil get to the
point I think you are driving at. These are graphs of successive daA's
in which the monkej s are taking codeine. The}' are taking about 60
injections a day. The monkey takes about 65, 58, 52, and so on,
injections a day. This goes on for months and months.
On this day we treat him with naloxone and he quits. He quits for
2 days. Only on the first day he got naloxone. But then a little bit of
exploration, a little bit of probing on the bar, brings him back to
experience the full effects of codeine. So, as codeine is available again
he goes back to the previous behavioral base line.
Mr. Brasco. The point is this. After the naloxone treatment he
still has the physiological urge for the drug.
Dr. ViLLARREAL. YcS.
Mr. Brasco. So than naloxone would be something that would have
to be given steadily also.
Dr. ViLLARREAL. That is right.
Mr. Brasco. As methadone.
491
Dr. ViLLARREAL. Until the reflex dies out completely. One shot of
naloxone is suflacient to block the drive for self-administration on that
da}^ but continued treatment would be necessary to block it completely.
Mr. Brasco. Do we know how long the continued treatment would
be?
Dr. ViLLARREAL. No.
Mr. Brasco. Thank you.
Mr, Winn. Have you tried continued treatment for as long as 30
days?
Dr. ViLLARREAL. No ; we have not done that yet.
[Slide]
Dr. ViLLARREAL. This graph illustrates that the same thing occurs
with the other drugs of the narcotic class. Again you have a baseline
of self-administration of pentazocine for 5 days and then on 1 day
the animal is treated with naloxone and then for 7 days the animal does
not return to bar pressing but then at the eighth day he goes back up
again.
[Slide]
Dr. ViLLARREAL. This is just dose response curves, how much
naloxone is needed. Before we can get to the point of investigating
how long a treatment must be, we have to investigate a number of
other variables, like what dose ratios are important, how much nalox-
one will antagonize, how much of what narcotic, whether or not the
animals have to have the drug around the clock or whether intermittent
administration of the antagonists will be sufficient
These are questions that are easy to ask but take a long time to
resolve in the laboratoiy. Each one of the experiments shown in this
graph took about a year to do.
Mr. Winn. Doctor, have you tried any other inert substance other
than saline?
Dr. ViLLARREAL. We have tried a whole lot of other drugs that
do not produce psychological dependence.
Mr. Winn. Can 3'ou give the committee several examples?
Dr. ViLLARREAL. Well, cyclazocine is one example of a drug that
is not self-administered. If an animal is, say, taking cocaine, which is
a very strong dependence-producing drug and he is switched to
cyclazocine, he quits immediately.
Mr. Winn. Just like the experiments that you have had with
saline.
Dr. ViLLARREAL. That is right. The same thing happens with other
narcotic antagonists such as nalorphine, levallorphan. The same
thing happens with phenothiazine, drugs used as major tranquilizers.
Mr. Winn. They just do not turn them on. The}' stop pressing the
bar because they have no desire for those because they get no results
from them: is that right?
Dr. ViLLARREAL. That is right.
Mr. Perito. Please continue.
Dr. ViLLARREAL. I think I will stop with the slides here.
Mr. Perito. Doctor, could you, for the benefit of the committee,
give a brief summary of your conclusions as a result of studying this
compulsive self-administration behavior in m.onke.ys?
Dr. ViLLARREAL. Ycs. I believc that the conclusions are tremen-
dously important. Conclusion No. 1 would be that we have a very
492
good model in animals of the problem of human drug dependence,
both of the physical type and of the psychological type, so-called
psychological type. The monkey model is especially good in my view,
and the view of many others, in that we are not likely to project into
the monkey our own prejudices and experimenters are a lot more
likely to analyze the whole problem in a completely objective way.
You^ have all the experimental controls that you need and, more
importantly, you have the potential for studying and developing
tools that can be used for intervention in the human instance of drug
dependence.
We know that rats and mice, not only monkeys, will self-administer
the drugs that man self-administers. So, we are dealing here with a
phenomenon that is low in the order of nervous processes. It is not
something that requires the highest abiUties or the highest psychologi-
cal features of man. It is not a disorder in which the brain is repro-
gramed, if you allow me to speak loosely. In a ^yay, one can under-
stand this if one thinks about cigarette smoking. When cigarette
smoking is done for the first time its effects are very unpleasant. A
high fraction of the first smokers get sick, but if their friends push
them to do a few more trials, then nicotine starts producing the re-
flex of self-administration and all of us who smoke know that most
of the pleasure from smoking comes from the satisfaction of an impulse
to smoke and not for any intrinsic sensory pleasure-producing prop-
erties of nicotine.
Mr. Pertto. Have any of these monkeys been given nicotine?
Dr. ViLLARREAL. Ycs. Moukcys take nicotine just like man with
alacrity.
Mr.PEKiTO. Well, would you coiiclude from all of these factors that
your clinical colleagues who say that addiction is 95 percent i)sycho-
logical and 5 percent physical, tluit it is just not true, based upon your
observation?
Dr. ViLLARREAL. Well, it is pyschological in the sense that you do
not have an abstinence syndrome. You do not have to have an ab-
stinence syndrome to have very strong self-administration. It is a
behavioral reflex — psychological if you want — it is an impulse not
related to an abstinence syndrome. The fact that rats and monkeys
do tliis in the absence of physical dependence, in the absence of an
abstinence syndrome, indicates we are not dealing here with a human
with a problem that is primarily existential. Of course, I am not saying
anything about the causes that lead people to start experimenting
with drugs.
Chairman Pepper. I was not clear that I got the doctor's con-
clusions.
Is the taking of heroin ])rimarily psychological or is it ])rimarily
biological?
Dr. ViLLARREAL. Well, the historical develo])ment of these con-
cepts is such that initially it was thought that physical dependence
and the abstinence syndrome were the main driving forces in com-
pulsive drug-seeking behavior. However, it was later found that phys-
ical de})endence is not the whole story with narcotic craving.
The reasoning was, well, if it is not in the body it has got to be in
the mind and if it is not physical it has got to be psychological. So,
we are left with the term psychological dei)endence, but what the
493
evidence strongly shows is that these drugs have the abiHty to gen-
erate, as a reflex, an imjnilse to take the drug. That impulse is gen-
erated in animals that have very sim])le central nervous systems.
Chairman Pepper. Woidd it be your conclusion that if you vise
drugs as an antagonist or as a blockage agent that you would still
need attention to the psychiatric aspects of this matter?
Dr. ViLLARREAL. Oh, Certainly. Perhaps Dr. Kurland and Dr.
Resnick would like to comment on this but in my own mind, I have
the following view: That there are just two ways of dealing with the
l)roblem of this behavioral impulse to take the drug. One is to block
the drug and to block the phenomenon, the development of this drug-
seeking behavior, and the other one is to generate strong competing
behavior. This is what psychologists and what psychiatrists do when
they treat their patients, to make it possible for their patients to
engage in productive channels of behavior.
Chairman Pepper. Would that lead you to suggest that when we
are treating, let us say, heroin addiction, that it would be desirable to
have some sort of an institution, a clinic, where attention could be
given, where there would be proper observation of the recipient of the
drug?
Dr. ViLLARREAL. Oh, Certainly.
Chairman Pepper. And where there be psychiatric and therapeutic
and other types of assistance given to the recipients?
Dr. ViLLARREAL. Ycs. Mechauisms that will generate competing
behavior.
Mr. Brasco. Doctor, you might clear something up in my mind.
With the drug, naloxone, in our last collociuy I got the impression that
this particular drug has the qualities to basically render an addict,
after use for a period of time, into a position where he does not need
it any more psj^chologically or physiologically. Is that correct?
Dr. ViLLARREAL. Ycs ; that is correct.
Mr. Brasco. That is what you feel this drug can do or you hope it
can do?
Dr. ViLLARREAL. We very strongly think that it will do it. We do
not have the proof jet because the evidence will have to come from
human work.
Mr. Brasco. But that is the direction you are working in.
Dr. ViLLARREAL. Ycs. There is very little question in my mind that
it will work.
Mr. Brasco. To get the addict in a position where he will not be
dependent on anything.
Dr. ViLLARREAL. Ycs.
Mr. Brasco. Now, just one last thing. This cyclazocine is a similar
kind of drug as naloxone; is that correct?
Dr. ViLLARREAL. That is correct.
Mr. Brasco. Now, I also understood you to sa}" that cyclazocine
has some bad side effects that are unacceptable medically; is that
correct?
Dr. ViLLARREAL. My understanding of the clinical trials with cy-
clazocine is that it has had low acceptance by a fraction of the addicts
at least, and the fact that Dr. Martin introduced the possible use of
this drug to the medical literature in 1965 and that so far we have had
60-296— 71— pt. 2 11
494
only about 500 or 600 ])eople on it, suggests that it has low acceptance.
At least, it is not something that people will come to.
Mr. Brasco. So, \\'hat you are basically talking about, is not so
much the bad side effects but theie is not enough work done on it?
Dr. ViLLARREAL. Well, there are bad side effects.
Mr. Brasco. There are bad side effects.
Dr. ViLLARREAL. The bad side effects can be dealt with effectively
b}' slow increases in dose. Dr. Resnick is more competent to answer
this question with regard to humans.
Mr. Brasco. All right. We will ask that of Dr. Resnick.
Thank you.
Dr. ViLLARREAL. 1 woulil like to say one last thing. The fact that
we have the animal models of human dependence has opened up the
possibilit}" for the j'esearch on other drugs that will block self-admin-
istration of narcotics, not just the narcotic antagonists.
Mr. Perito. Are such tlrugs within our (•aj)abiHty of developnx'ut?
Dr. ViLLARREAL. Well, this is more remote. The antagonists — we
already have quite a few, as you know. It is just a question of develop-
ment. There is no more research that has to be done. The question is
to have effective delivery methods of keeping up concentrations in the
blood and tissues for long periods of time.
Ml". Perito. You mean you know the basic concept of an an-
tagonist. What you need to Jo is develo]) one that has a longer diu-a-
tion of action. Is that what yen are saying?
Dr. ViLLARREAL. That is right. We have a whole lot of very potent
drugs on the shelf.
Mr. Perito. What is the reason we have not developed this?
Dr. ViLLARREAL. There have been ver}^ few people who have
thought about it. Leadership has been missing. Dr. Martin had been
behind it. A group of doctors, mainly Freedman and Fink, have been
pushing it but there have been very few isolated instances of human
research.
Chairman Pepper. Doctor, have the efforts to develop some of these
different drugs, blockage drugs and immunizing drugs, have those
eff'orts been impeded b}' lack of funds?
Dr. ViLLARREAL. They have not been encouraged.
Chairman Pepper. Well, now, you are at a university. You evi-
dently are a verv great leader in this field. Have you had adequate
financing foi the programs upon which you are working?
Dr. ViLLARREAL. We do not have specific financing for the develop-
ment of antidependence drugs. Our research is funded on the basis of
the work we do for developing analgesics. We have done the anti-
dependence research on the side.
Chairman Pepper. Do you think if the Federal Government,
through an appropriate agency, after a proper screening process,
made funds available for the development of leads that scientists
have uncovered, that we could make a great (h>al of progress toward
finding the necessary drugs to treat these addictions?
Dr. ViLLARREAL. I would ihiuk that would be indispensable to make
serious progress along these lines, eillicr formalizing and organizing
the isolated efforts of different indivicknds or by making contracts to
specific drug firms to th'veloj) compouutls along the lines we have
discussed.
495
Chairman Pepper. One other question. Is there a reservoir of talent
in the coUeges and universities of the coiuitry that coukl be devoted to
such objectives as these if tliey were adequately financed and
encouraged?
Dr. ViLLARREAL. Yes; there would have to be a great deal of leader-
ship and organization centrally to see what people could do and per-
haps a committee of the peoi)le that have already done work in this
field could organize something along the lines you suggest.
Chairman Pepper. Now, would it be desirable, Doctor, if you had a
Federal agency that could not only make funds available and assist in
screening in collaboration with the scientific community the proposals
that were made but could coordinate as among Federal, State, and
other agencies, the drug industry, and the colleges and universities of
the country, a massive research program toward these objectives?
Dr. ViLLARREAL. Ycs, it would be very highly desu'able. There is
just one factor universities do not have. They do not have the know-
how and the wide experience that industry has in certain stages of
development. The studies of toxicology, the j)harmaceutical formula-
tions, the red tape to get the clinical trials, and so on.
Chamnan Pepper. I have also been told — I would like to ask you
if you think there is any truth in this — that one reason the universities
are reluctant to get into these areas is because these men are valuable
men and there are many demands upon their time and at the same
time, they have to think about continuity of their own employment.
So, if they are pulled off of a program that seems to have permanence
and put on a program which is only temporary in character, which may
terminate at an early date, it is more difficult to get these good men to
give continuity to such programs; is it not?
Dr. ViLLARREAL. Well, that is right, but that is a generalized prob-
lem for all research. I would note, though, that there are some prece-
dents in the antimalarial drug research programs that were carried
out in universities during the war and also the anticancer program of
the National Institutes of Health.
Chairman Pepper. Do you have any questions, Mr. Blommer?
Mr. Blommer. One question, Doctor. I have talked to a man who
was a drug addict and was sent to Dannemora Prison for 6 years
without any drugs. When he got out of prison he got on the train going
back to New York City. He got 30 miles from New York City and
started going into withdrawal symptoms and he was vomiting.
Now, at the point that that man physically had withdrawal symp-
toms, would you say he was suffering from a mental problem or a
physical problem, or both?
Dr. ViLLARREAL. WcU, both. That is, the impulse to take the drug
is a physical thing as well as a psychological thing, if you want. That
is, the main point is that the drug users do not reason, well, I am
going to have a drug, and go through a syllogism and a formal reason-
ing. It is something that occurs to them. They find themselves looking
for the drug. It is like the alcoholic who drinks or is looking in his
pocket for the money. He finds he is an alcoholic when he is spending
$15 a week on whisky, but not before.
These are not rational decisions made. These are things that
happen. The addict finds that you have this impulse to take the drug.
496
Mr. Blo-mmer. Can the learning behavior that he must acquire be
induced by chemical means or is psychotherapy enough?
Dr. ViLLARREAL. Psychotherapy has been enough for some people
because it generates competing behavior. It straightens them out in
other ways so they can have other forces engage their behavior and
not leave them time to go for drugs. This, of course, is rare.
Synanon is one case in which a lot of competing behavior is pro-
duced. Synanon and Synanon-type organizations generate an enormous
amoimt of competing behavior and an enormous amount of self-
discipline which have been effective in the people that are adequately
qualified to get into that ])rogram.
The point is that if you block the effect of a drug and the subject
falls into the temptation provided by the impulse or the environment,
the im])idse to take the drug will die out inevitably.
Mr. Blommer. But has not Synanon really failed to teach people
that consistently?
Dr. ViLLARREAL. Well, they have been very successful with a
fraction of the population of the addicts without any question. A
small fraction, unfortunately. It requires a great deal of commitment.
And not all addicts can go that route.
Mr. Blommer. That is all I have.
Chairman Pepper. Mr. Brasco.
Mr. Brasco. Yes; Dr. Villarreal, let me see if we can reduce this to
where I personally can understand it. I thought I did before.
In your slides you seem to indicate that the repeated taking of
drugs was a physical thing rather than the process of making a deter-
mination activated by the thought processes. And, of course, you use
the animals because they do not have the same thought processes as
man. But getting back to the situation that counsel just mentioned
and having practiced criminal law some 10 years myself before I was
elected to Congress, I have found people who were in prisons for a long
period of time have the same reaction as was just described.
Now, I cannot see how that would be primarily j)hysically moti-
vated because if it was, I would think he would have those symptoms
while he was incarcerated as well as when he got back to his home
environment. It would seem to me that the fact that he was off
drugs for 6 or 10 years and goes through withdrawal symptons would
be primarily something that is activated by the mind. Do you under-
stand my question?
Dr. ViLLARREAL. Yes; I think I do. Your question is similar to
the following: We humans eat food; we do not eat things that are
nonnutritiovis; we feel imi)ulses to eat things that are food and not
things that are nonnutritious.
What are the elements in food that determine that? How ilo we
know what materials are food? Again, in sexual behavior, men are
attracted by women and vice versa and we are not attracted to other
animals, or animals to aiiinuds of different species, and the (juestion
is what determines those programs that aiv i)rinted in the brain?
In the case of food materials, food materials are those materials
that have the properties of generating eating behavior. You eat
them once. Tlic im|)ulse comes back to do the same thing again and
you know you are hungry when you feel the imj)ulse to eat.
Mr. Brasco. Well, I understand what you are saying.
497
Dr. ViLLARREAL. So, it is a biological thing that has very strong
psychological connotations.
Mr. Brasco. That is the point that I am trying to make, Doctor.
I understand what you are saying but my point was trying to get a
conclusion as to whether or not the impulse to eat — is that just a
physical thing or is that a mental thing or a combination of both?
Or is one more dominant than the other?
It would just seem to me while it may be an impulse, it is motivated
more by the mind than just the physical.
Dr. ViLLARREAL. Its Origins are refle.x, though, just as the drug-
taking })ehavior. I will just say this: There is eviclence that both the
cocaine-type drugs antl morphinelike and heroinlike drugs have
actions in the brain very similar to actions of other stimuli such as
food in a hungry organism or water in a thristy organism.
Mr. Brasco. Let me just ask you this. Doctor. Do you receive
any Federal grants in your program that you were just describing?
Dr. ViLLARREAL. Ycs; our dej)artment has a grant from NIMH.
Mr. Brasco. Can you tell us how much that is?
Dr. ViLLARREAL. I think so. It is $110,000 a year.
Mr. Brasco. And that is not primaril}" for doing the work that
you just described for us and showed us in the slides; is that correct?
Dr. ViLLARREAL. I havc to elaborate on this. We have another
grant from the National Research Council for the development of
depentlence-free analgesics and the grant from NIMH is a grant for
the general study or the phenomenon of the basic events in the
l)henomenon of drug self-administration.
Mr. Brasco. Here is what I am trying to find out.
Dr. ViLLARREAL. There is no specific money for the development
of antagonists for the treatment of dependence.
Mr. Brasco. None.
Dr. ViLLARREAL. Noiie.
Mr. Brasco. What would you need to follow through the program
that we discussed moments ago in connection with trying to perfect
naloxone or similar kinds of drug which would hopefully render an
adchct into a position where he would not be dependent on anything?
Dr. ViLLARREAL. I think that the most urgent need is to have the
formal organization or formal committee or formal reference point
where people who are working in this field put together their heads
and organize their needs and set priorities.
Mr. Brasco. I understand that, but as you said before, that is
easily talked about but up to this point not easily accomplished and
I was curious as to your individual program.
Would 3'ou have any idea what kind of a budget you may need
just in that specific area in order to make some progress?
Dr. ViLLARREAL. We are limited in what we can do. That is, our
department has just so much space and so much personnel, and most
of the development aspects of the work cannot be done in our place.
They would be better done in private research institutes or through
contracts with the drug industry.
Mr. Brasco. So, what you are basically saying: You are develop-
ing the seeds of different ideas and approaches which would be better
turned over to some larger organization or agency for final culmina-
tion of conclusions.
49S
Dr. ViLLARREAL. That puts it very well; yes.
Mr. Brasco. Thank you.
Chairman Pepper. Mr. Steiger?
Mr. Steiger. Thank you, Mr. Chairman.
Doctor, I am sorry I missed what aj){)arently, by all reports, was
a fascinating discussion. You mentioned that the primates on cocaine
exhibited the ability to undergo the most rigorous kinds of barriers
in order to continue to acquire the cocaine.
Is the brain structure sufficiently similar between the primates
that you used and the addict on the street that we could assume
that there are many addicts that would undergo equally torturous
efforts?
Dr. ViLLARREAL. I think the evidence clearly shows that there is a
very strong analogy between the two species. I personally know of
one addict w^ho spends $800 a month in cocaine. Spending $800 a
month in cocaine represents a lot of investment.
Mr. Steiger. Is that stronger or more addictive than the heroin?
Dr. ViLLARREAL. It is vcry difficult to make those conclusions
unequivocally.
Mr. Steiger. Well, have you got any qualitative analysis of the
primate which would indicate the relative strengths of addiction to
cocaine and heroin?
Dr. ViLLARREAL. We are doing work on those issues now, but we
do not have solid data yet.
Mr. Steiger. Thank you, Mr. Chairman.
Chairman Pepper. Mr. Mann.
Mr. Mann. Doctor, are the services of your laboratory available to
drug manufacturers on a fee or contract basis?
Dr. ViLLARREAL. Wo have not done that because we have a commit-
ment with the National Research Council and the way we test drugs
from the private drug industry is through the mediation of the
National Research Council.
My policy, the policy of my chairman, has been that we do not work
wdth direct contracts with the drug industry but there is nothing
really specified
Mr. Mann. To prevent it.
What basis does the National Research Council use or what agree-
ments do they have with the private drug manufacturer to channel
the testing of their experimental drugs to your laboratory; do you
know?
Dr. ViLLARREAL. Oil, ves. For some 30 years or so, the arrangement
has been an extremely informal arrangement. Dr. Nathan Eddy
corresponds \vith the drug manufacturers and the drug manufacturers
give the drug dependence committee voluntary contributions every
year which support the work of the National Research Council on
Drug Dependence. And then, as these private manufacturers produce
drugs that require testing, they s(Uid those drugs to the National
Research Council group and they distribute them either to us for
monkey tests or for the clinicians to do the cliuii^al work with them
after they are tested in monkeys.
Mr. Mann. Well, some agency such as the National Research
Council or a change in the thrust of the National Research Council
t^
499
could result in a laboratory such as 3'ou are having the primar}' func-
tion of developing antagonists or in the drug dependency field.
Dr. ViLLARREAL. That is correct.
Mr. Mann. You would recommend that as well as the broader
coordinating effort? '.
Dr. ViLLARREAL. That is right, because it would require the coordi-
nation of clinicians, pharmaceutical chemists, pharmacologists, be-
haviorists, toxicologists.
Mr. Mann. I am ver}' much interested in 3'our expression of con-
fidence in the fact that naloxone may be an eventful cure.
Dr. ViLLARREAL. I think Dr. Resnick may address to the limitations
of naloxone. Naloxone or one of its analogues will do the job.
Mr. Mann. Based upon your experiments what motivation can be
generated for an addict to take naloxone?
Dr. ViLLARREAL. Naloxouc is prett}' inert except in large doses. So,
it is like water, like nothing.
Mr. Mann. But assuming that he took it in a single dose and found
that he got no kick, then, from the next dose of heroin, what is going
to make him continue on naloxone?
Dr. ViLLARREAL. Well, these are questions about behavioral con-
trol which I think would be better dealt with by those witnesses that
deal with humans. I can think of some possibilities but I do not have
firsthand experience in that.
Mr. Mann. Since your work is primarily with analgesics, you no
doubt have been involved in a study of the question of whether or
not an analgesic can ever be nondependency creating on a psychologi-
cal basis.
Dr. ViLLARREAL. Well, cyclazocine itself is a pretty good analgesic
except that it has some unpleasant side effects and its developers
preferred to promote pentazocine, Talwin, which is ^^■idely used and
has remarkably reduced dependence potential compared with mor-
])hine. It is a strong analgesic and it produces very little i)hysical
de])endence. There are very few people that abuse Talwin.
To give you some figures, the standard clinical dose of morphine is
10 milligrams. If you take 300 a dhj, you become very sev^erely de-
pendent and have a horrendous abstinence syndrome.
Now, the standard dose of Talwin, pentazocine, is 30 milligrams.
There are people who have taken u]) to 900 milligrams a day, thirty-
fold, the same 1 to 30 ratio as I said with morphine. Nine hundred
milligrams is 30 times the clinical dose, for long periods of time and
then withdrawal produces a very minimal abstinence. The subjects
feel a few cramps, feel a little uneasy. There is a vast difference
between pentazocine and morphine and I know there are better drugs
than pentazocine in the development stage.
Mr. Mann. Thank you. Doctor.
Chairman Pepper. Mr. Winn.
Mr. Winn. Thank you, Mr. Chairman.
Doctor, you keep referring to leadership and Congressman Mann
was asking you some questions on this. Who, other than the Presi-
dent— I believe recently he has expressed his concern — should furnish
the leadership in this fight against drugs? ^
Now, you mentioned the National Research Council. wShould we
look to HEW, the National Science Foundation? Who should furnish
this leadership, in your opinion?
500
Dr. ViLLARREAL. Well, the National Research Council has a long
history of very strong leadershij) in this business.
Mr. Winn. Does the National Research Council work closely with
the medical schools, particularly those who are receiving large grants
in the research field?
Dr. ViLLARREAL. The National Research Council is not, primarily,
a fund-granting agency. I believe that the only group in the whole of
the National Research Council that has granted money for research
is the committee on drug dependence and their budget is really very
low. I think the budget has been of the order of $200,000 a year,
something like that. Now it is about $300,000 or $350,000.
Mr. Winn. Well, have not some of the medical schools, working
on drug dependence been given grants?
Dr. ViLLARREAL. Oh, yes. By NIMH.
Mr. Winn. What I am trying to figure out in my own mind is who
should coordinate all of this. We are looking for the leadership now.
Dr. ViLLARREAL. I think NIMH people; Dr. Martin, who has had
a long interest in this.
Mr. Winn. I am talking more from an agency standpoint rather
than individuals.
Dr. ViLLARREAL. NIMH probably would be the best place.
Mr. Winn. All right. In a little different i^oint, now. In your studies
that you showed us on the screen, and we appreciated your testimony
here this morning, did you find any psychological indications in the
monkeys? Do you have any way of testing that? You showed us the
physiological results. Do I make myself clear?
Dr ViLLARREAL. Yes.
Mr. Winn. Psychologically, did things show up in your studies
that surprised you?
Dr. ViLLARREAL. We believe that what we call psychological is
what shows up as behavior in this particular case.
Mr. Winn. It is more a behavioral study than psj^chological.
Dr. ViLLARREAL. Yes, but the drug issue in my opinion, and many
others, is a behavioral issue primarily, the core of the drug dependence
problem, and this is what I think is the main lesson of the animal
experiments.
Mr. Winn. But as I understood it, you contend that it is more
physiological than psychological.
Dr. ViLLARREAL. It is pliysiological in the same way that eating is
physiological. Eating has psychological connotations to it, and sex,
of course, has all kinds of connotations to it. But the sex drive is
primarily biological and I think the conclusions of these experiments
is that with the major drugs, the drug-seeking drive is primarily
biological. We like to call it ])sychological because there is no ph3^sical
de])endence.
Mr. Winn. So, it is botli physiological and psychological which
combines the behavioral i)attern, is that right?
Dr. ViLLARREAL. Yes.
Mr. Winn. Now, just for my own clarification. Where are these
bars that these monkeys press? Are they in front of them or are the}'
hooked on to them, on their arms, or what?
Dr. ViLLARREAL. No; the cubicle is about this big and the bar is a
little 1-inch thing that sticks out of one of the walls. The monkey
5qi
finds it in normal exploration. People have used other devices, plungers,
for instance. It does not really matter.
Mr. Winn. Something built in that is not part of the ordinary walls
of the structure.
Dr. ViLLARREAL. That is right.
Mr. Winn. So, he can get hold of it, push it, pull it or whatever he
does.
Dr. ViLLARREAL. It does not have to be verj^ prominent.
Ml. Winn. They find it pretty fast.
Dr. ViLLARREAL. Soiiic moiikcys take longer than others, but they
find it; yes.
Mr. Winn. Thank you, Doctor.
Chairman Pepper. Mr. Keating.
Mr. Keating. Thank you, Mr. Chairman.
Doctor, I wonder if you could bear with me and repeat the answer
to one of the earlier questions and define antagonist and how it is
contrasted with blockage drugs.
Dr. ViLLARREAL. Well, the antagonist is a drug which either pre-
vents or reverses the efTect of the narcotic and it does it in a very
complete and thorough way and the antagonist is also a drug that in
its own right does not have an efTect.
Mr. Keating. Not addictive or
Dr. ViLLARREAL. Or no effect of any kind. Naloxone is a pure
antagonist, a drug that does not have any other properties. Cyclazo-
cine is an antagonist with some side effects.
Now, methadone is just like morphine, like heroin, except that it
has certain subtle differences that make it useful for the management
of addicts.
Mr. Keating. How close are we to real usage of naloxone?
Dr. ViLLARREAL. I do iiot think we are close to that but perhaps
the other witnesses will address themselves to that. There are problems
that have to be solved with development research.
Mr. Keating. I am just wondering how close we are to actually the
use in the i)ublic or public use. Your experiments, you saj, are pretty
far along in its usage?
Dr. ViLLARREAL. Tlicrc are clinical trials that I believe Dr. Kurland
and Dr. Resnick can discuss more up-to-date than I.
Mr. Keating. Is there any application to humans at this time?
Dr. ViLLARREAL. Oh, yes. I understand naloxone was just released
by FDA as an antidote for narcotic overdoses. So, the drug is in the
market already.
Mr. Keating. On hov: limited a usage?
Dr. ViLLARREAL. I liavc not read the specific list of approved uses
but it is an antidote for narcotic overdoses.
Mr. Keating. Could you answer or could one of the other gentle-
men answer, if everything goes according to the way you expect it to
go apparently, how long it could be before general use?
Dr. ViLLARREAL. If pcoplc really worked hard on it, I suppose a
couple of years, 3 years at the most.
Mr. Keating. Two or 3 years.
Dr. ViLLARREAL. That is right.
Mr. Keating. And this is the closest thing we have now as an
antagonist.
502
Dr. ViLLARREAL. There are a few others that are just as exciting;.
M-5050, a British ilriig, a compound — I understand Dr. Martin
talked about it yesterday — which is a hybrid naloxone and cyclazocine.
Mr. Keating. I have no further questions.
Chairman Pepper. Just one last question. After the question asked
by my colleague, Mr. Winn, if Congress vrould provide the mone}'
and designate the agency to spend it, we could establish the kind of
leadership that you say would be desirable in this field; could we not?
Dr. ViLLARREAL. I think so; 3^es.
Chairman Pepper. Well, Dr. Villarreal, we are very grateful to
you for your valuable testimony here and giving us the benefit of
your views.
Dr. ViLLARREAL. Thank you very much.
Chairman Pepper. Thank you very much.
(Dr. Villarreal's prepared statement follows:)
[Exhibit No. IS]
Statement by Julian E. Villarreal, M.D., Ph. D., Associate Professor
OF Pharmacology, University of Michigan Medical School
On the subject of drug dependence, as with many issues or human behavior,
it appears as if everyone would wiUingly claim some insight into its nature, its
causes, and its possible remedies. In the last few years we have seen how the great
interest which our society has shown on this topic has led iiidividuals with very
diverse backgrounds to quickly become writers or speakers on the subject. It has
even been considered by many that the most appropriate speakers on "drug edu-
cation" programs for young audiences are either peers or only slightly older stu-
dents. Not intending to demean the good will of those involved in these activities,
it is necessary to call attention to the fact that many of us behave as if knowledge
on the nature of drug dependence was very easy to come by, as if any reasonably
intelligent person could form an acceptable picture of the phenomenon if he were
to take the trouble to understand the chemistry of the drugs, their physiological
and psychological effects, and their toxicities. Even some of the professionals show
this same kind of attitude in studies where the causes of compulsive drug use are
sought by simply interrogation of the drug users. The causes of drug-seeking
behavior do not even appear accessible to the techniques of psychoanalysis which
probe into events that were once repressed from consciousness. Analysis of the
information we now possess does not give any indication that organisms have to
have any kind of awareness of what is happening to them in the process of be-
coming drug dependent. The corollary of all this is that verbal probing and just
thinking through the events in the histories of drug addicts is not likely to carry
us very far in our attempts to understand and control drug dependence. Only
work in the physical sense, experimental work, analysis by manipulation of causal
factors, has allowed really solid advances in our knowledge of the rclati\e im-
portance of some of the factors which play roles in the generation and maintenance
of strong self-administration behavior. Experimental work on drug dependence
has also produced a technology which has predictive value and which has
opened the way for analysis of neurophysiological and neurochemical mechanisms
as well as for the possible development of therapeutic tools and effective treatment
strategies.
The purpose of my presentation today is twofold: in) to briefly review the most
im]:)ortant accomplishments of laboratory work on narcotic dependence: and
(h) to discuss the possible uses of the technology and the concepts which have
emerged from this work for the purposes of developing rational strategies for the
treatment of dependence as well as tools for a more effective management of
narcotics addicts.
Lalioratory work has a very long history of contributions to the problem of
narcotic dependence. Chemists have synthesized thousands of narcotic analgesics
with a wide variety of chemical and pharmacological characteristics — high or low
solubility in water, short or long duration of action, effective when taken orally
and when injected or effective only when injected, etc. Chemists, too, have
503
synthesized a large number of narcotic antagonists, also with a wide variety of
properties.
Laboratory work on the biological effects of narcotics not only led to the
characterization of the actions of these drugs but to the emergence of the most
fundamental concepts of the phenomenon of drug dependence. Clinical studies
on addicts carried out as late as 1929 did not allow firm conclusions as to whether
the withdrawal illness was due to organic or to psychological causes or even to
simple malingering. In contrast, laboratory studies in animals led to the demon-
stration of the phenomenon of physical dependence to narcotics and of the
physiological nature of the withdrawal illness.
The most important contribution of laboratory work to the analysis of depend-
ence came with the development of techniques of drug self -administration in
animals. Rats and monkeys are prepared in surgery with permanent intravenous
tubes connected to motor-driven syringes containing a drug solution. The animals
are then placed in a chamber where they can give themselves drug injections by
pressing on a bar switch.
With these techniques a large number of drugs have been shown to generate
and maintain self-administration in animals: morphine, dihydromorphinone,
codeine, meperidine, methadone, etonitazone, pentazocine, profadol, hexoijarbital,
pentobarbital, phenobarbital, chlordiazepoxide, ethanol, chloroform, diethyl ether,
lacquer thinner, cocaine, f/-amphetamine, methamphetamine, phenmetrazine,
SPA, methylphenidate, ])ipradol, caffeine, and nicotine.
All the drugs tested in monkeys which generate persistent compulsive self-
administration behavior in man also generate strong self-administration behavior
in the monkey. Conversely, drugs tested in this species which are not known to
be used compulsively by man do not induce self-administration behavior in
monkeys: chlorpromazine, nalorphine, mixtures of morphine with nalorphine,
levallorphan, and mescaline. This evidence of parallelism between monkey and
man very strongly suggests that we are dealing with the same phenomenon in
both species, what we call psychological dependence in humans and what we see as
sustained self-administration in animals.
The parallelism between animals and man is shown not only with regard to
their respective responses to specific drugs; the patterns of self-administration for
different drugs are also similar. As in man, the self-administration of opiates by
rhesus monkeys is a very steady form of behavior which is remarkably stable
over very prolonged periods of time. Amphetamine-like stimulants, in contrast,
generate very irregular patterns of self-administration in both rats and monkeys.
Human addicts on these drugs similarly show irregular cycles of drug use and
abstinence.
These findings of animal experimentation on drug dependence have placed the
phenomenon of drug-seeking behavior in a completely new perspective. The
laboratory investigator is much less prone than his clinical colleagues to project
personality and character disorders into his animal subjects as the basis for drug-
seeking behavior. The fact that "simple-minded" animals show very much the
same behavioral response to drugs which are self-administered indicates that we
do not need to invoke attributes peculiar to the psychology of man to account for
drug-seeking behavior. With rats and monkeys there are no generation gaps, no
identity crises, and no desperation because of the evils of society. Also, animal
experimentation has shown that in the face of maximum availability of drugs
individual differences in the tendency to self-administer drugs are wiped out. All
monkeys that are given full access to morphine and other opiates or to cocaine will
develop the predictable patterns of strong self-administration behavior. In this
light, the differences between human drug users and non-users may turn out to be
primarily differences in access to drugs for self-administration, differences in the
tendency to do the initial experimentation which will allow the drug to exert its
predictable behavioral effects, or differences in the strength of competing be-
haviors which are incompatible with drug use.
With these techniques, it has been demonstrated that the treatment with
effective doses of narcotic antagonists will block the self-administration of opiates
by animals that have full access to these drugs. It is highly likely that the narcotic
antagonists will also block the behavioral impulse to take narcotics in human
addicts. Plowever, many important aspects of these behavioral effects of the antag-
onists rt-nuiin to be systeniutically explored; that is, the effects of low doses of
antagonists, the effects of intermittent rather than continuous antagonist treat-
ment, the question of whether or not animals given insufficient doses of antagonists
will work to obtain more opiate to surmount the effect of the antagonist, and so
504
forth. It is to be hoped that these investigations coupled with appropriate studies
in man will lay the groundwork for the design of effective treatment schemes
for human addicts.
It appears that one of the most important requirements of this form of treatment
will be the maintenance of continuous levels of the antagonist around the clock.
We do not have yet a preparation of antagonist drugs that will conveniently allow
the meeting of the requirement of continuous coverage. However, sources working
under contract with NIMH are attempting to develop slow-release preparations
which might maintain effective tissue levels of antagonists for periods of at least
several days.
There are a number of very potent narcotic antagonists, most of which are sitting
idly on the shelves of private pharmaceutical houses. Potent narcotic antagonists
have only a small market in their established medical use (as antidotes for nar-
cotics overdose) . The potential market for the use of antagonists in the treatment
of narcotics addicts is not very large either. Furthermore, it is uncertain what
fraction of the total population of addicts might be amenable to long-term control
with antagonists. We have, then, a good number of substances that are good
candidates for development as tools for the treatment of addicts. Yet, we cannot
expect private drug industry to take the initative in these endeavors.
The responsibility for this research and development work has fallen in the
hands of those of us interested in the solution of the problem of narcotics de-
pendence. Unfortunately, separate groups of investigators working in a loosely
coordinated way cannot be expected to have the eflicienc.y, all the practical know-
how, and the wide variety of resources which drug industry has available for new
drug development.
It is to be hoped that the efforts of investigators currently working on the
development of antagonists for the treatment of narcotic dependence would
become formally organized and formally supported by those agencies in govern-
ment that have responsibilities in the area of drug dependence. Private drug in-
dustry should also be encouraged to participate in these efforts, if necessar^y through
formal arrangements such as government contracts.
Chairman Pepper. The committee is pleased no^v to call as the
next witness Dr. Albert Kiirland, director of the Maryland State
Psychiatric Research Center in Bahimore.
"Dr. Kiirland holds a medical degree from the University of Mary-
land. He is a certified board psychiatrist, a fellow of the American
Psychiatric Association, a member of the American Medical Associa-
tion, the Society of Psychophysiological Research, the Council on
Medical Television, and a long list of other professional societies and
committees.
Dr. Kiirland has recently received a grant of more than $66,000
from the National Institute of Mental Health to conduct a controlled
study of the narcotic antagonist naloxone, and its effectiveness in
treatment of the narcotic drug abuser. Over nearly a 2-year period,
Dr. Kurland has been administering naloxone to approximately 75
parolees from Maryland correctional institutions. This preliminary
research has been su])ported by State and private fimds.
Dr. Kurland is here to advise the committee on the current status
of his research, its success thus far in rehabilitation of herion addicts,
and the ]:)rospects for broader application of this nonaddictive treat-
ment approach in the future.
We are very much jjlcased to have you with us today, Dr. Kurland.
Mr. Perito, will you inquire?
Mr. Perito. Thank you, Mr. Chairman.
D]-. Kurland, you have ])resented us with a rather extensive state-
ment. Would you care to ofTer that statement at this point for the
record?
505
STATEMENT OE DR. ALBERT KURLAND, DIRECTOR, MARYLAND
STATE PSYCHIATRIC RESEARCH CENTER, ACCOMPANIED BY
WILLIAM McCOY, AND ROBERT TAYLOR
Dr. KuRLAND. Yes; I would.
Chairman Pepper. Without objection, it will be received.
Mr. Perito. Thank you, Mr. Chairman.
Dr. Kurland, I understand you have brought with you some of the
particijjants in 3'our program; is that correct?
Dr. Kurland. That is correct.
Mr. Perito. Would they care to sit with you during your
presentation?
Dr. Kurland. I will be glad to have them.
Mr. Perito. Could 3 ou kindly introduce them for the record, as you
see fit, please.
Dr. Kurland. Yes, sir. Before I introduce these clients, I would
like to make a brief statement in addition to wdiat you have in the
record. I might say that with the great interest that this committee
has expressed in naloxone, that this interest is well founded, that we
do have here an agent that we have seen, from the clinical standpoint,
offers potential clinical promise if certain difficulties can be resolved,
could im.mediately be made available to large populations of narcotic
abusers. This approach, in my opmion, may be one of the most effec-
tive means we have for coping with this disorder.
I think if proj^erly utilized, naloxone may even surpass the use of
methadone and furnish a much more effective means.
The basis for this strong position arises from a 10-year clinical
research effort that began with an evaluation of narcotic addicts and
narcotic abusers admitted to a State psychiatric hospital and the
reaction to the medical services provided.
The experiences in this initial undertaking indicated that this was,
expressing it very charitably, except for detoxification, apparently a
waste of medical resources.
This led to our next stej) in studying this type of patient and this
was their evaluation in an outpatient setting. In this approach, atten-
tion was focused on intlividuals coming out of correctional institutions
with a history of narcotic abuse to determine their narcotic abuse
patterns.
This is not the kind of a research that wins anybody a Nobel Prize.
It is very mundane, very unimaginative, but very basic in identifying
the patterns of narcotic usage. In this endeavor, we were fortunate
enough to obtain support from the NIMH w^ho supported the project
for a period of 5 years. Subsequently, additional sui)i)ort was ju-ovided
by the State of Maryland and Friends of Psychiatric Research, Inc.,
a nonprofit organization.
Chairman Pepper. What has been the total amount of money?
Dr. Kurland. The total amount of money involved was ai)proxi-
mately half a million dollars over a 5-year period.
In the course of research we admitted several hundred parolees
from the correctional institutions of Maryland with histories of narcotic
abuse. These were released to this experimental program which pro-
vided aftercare primarily in terms of abstinence and daily monitoring
506
of urine testing, plus psychotherapy provided in a weekly groiq)
j)sycho therapy meeting.
The gentlemen on my left and right are individuals who participateil
in such a program and shortly will give you some of their impressions
on the benefit of their experiences.
In the survey of just exactly what happened to these individuals,
following their release from a correctional institution, we learned that
85 percent of these individuals will reexpose themselves to a narcotic
experience within 12 weeks after release from a correctional institu-
tion despite the fact that they face the possibility of being returned
to jail.
In exploring this matter further we also learned that despite the
fact that 85 percent will reexpose themselves to a narcotic experience,
there were only 15 percent that indicated so little control that they
immediately relapsed into continuing drug use that necessitated their
immediate removal from the program.
The great majority attempted to cope with this need for or urge
for drugs through intermittent episodes of exposure and then becom-
ing abstinent for a varying period.
As we became acquainted with this pattern of behavior and sought
more effective therapeutic means for coping with this disorder, we
were very fortunate in becoming aware of some of the experiments
with naloxone being carried out by a New York group of researchers
under the leadership of Drs. Max Fink and A. M. Freedman, who
had learned that large doses of naloxone, namely, between 2,000 and
2,500 milligrams, administered on a daily basis, would provide a
total blockage lasting for a period of 24 hours. However, this raised
a very formidable problem because of the costliness and scarcity of
supplies of the naloxone handicapping expanded investigation.
Since our investigations had outlined some of the patterns of the
episodic and intermittent usage, it was suggested, in view of the
scarcity of naloxone, that a compromise might be effected b}^ utiliz-
ing a system of low dosage, although this yielded only partial
blockade.
Employing this aj^proach, it was learned that the low dosage
blockade did not appear to achieve a greater level of retention than
abstinence alone in retaining individuals in the program. The longer
the individual was retained in the program, the more meaningful
this was felt to be. The hypothesis had been that a dosage range of
between 200 and 800 milligrams, given only at night, would blockade
the ev^ening hours, a time when these individuals were considered to be
most vulnerable to drug usage since all were requu'ed to maintain a
job as a condition of their parole.
We found in the course of the pilot study that we could administer
the naloxone either up or down the scale of dosage very (piickly
without any Ul or particular disturbing effects on the patients,
although the effects were short lived; namely, 3 to 5 hours. In the
course of this treatment many of the individuals soon learneil to
bypass this period of time through their self-experimentation, dis-
covering if they gave the drug beyond this time interval they could
still get their high.
As we revievved the results of the pilot investigation and totaled
the dosages of naloxone that had been used in this experiment, we
507
discovered if we iiad taken the same dosage and given this total dos-
age just as those points in time when these individuals had experi-
enced a stress — resorted to drug usage — it would perhaps been more
meaningful to have used the naloxone in a manner similar to that
used for penicillin.
When an individual resorted to opiate usage, as revealed by daily
monitoring, and this extended over a j)eriod of 2 or 3 days, the block-
ade would be carried out with an administration of high dosage, 2,500
milligrams, until he once more became abstinent. Usually this could
be anticipated to occur within a period of 2 or 3 days, with the indi-
vidual once more continuing his abstinent course.
We feel that with adequate supplies of this drug that we could
approach this disorder on the same basis we deal with an infection;
that is, as the individual reached a point where he was exposing him-
self to drugs he would, at this time, be administered sufficient naloxone
to provide him with total blockade and the naloxone discontinued
with the return to abstinence. Following this, there might be another
period of weeks or months before reexposing himself again. You must
remember, we are dealing with a chronic disorder which, as yet, we
do not know how to treat effectively, nor do we know what causes
this disorder.
With that brief introduction, sir, I would like to turn to some of
the gentlemen accompanying me who have been kind enough to vol-
unteer to express their thoughts and feelings.
Chaimian Pepper. Would you care to give their names or would
thev i)refer not to?
Dr. KuRLAND. They indicated a willingness to present their name
and identify themselves. I w'ill start with the gentleman on my right
and this is Mr. McCoy.
STATEMENT OF WILLIAM McCOY
Mr. McCoy. My name is WiUiam McCoy and I have been an
addict for over 25 years. I have been in and out of different institutions
going back to the year 1939. And up until recently I have never been
given a chance on parole or anything of that nature as far as helping
me or having any ideas of wanting to help myself. Dr. Kurland and
his program started the thing about taking addicts out of the in-
stitutions on an outpatient basis, and I was accepted on this because
of the fact that I showed potentials of wanting to leave drugs alone.
Now, when I first came home, for the first month or two, I did very
good and then an incident happened about a friend of mine that got
killed and I went back into a rut and for about a period of 3 or 4
months I went back to drugs.
Then I volunteered for this naloxone program and I stayed on that
for a period of 6 months and as of the present date I have been drug
free for over a period of a year and have not had the urge to take
drugs nor do I want drugs any more. And personally s])eaking, I say
that this medicine, naloxone, has shown to me that it is a good de-
terrent for the usage of the drugs because the first night I had taken
the naloxone I had drugs in my system and 5 minutes after I had
taken it, it made me ill. I threw up all the drugs, brought the drugs
out of my system, and I began to realize if I were to continue to take
508
naloxone, then I would be a fool to inject heroin or any other opiate
into my system when I would not get any feeling out of it. So, I left
it alone completely.
I have been working the ])ast 2 years and have not had any ])roblems.
It would be foolish of me to go back to drugs and I strongly advise
that something be done to make the use of naloxone available to the
general public, because, personally, I believe it could be very useful.
It has been useful to me.
The Chairman. Mr. McCoy, that is an exciting statement you have
just given and we commend you upon it.
Was the administration hj a doctor or at a clinic, Dr. Kurland?
Dr. Kurland. It was at our clinic. We have a special narcotics
clinic that is operated by Friends of Psychiatric Research, Inc.
Mr. Perito. Would the other witness like to make a statement?
Dr. Kurland. Mr. Taylor.
STATEMENT OF ROBERT TAYLOR
Mr, Taylor. I was using drugs since 1968.
Mr. Perito. Do you mean heroin?
Mr. Taylor. Heroin. And after my incarceration, I did not, you
know, really want to come to the narcotic clinic but after hearing
about the naloxone, it gives you a draw, it stops the blockage. You
want that desire. So, I got on the program and when I came out, I
used it but I did not feel it.
Mr. Perito. You mean you were taking naloxone and thc^n you
shot heroin but you had no pleasant feeling?
Mr. Taylor. No feeling. I think I shot about four bags and did
not feel it.
Mr. Perito. And 3'ou continued to keep taking naloxone?
Mr. Taylor. Yes; I did.
Mr. Perito. How long have you been taking naloxone?
Mr. Taylor. I am off of it now. Maybe a year. I just recently got off.
Mr. Perito. Were you detoxified on methadone?
Mr. Taylor. No.
Mr. Perito. You were not.
Dr. Kurland. May I interject a remark here? Have either of j^ou
gentlemen been on a methadone program?
Mr. Taylor. No. Never been on it.
Mr. McCoy. No; I have not.
Chairman Pepper. So naloxone was not only a blockage drug but it
was a de toxicant.
Dr. Kurland. No. I have to correct somethhig there, Mr. Chau'-
man, and the correction is this, that these peoi)le came out of jail,
correctional institution, came right into the i)rogram.
Mr. Brasco. May I ask tliis one cpiestion to the gentkunau on the
left who said that he had taken naloxone for 6 months. Are you using
■it now?
Mr. McCoy. No.
Mr. Brasco. You are not using aii}^ drug now?
Mr. McCoy. Not using any drugs.
i Mr. Brasco. You Inne been drug free for over a year.
Mr. McCoy. Drug free for over a year.
Mr. Brasco. Very interesting. Thank you.
509
Mr. Perito. Dr. Kurland, do you see the possibility of developing
naloxone in the form of a vaccine?
Dr. Kurland. It would not be necessary in my opinion, and I
would like to elaborate on that for a few minutes, if I may.
As you just heard, we used a low system dosage application here
and hi many of the individuals it does not work because they override
the system and it breaks down because the}^ do not have the capability
or cannot muster the self-disciplinarj^ resources that these two iji-
dividuals have been able to do. The indications are that naloxone
might be used much more economically and effectively than employed
in our initial experimentation. This would be the administration of the
medication only at those times when the individual is exposing him-
self to drug use, wliich is readily revealed by the urine analysis. At
such times the subject would be admhiistered a dosage yielding the
24-hour blockade.
The major problem at this time relates to the supply of naloxone
and I would like to indicate what the difficult}' is. Naloxone is made
from a substance called thebaine. Thebaine is a substance obtained
in the processing of opium, although itself, not an opiate. In this
country we process about 200 tons of opium per 3-ear for medicinal
purposes through licensed pharmaceutical firms. In the processing of
opium there is obtained about 1,500 kilograms of thebaine. It is from
this substance that naloxone is synthesized and also creates the limit
of use. I might say, in defense of the drug company supporting this
research, that the}- have been very supportive of this effort, although
other investigators have had difficulty in this area because of the
necessity of restricting the use of the limited supplies available.
Mr. Perito. Doctor, excuse me, are you aware of any research
going on? Dr. Eddy informs our committee that there is some research
going on to develop and synthesize a drug which comes from an
opium — a poppy plant — which does not produce poppy pods or
opium pods. Are you aware of that?
Dr. Kurland. Yes. There are some plants that have a high content
of thebaine and it is the hope that such plants ultimately might be
grown in this countr}-, and I would recommend to this committee that
the}- interest the Department of Agriculture to pursue this objective
because this is a very important element in this approach to developing
the narcotic antagonists. It is known that such plants grow in Iran
and contain a high content of thebaine in their roots. These plants,
although members of the poppy family, themselves do not produce
any opium compounds.
Mr. Perito. Do you believe that an accelerated research program
in that area could bear fruit?
Dr. Kurland. In my opinion, such an approach should have the
highest priority because I feel we have an extremely effective agent
here in coping with this disorder and we have gleaned enough experi-
ence to know that we are on the right track here.
Chairman Pepper. Doctor, we thank you very much for that and
we will look into it immediately.
60-296 — 71 — pt. 2-
510
(The following letter was received for the record :)
[Exhibit No. 19]
Department of Agriculture,
Office of the Secretary,
Washington, B.C., July 23, 1971.
Hon. Claude Pepper,
Chairman, Select Committee on Crime,
House of Representatives.
Dear Mr. Chairman: Tiiis is in reply to your letter of June 29, requesting
information on plant sources of the alkaloid thebaine. We are pleased to learn
that thebaine may prove to be a useful antagonist to heroin and its effects on the
human body.
As far as can be determined, thebaine occurs only in species of the genus Papaver
(poppies). The Great Scarlet Poppy (P. bracteatum), the Oriental Poppy
(P. orientale), the Corn Poppy (P. rhoeas), and the Opium Poppy (P. somniferiim)
all contain thebaine in amounts varying from several tenths of 1 percent to over
4 percent of the air-dried milky exudate. All of these poppies have been grown in
parts of the United States. The Corn Poppy and the Oriental Poppy are popular
garden ornamentals.
This Department has no research underway on these plants as sources of
thebaine. Adequate seed supplies are available for experimental plantings. Should
medical evaluation indicate an expanded need for thebaine we would be pleased
to undertake production research on the source plants.
Information from the literature indicates that thebaine is much less narcotic
than morphine but in large doses may produce convulsions and damage to
peripheral motor nerves in laboratory animals. Perhaps recent pharmacological
research has established safe dose regimens. If so, we could not find literature
references to this effect. We have no basis for judging the potential effectiveness
and usefulness of thebaine in the fight against drug abuse.
Please be assured that this Department stands ready to assist your committee
in any way possible.
Sincerely,
N. D. Baylky,
Director of Science and Education.
Chairman Pepper. Proceed, Doctor.
Dr. KuRLAND. I will be brief. I suppose I will summate my position
at this point.
We have a very useful agent here. It has come out of the laboratories,
in this particular case out of the Endo Laboratories. They have been
confronted with a number of difficulties in utilizing these compounds
but they have — as you have heard Dr. Villarreal indicate that there are
other comi)ounds available — and we have learned how to use these
more effectively. We have also learned about the patterns by which
individuals use drugs.
Chairman Pepper. Doctor, did these two gentlemen or any other of
the people with whom you work have any side effects that were
injurious from taking the naloxone?
Dr. KuRLAND. Every drug has some side effects. The side effects we
noted in these particular patients are based on the 75 that we have
evaluated over this 20-month period. Some of the patients will com-
plain, for example, of a loss of api)etite for a period of time or they
will complain of feeling somewhat dizzy or — we have noticed in one
or two patients — they have complained of nosebleeds, but this has been
the most serious finding we liavc run into and I do not know whether
this is really due to the drug j)er se, because these individuals, j^ou
must remember, may be taking other drugs from time to time.
511
Chairman Pepper. Has the Food and Drug Admmistration ap-
|)roved the use of naloxone?
Dr. KuRLAND. It has only recently released this drug specifically as
an antidote for morphine or opiate poisoning, but not for an agent
the way we are using it. This is only on an experimental basis.
Chairman Pepper. Not for maintenance?
Dr. KuRLAND. No.
Chairman Pepper. Thank you. Go right ahead.
Dr. KuRLAND. In my opinion, I would like to recommend to this
committee that they give very strong consideration to developing the
means for making this drug more available and to establish a high
priority research group to specifically take this material and explore
it as actively and as aggressively as they can clinically.
Chairman Pepper. Doctor, I would like to ask each of the gentle-
men with you, would each of you j)lease tell us what caused you to
volunteer for Dr. Kurland's ])rogram?
Mr. McCoy. Well, sir, mainly 1 wanted freedom out of the insti-
tution. When I was first offered the i)ossibility of making parole if
I were to join some type of self-help j)rogram which would encourage
me to stay away from drugs I said, well, I will take the chance on it,
because while in the institution, I was instrumental in organizing a
self-help organization down at the ]Maryland House of Corrections,
which has been fundamental in getting quite a few addicts back on
the road to the right type of life, and I saw this as a stepping stone
tow^ard helping myself, so I made plans of that nature.
Chairman Pepper. What would the other gentleman say?
Mr. Taylor. I was in Hagerstown and through a therapy group,
my classification officer, we talked about it. I did not really want to
get on the program but after discussing it, I found it would be the
best thing and I went on through with it and it is coming along pretty
good. I feel that I really enjoy it. I enjoy most of all the therapy.
Chairman Pepper. One other question of you gentlemen. We have
heard stories that heroin and other drugs are available for inmates in
correctional or penal institutions. Were drugs procurable in the in-
stitutions in which you gentlemen Avere confined?
Mr. McCoy. Yes, sir; to a very high degree. It was to a very high
degree.
Mr. Taylor. To a small extent in Hagerstown; yes.
Dr. KuRLAND. I w^ould just like to add one more comment to the
discussion on naloxone.
The thing that also intrigued us about this particular compound is
that it may be very useful in the younger addict for whom there is a
lot of concern about putting him on a drug such as methadone, and
this is also one of the factors that directed our attention to it early
in our investigation.
Chairman Pepper. Mr. Steiger.
Mr. Steiger. Thank you, Mr. Chaii-man.
Mr. McCoy, I gather from Dr. Kurland's remarks and yours, that
once you got on this program, you checked in, at least for a certain
period of time, on a daily basis into the clinic and among other things,
you had a urine test and then they talked to you. Is that the way that
worked?
512
Mr. McCoy. Yes; when you first come out 3-ou have to go contm-
uously for 7 days a week until you earn credit days off and one night
a week you have therapy with a ps3^chiatrist up there.
Mr. Steiger. Discussion.
Mr. McCoy. That is right.
Mr. Steiger. Mr. McCoy, you are aware, I suspect, that there are
lots of ways to beat the urine sample. We have had testimony as to all
kinds of devices for masking the urine— take bicarbonate of soda, use
somebody else's urine in a syringe.
Mr. McCoy. Well, sir, at that point I would say that is highly
impossible because of the way the thing is situated. You have mirrors
on all sides of you and you have an attendant with you all the time,
and he practically holds your private while you put it into the jug.
Mr. Steiger. Incidentally, is the naloxone injected?
Mr. McCoy. No; it is four tablets. You take them with a small cup
of water.
Mr. Steiger. When 3^ou had taken the naloxone, did you ever try
any speed or cocaine?
Mr. McCoy. Never.
Mr. Steiger. Or anything else?
Mr. McCoy. Never had the urge for it.
Mr. Steiger. Do 3^ou know of any other fellows on the program
who tried anything else, besides heroin?
Mr. McCoy. Yes; they tried other things but they became ill. They
became ill. The}^ did not get any feelings from whatever they injected.
Mr. Steiger. Thej did not get a high?
Mr. McCoy. No; they did not. The only thing, the}^ became ill.
As I previously stated, I had drugs in my system the night the\^ gave
me my first dose of naloxone and 5 minutes after that I became ill
and threw it all up.
Mr. Steiger. Is that a typical reaction with naloxone as far as
you know, or ])erhaps Dr. Kurland could better respond to this. In
addition to being unable to achieve a high, is there a generally nauseat-
ing effect if you have naloxone in the system and you take heroin?
Dr. Kurland. It is a very interesting c^uestion that you ask, sir.
One of the things we learned in the exi)erimentation is that those
individuals who were by])assing the 5-hour period, say, and taking the
drugs, if they continued to take drugs for a period of 3 or 4 daj^s, the
naloxone i)reci])itated a withdrawal reaction of moderate intensity in
the individuals and this was completely an unexpected finding from
our standpoint.
Mr. Steiger. Even while they were on the drug they were getting
some mild withdrawal symi)toms.
Dr. Kurland. If they continued to take o])iates every day. For
exam[)le, if we gave the drug between 6 and 9 in the evening, which
we always did, and they took the drug, say, the next morning they
might get a high but if they continuetl to take the drug every morning,
say, for 3 or 4 da.ys, then a withdrawal reaction was ])r(>cipitated in
which the}^ became nauseated, vomiting, chills, some persphation, felt
jittery, and they identified it as a moderate withdrawal reaction.
Mr. Steiger. Mr. McCoy, do you know of any illegal traffic in
naloxone? Can you buy it on the street at all as far as you know?
Mr. McCoy. No; I do not think >^ou can because it has not been
released to the general public for usage yd.
513
]Mr. Steiger. Do you feel from your past experience that this would
be a problem in that it might achieve a popularity in the street?
Mr. McCoy. No, I do not think it would create a problem in the
street because those that want to stay on drugs would not want to
use anything that would stop them from using drugs.
Mr. Steiger. That is a very reasonable answer. I wonder in your
opinion, if it it would be necessary to have more than just a casual
desire to get off drugs in order to be successful jKirticipants in this
program. In other words, it takes either somebody who is less hooked,
who does not have a real heavy habit or who really wants to get
straight; woidd he be the most likely to be successful under this par-
ticular program?
Mr. VicCoY. Well, it depends upon the willingness of the person
himself to get away from it.
Mr. Steiger. I will ask the question this way: From the hard
addicts that you may have known, would you say that if you could get
them started on this program, there would be as much likelihood of
success there as it would be from somebody who really wanted off?
Mr. McCoy. Well, owing to the fact of personal experience after
using drugs for 25 years myself, I would say if you can take a person
like me, if he really wanted to get oft", I see possibilities of this being a
good chance for him.
Mr. Steiger. Dr. Kurland, did you have anybody else who had the
extensive experience of Mr. McCoy. Were there others who had that
long a history of addiction in your program?
Dr. Kurland. Yes, we have; and we have had our successes and
we have had our fcdlures. As I mentioned earlier, we were working
with a low-dosage system. We could not apply the dru^ in a manner
that we would have liked to as we knovv' now, and this is the next
crucial ex}:)eriment that has to be carried out in this continuing in-
vestigation, plus the fact there was another element; namely, these
were patients, these were parolees, over whom mandatory control
could be exercised.
In a program where there is voluntary admission, I do not think
that the program would be as acceptable because where individuals
have a free clioice, the first drug would be heroin, the second, metha-
done, and naloxone would be last.
Mr. Steiger. If I understand correctly, if anybody in this ])rogram
now who has reacheti the stage, say, of Mr. McCoy, where he has been
clean for a long period of time, if he feels a stress situation or feels the
need, is he free in this particular jjrogram to request naloxone?
Dr. Kurland. I will let Mr. McCoy answer that.
Mr. McCoy. I would like to clarify that by saying when I was first
released on parole I was released on complete abstinence. I was not
taking any type of drug and I started deviating while I was out, so I
personally volunteered myself for the naloxone j^rogram. They did
not ask me. I volunteered to keep from going back into this rut. I heard
it was something helpful and useful to the addicts, so I went to my
therapist and said could he tell my counselor and see if I could get on
this program because I was going back to drugs and I did not want to
get back to it.
Mr. Steiger. If now, for some unknown reason, you should feel the
need, could you get the medication now upon request?
514
f r
Mr. McCoy. I believe I could if I asked the doctor or my therapist,
if they saw fit that I really needed to pro back on it.
Mr. Steicier. Is that the situation, Doctor?
Dr. KuRLAND. To a certain extent that is correct, but it also depends
upon the supplies of naloxone, and we hoard that. It is more precious
right now than gold.
Mr. Steiger. Thank you very much.
Chairman Pepper. Mr. Kurland, we want to thank you. I think
vour testimonv this morning vivitllv shows that a lot of things can be
done if we just provide the money and the j:)eople to do them, ^'ou
give us encouragement.
Mr. McCoy, Mr. Taylor, we want to thank you gentleman or coming
and we want to commend you for the motivation that has led you to
take advantage of this program of Dr. Kurland 's and get yourself
free of diugs. We pray you will stay free of it and you will give your
experience to as many others as you can and encourage them to follow
your example. Thaiik 3^ou.
(Dr. Kurland's prepared statement follows:)
[Exhibit No. 20]
Prepared Statement of Dr. Albert A. Kurland, Director,
Maryland State Psychiatric Research Center
It is assumed that the members of the Select Committee on Crime of the House
of Representatives, on the basis of its previous hearings, are quite familiar with
the many aspects of the abuse of narcotic drugs and the destructive effects on the
social fabric that accompany this activity, and briefly state my own position
relative to the medical approaches seeking to cope with this abuse. Essentially, it
agrees with that of most authorities that the traditional techniques of psychiatric
treatment have not been particularly effecti\-e in the management of opiate
dependence and there is a need for more effective therapeutic measures. In
pursuit of this objective, this investigator (see attachment No. 1), has carried
out a series of clinical studies of the narcotic abuser. The first of these initiated
in 1960, began with the survey of the cour.se followed by narcotic addicts admitted
on either a voluntary basis or by order of the court to a State psychiatric hospital.
This survey reemphasized the unrewarding accomplishments of hospitalization,
except for detoxification (see attachment No. 2). Because of these findings there
was carried out a second study exploring the possibility of managing the detoxified
narcotic abuser over whom mandatory supervision could be maintained in an
outpatient setting, employing abstinence combined with a sj^stem of daily
monitoring.
The statistical data obtained from the study (see attachment No. 3) indicated
that a population of parolees with a history of narcotic abuse, if promptly con-
fronted with evidence of their illicit use of opiates, would respond to their being
challenged. The magnitude of this response was indicated l)y a retention rate in
which approximately :^.') percent of the participants remained in the program for
a period of 6 months or longer. Moreover, if one eliminated the absconders from
the program as being j^oorly motivated, as indicated by the lack of e\idence of
opiate usage at the time of their flight, the retention rate approximated oO percent
(see attachment No. 4). The data also revealed a total of 23 new arrests in this
population of approximately 400 parolees during the i)eriod of their participations.
When the nature of this population is considered, this was felt to be a rather
encouraging finding.
Although there was a strong desire to compare the statistical information with
the data i)eing obtained from methadone programs, this had not been possible for
a nuniljer of reasons. This was the absence of svu-h information on a comparable
population of subjects with no possiblity of obtaining such information in the
foreseeable future. This arose from the fornndablc issue that such attcnptod com-
parison would have posed ethically. In our opinion, it would hav(; been quite
objectionable to have placed a ijopulation of parolees, who had been rendered
abstinent as a result of their incarceration, back on a projirain of niethadono
maintenance immediately on their nsleasc to the {n-v socirl \ .
515
In this second study there was another observation which aronsed considerable
attention and related to the fact that only a small proportion of the population,
approximately 15 percent, quickly relapsed into a level of narcotic use suggesting
an inability to contain their use of narcotics within the first 12 weeks on the pro-
gram, out of the approximate 85 percent who had exposed themselves to an
incident of narcotic usage within the first 12 weeks on the program. The fact that
85 percent of the subjects out of the population v\ith a history of narcotic abuse
and a life style indicating a pattern of highly recidivistic behavior were making
some effort to contain their usage of narcotic drugs, led to an exploration of the
possible usefulness of the administration of a narcotic antagonist in coping with
these flareups of episodic usage and resulted in initiation of the third study. In
this third study the course was pursued of superimposing the use of a narcotic
antagonist in the abstinence program emjjloyed in the second study.
The factors leading to the selection of the particular narcotic antagonist,
naloxone, and our understanding of these substances, will be most briefly reviewed
for the members of the committee before proceeding. The pharmacological history
of the narcotic antagonists began with an observation by a German pharma-
cologist, Pohl, in 1914. In investigating the effects of the substitution of an allyl
for the methyl group on the nitrogen atom of codeine, the resulting compound,
N-allylnorcodeine, was found to antagonize the effects of morphine. The sig-
nificance of this observation, namely, the antagonism of the respiratory depression
caused i^y morphine, and the accompanying arousal that occurred when this
compoimd was administered to animals made lethargic with morphine went un-
noticed for almost 30 years. In the early 1940's, planned research, based on the
thought that there might be combined within the molecule of a narcotic com-
i:)0und, itself an essentially depressant structure, a moiety which was independently
a stimulant enabling one property to counteract the other, led within a few years to
the confirmation of the existence of compoiinds with specific opiate antagonism.
The first product of this endeavor with clinical significance was the synthesis of
N-allylnormorphine (nalorphine).
As an antagonist, nalorphine was found to be much more potent than its
predecessor compounds. The presence of this antagonistic action led to its in-
vestigation in medical treatment as an antidote for overdosages of morphine and
morphine-like drugs with life-saving results. Subsequently, it was found that
nalorphine administered to an animal or man who had been made dependent on
morphine promi^tly precipitated an acute abstinence syndrome. This observation
in turn led to the investigation of nalorphine as a test for narcotic usage, "the
Nalline test," extensively used in California.
The clinical importance of nalorphine inspired chemists to seek even more
potent clinical analogues of these compounds with the result that by the 1960's
there was synthesized such compounds as levallorphan and naloxone (see attach-
ment No. 5). In the midsixties, other classes of compounds — not as closely related
to each other as the above — such as cyclazocine, weie foimd to have antagonistic
properties. With the continuing pharmacological and clinical investigations,
their comparative effects began to reveal their advantages and disadvantages.
Among the disadvantages in the chronic administration of some of these com-
pounds was their potential for inducing some degree of physical dependence of
their own, sedation or dysphoric effects, which -were governed by the narrowness
of the dosage range between the level of their therapeutic effectiveness and the
onset of their toxic symptoms. There was also the incidence of serious side effects
resulting from their initial administration; the effect of patients attempting to
skip a day or two as they resorted to the illicit use of an opiate; and the effects
resulting from the withdrawal of the particular antagonist employed.
From the standpoint of these potential hazards, naloxone appeared to be one
of the safest compormds and a pure antagonist, as revealed by the cl'nical studies
of Max Fink and his coworkers. With naloxone there has been remarkable absence
of troublesome side effects which have been associated with the use of other
antagonists, such as nalorphine and cyclazocine. Their side effects have ranged
from psychotomimet'c-like experiences to the feeling that one's thoughts were
following an uncontrolled racing course. Other manifestations of their dysphoric
impact have been an increased sense of impending death. On occasion the dysphoric
effects have been sufficiently disturbing and have occurred with a frequency that
made repeated administration difficult. Moreover, with both nalorphine and
cyclazocine there was some indication that discontinuation of these drugs was
associated with some degree of physical discomfort. However, Fink's studies had
also revealed a number of serious logistical obstacles to the use of naloxone as a
narcotic antagonist. This was the relatively high oral dosage required, namely
516
2,500 milligrams to obtain a 24-hour blockage and the problems this raised as to
the supply of the drug and its cost.
Nevertheless, despite these formidable oVjstacles, its pure antagonistic properties
suggested that naloxone might be effectively employed in reduced quantities
utilizing a system of partial blockade. This became the subject of the third study,
a pilot investigation in which the administration of a dosage of 200 milligrams on
a prophylactic basis was administered in the evening hours between 6 and 9 p.m.
On those occasions when evidence of opiate usage was found, the dosage was
increased to 800 milligrams. It was hypothesized that this dosage although only
providing a l)locking effect for a jieriod of 3 to .5 hours would nevertheless neutralize
the effect of opiate drugs administered during that part of the day in which the
individual was particularly vulnerable to drug use; namely his leisure hours.
In this study (the third), a population of parolees participating in the abstinence
program of the outpatient experimental clinic was utilized and over a period of 20
months (from September 1970 to May 1971), a total of 74 subjects were admitted
to the study. Of these, 23 were those who had V:)egun to display indications of an
increasing relapse into episodic or intermittent opiate usage while on the abstinence
program, and were facing the increasing possibility of being returned to a correc-
tional institution because of this violation of their parole. A second group of 51
subjects was made up of those individuals coming directly to the program from a
correctional institution, specifically selected because of their youthfulness and the
generally poor prognosis they faced in the usual therapeutic effort at this period
in their lives.
From among these 74 subjects a number of charts have been selected which
portra.y the course that both the transfers to the naloxone program follow as well
as the course pursued by those parolees admitted directly to the naloxone program.
(See attachment No. 6.) Inspection of these data reflects some of the problems
that are encoimtered in attempting to maintain these patients in this type of
program. The overall impression from these pilot observations, employing a system
of only partial blockade, was that those subjects who had begun to do i^oorly in
the abstinence program and were transferred to the naloxone program as a whole
had not done as well as those directly admitted to the naloxone program. On the
other hand, when the direct admissions to the naloxone i)rogram weie compared
with the achievements of the regular abstinence program subjects, as reflected by
the period of their retention in the program, there did not appear to be a difference
whose magnitude appeared significant. Yet, when it is realized that this was a
younger age group whose prognosis under ordinary circumstances would have been
bleak, this shift develops increasing significance which is further emphasized by the
fact that the system was employing only a partial blockade.
Over half (eight of fourteen or .57 percent) of the active patient population
currentlv being maintained on naloxone have shown no ]50sitive urine tests. The
range of program participation for these active cases is: 95 to 585 days; with the
average (M) length of participation was 274 days. Of the 51 patients admitted
directly to the naloxone program, 16 (32 percent) possess an abstinent record as
indicated by no positive urine samples. (However, in these 16 cases, despite no
positive urine samples, four of these patients absconded from the program and
two were returned to the correctional institution Ix-fore completing parole.)
Despite the uncertainty of these findings, there was no imcertainty about the
safety of the naloxone and the ease with which it can be administered (the
dosage raised or discontinued) without any ill effects. The surprising observation
was made that even in view of the subjects' awareness of the duration of the
neutralizing effects of naloxone, which became rather common knowledge through
their self-experimentation, there occurred, nevertheless, with the continuing
illicit use of opiates over a period of a few days the ]:)reci|)itation of a withdrawal
reaction of moderate tmcertainty. This reaction was cliaracterized by feelings of
nausea, vomiting, cramps, jitteriness, and feelings of faiutness which alerted the
patient to the increasing hazard that he was facing. There was also a clinical
impression that the continual administration of narcotic antagonists was in some
manner delaying or attenuating the onset of a physical denend'Micy reaction in
those subjects who wer(> resorting to the usage of narcotic drugs with increasing
frequency. This impression arose from the observation of the mildness of the
withdrawal symptoms in those parolees whose course had been suddenly inter-
rupted in the program by the return to a correctional institution because of this
violation of thi'ir jiarole.
These considerations and the necessity of providing increa.sed clarity as to their
significance led to the initiation of a fourth study — currently in i)rogress. This
study, a controlled one, has been initiated to determine precisely whether there
517
were any significant differences between subjects maintained on a partial system
of naloxone blockage; a group receiving a placebo; and a group attending the
experimental clinic, but receiving neither naloxone nor a placebo. The results of
this study will probably not be known for another 18 to 24 months.
Out of these endeavors there has begun to emerge yet another perspective as
to the more effective use of naloxone. As had been indicated earlier, the previous
study focused on the results of the parsimonious reduced dosage of naloxone
producing a continuing partial narcotic blockade. It would appear that this
system entails substantial amounts of naloxone usage as the drug is administered
over extended periods of time. The plan suggested itself that it might be more
meaningful to alter the therapeutic strategy by administering naloxone in high
(24-hour) blockage dosage only at those times when narcotic usage occurs, and
quickly terminating the administration of the narcotic antagonist when the
subject once more reverts to abstinence. Such a total blockade extending over a
24-hour period in which the high producing effects of the illicit opiate admin-
istration is sought would be completely neutralized. This system of naloxone
administration would be maintained until the stress-])roducing urge for the narcotic
experience has been ameliorated and the individual once more resuming his
abstinent course.
Obviously, a variety of responses to this form of therapeutic management may
be anticipated. These would range from the individual who deliberately absents
himself from the clinic in order to resort to his surreptitious administration of a
narcotic drug, to the individual who responds dramatically to the protection
provided by the narcotic antagonist as it carries him through a period of stress
bringing about his urge for the narcotic experience. There is no reason to believe
that the former consideration, namely the attempt to resort to unauthorized
absences, cannot be dealt with promptly and effectively, particularly in programs
entailing mandatory supervision. It can be anticipated on the l)asis of previous
experience that the great majoritj' of the subject population, despite their occa-
sional relapses from abstinence, will be cooperative toward taking the naloxone
medication. This cooperation in turn will be promptly rewarded by a prompt
discontinuation of the naloxone as the individual displaj^s his capacity to maintain
abstinence.
With this possibility in view, a number of recommendations are being made to
allow for a more vigorous exploration of the possibilities of employing this system
of treatment. One is that a vigorous effort be instituted to make larger supplies
of naloxone available to qualified clinical investigators in order that the explor-
ation of its therapeutic application may be more actively pursued. In order to
bring this about, it is recommended that a high priority be established for investi-
gating ways and means for increasing the supplies of thebaine, from which naloxone
is synthesized. With adequate supplies of naloxone it may be possible to manage
large numbers of patients whose only alternative to an abstinence program at the
present time is their maintenance on a narcotic drug such as methadone. With the
ability to manage patient populations on programs maintaining a high level of
abstinence, it may be that there will be opportunities for bringing about a re-
habilitation of the narcotic abuser by minimizing the need for maintenance on a
methadone program or the resort to illicit drugs. Moreover, it will also help to
ameliorate a hazardous state of affairs of the sociopathic individual whose nefarious
activities as a participant on a methadone program maj' only be enhanced with
their resultant deleterious consequences to the social structure.
In conclusion, it is my impression that the narcotic antagonists, particularly
naloxone, which may be a forerunner of even more potent com]3ounds of this
nature, hold a great deal of promise as a treatment modality, particularly in the
individual against whom society has had to deal punitively because of the criminal
activity associated with the procurement of drugs for his illicit use. The potential
of these compounds, the antagonists, should be actively investigated by an in-
creasing commitment of research activities in this area, with emphasis on their
priority. Hopefully, as more ample supplies of these drugs are made available, an
expansion of their clinical investigation can be carried out.
Attachment 1
Name. — Albert A. Kurland, place and date of birth: Wilkes-Barre, Pa., June 29,
1914.
Marital status. — Married, 1941.
Education. — Baltimore City College, 1932; Universitv of Maryland, B.S., 1936;
M.D., 1949.
518
Inlernship. — Sinai Hopital, Baltimore, Md., 1940-41.
Military service. — In the Armed Forces from 1941 to 1946. Positions held —
Battalion surgeon: Office of the psychiatric service of the Valley Forge General
Hospital. Attended the Arm.y School of ^Military Neuropsychiatry at the Mason
General Hospital. Awarded the Legion of Merit and the Combat Medical Badge.
Special training.- — Electroencephalography CArmy — 1945), research fellowship
in neuropsychiatry (Sinai Hosj^ital, Baltimore, Md., 1946-47), personal analysis
and attended courses at the Baltimore- Washington Psychoanalytic Institute
(1947-49).
Positions held.- — Psychiatrist part time in the mental hygiene clinic of the
Baltimore Regional Office, Veterans' Administration (1947-49) ; staff psychiatrist.
Spring Grove State Hospital, Catonsville, Md. (1949-53) : psychiatric consultant.
Fort George G. Meade, Maryland State Hospital (1950-51) ; psychiatric con-
sultant, Aberdeen Proving Grounds, Maryland Station Hospital (1951-52);
director of medical research. Spring Grove State Hospital, Catonsville, Md.
(1953-60) ; director of research. Friends of Psychiatric Research, Inc., Catonsville,
Md. (1953 to present) ; director of research, Maryland State Department of
Mental Hygiene (1960-67) ; director, Maryland State Psychiatric Research Center,
(1967-) ; assistant commissioner for research, Maryland State Department of
Mental Hygiene (1967-).
Certification. — In psychiatry by the American Board of Neurology and Psychi-
atry, 1951. Fellow of the American Psychiatric Association, 1955.
Societies. — American Medical Association, American Psj-chiatric Association,
Collegium Internationale Neuro-Psycho Pharmacologicum, Societ}^ for Psj'cho-
physiological Research, member, Council on Medical Television.
Societies. — Member, American College of Neurophyshopharmacology; member,
the Maryland Society for Medical Research: member, NIMH, Committee on
Clinical Drug Evaluation of the Psvchopharmacology Service Center (July 1,
1963, to June 30, 1967)).
Research publications. — A total of approximately 150 have been publi.shed over
the past 30 years.
Specific publications in the area of narcotic research up to the present time (10) :
Laboratory Control in the Treatment of the Narcotic Addict : Kurland, A. A.,
Ibanez, Ricardo, and Derby, I. M. Presented at 24th Annual Meeting of
Committee on Drug Addiction and Narcotics, National Academy of Sci-
ences, Washington, D.C., January 30, 1962.
A Practical Application of Thin-Layer Chromatography in Urinalysis for the
Detection of Narcotic Drugs: Kurland, A. A., Kolvoski, R. J. Presented
at third annual meeting of .\CNP, San Juan, P.R., December 15, 1965.
Urine Detection Tests in the Management of the Narcotic Addict: Kurland,
A. A., Wurmser, L., Kerman F. and Kokoski, R. J. .\mer. J. Psvchiat.,
122: Jan. 1966.
The Narcotic Addict — Some Reflections on Treatment: Kurland, A. A.
Maryland State Medical Journal, March 1966.
Laboratory Control in the Treatment of the Narcotic Addict: Kurland, A. A.,
Wurmser, L., and Kokoski, R. J. Curr. Psvchiat. Ther., volume 6: 243-
246, 1966.
Intermittent Patterns of Narcotic Usage: Kurland, A. A., Kerman, F.,
Wurmser, L., and Kokoski, R. J. Presented at fourth annual meeting of
ACNP, Puerto Rico, December 9, 1966.
The Deterrent Effect of Dailv Urine Analysis for Opiates in a Narcotic
Out-Patient Facility— A Two and One-half Year Study: Kurland, A. A.,
Wurmser, L., Kerman, F., and Kokoski, R. J. Presented at annual meeting.
NAS, Committee on Drug Addiction, Lexington, Ky., February 16,
1967.
Narcotic Detection by Thin-La.ver Chromatography in a Urine Screening
Program: Kokoski, R. J., Waitsman, E. S., Sands, F. L., and Kurland,
A. A. Presented at annual meeting. NAS, Committee on Problems of
Drug Denendence, Indianapolis, Ind., February 21, 196S.
Morphine Detection by Thin-Layer Chromotography in a Urine Screening
Program: A comparison of ion exchange resin loaded paper extraction with
direct solvent extraction: Kokoski, R. J., Sands, F. L., and Kurland, A. A.
Presented at 31st aiuiual meeting of the Committee on Problems of Drug
Dependence, NAS-NRC, Palo Alto, Calif., Feb. 2.5-26, 1969.
The Out-Patient ManagerncTit of the Paroled Narcotic .\buser — A 4- Year
Evaluation: Kurland, A. A., Bass, G. A., Kerman, F., and Kokoski. R. J.
Presented at 31st annual meeting of the Committee on Problems of Drug
Dependence, NAS-NRC, Palo Alto, Calif., Feb. 25-26, 1969.
519
The Deceptive Communication and the Narcotic Abuser: Kurland, A. A.
Rutgers Symposium on Comnnmication and Drug Abuse, Sept. 3-5, 1969.
Rutgers University, The State University of New Jersey, New Brunswick,
N.J.
The Out-Patient Management of the Narcotic Addict: Kurland, A. A. In
Perry Bhick (Ed.) Drugs and the Brain. Baltimore, Md.: The Johns
Hopkins Press, 1969, pp. 363-370.
The Daily Testing of Urine for Opiates as a Deterrent to Opiate Usage. The
Results of a .VYear Study: Kurland, A. A., Kokoski, R., Kerman, F., and
Bass, G. A. Presented at 32d annual meeting of the Committee on Prob-
lems of Drug Dependence, NAS-NRC, Washington, D.C., Feb. 16-18,
1970. (Published in 1970 Report, pp. 6719-6730.)
N-allyl-14-hydroxydihydronormorphinone (Naloxone) in the Management of
the Narcotic Abuser. A Pilot Study: Kurland, A. A., and Kermai, F.
Presented at the 33d annual meeting of the Committee on Problems of
Drug Dependence, NAS-NRC, Toronto, Ontario, Canada, Feb. 16-17,
1971.
Attachment No. 2
[Reprinted Froui the American Journal of P.sychiatr.v. vol. 122. No. 7, January 1966]
Urine Detection Tests in the Man.\gement of the Narcotic Addict
(By Albert A. Kurland, M.D., Leon Wurmser, M.D., Frances Kerman, R.N.,
and Robert Kokoski, Ph. D.)
The focus of this study was the data originating from the daily analysis of urine
of narcotic users being treated in an inpatient and outpatient setting. This infor-
mation has provided impressions suggesting certain treatment approaches which
may provide for their more effectiv-e management. The inpatient group was made
up of court-referred narcotic addicts and patients seeking voluntary admission to
the Spring Grove State Hospital because of narcotic addiction. The outpatient
group was made up of parolees from the correctional institutions of Maryland who
had been penalized for their use of narcotics.
The background and history of the role of laboratory control in the supervision of
the narcotic addict are relatively brief. Until 10 years ago the only means available
to the clinician for ascertaining the addict's use of narcotics were his clinical
observations and complex, time-consuming laboratory procedures for analyzing
urine for narcotics.
The introduction in California of nalorphine testing (the measurement of a
pupillary response following the administration of a single dose of this drug) in
I9r)~) as a medicolegal procedure in testing convicted narcotic users on parole or
probation to determine their abstinence from narcotics opened up a new approach
in the attempts to control the ingestion of narcotic drugs (5, 6, 7). By 1962, over
6,000 nalorphine injections were being administered per month (9, 10). The test
will yield a negative result if it has been preceded by a drug-free period of 24 to 48
hours, or if a drug that produces a dilatation of the pupil has been administered
prior to the test procedure. Also, the test is not as accurate or sensitive as chemical
tests for narcotics in urine (•?, 4). Nevertheless, nalorphine testing was thought to
be useful by the parole and probation officers (.9, 10). It was their impression that
although the potential for addiction remains, the problem is contained. However,
Terry and Teixeira {10) were not able to make a conclusive statement on this
when they summarized their impressions in 1962 after having observed the use of
the test in California for several years.
METHOD
Our own experience with the management of the narcotic addict began in 1960
with court-referred narcotic addicts who came to the hospital for diagnostic study
and treatment. In an effort to determine the patient's receptivity toward treat-
ment, we attempted to determine his freedom from narcotics on a daily basis.
For this purpose nalorphine testing was not feasible, but a spot test for narcotics
in urine was employed. This procedure, the Motley spot test {8), was accepted as
being neither sensitive nor specifically reliable. However, the test was helpful in
alerting the hospital staff to possible breaches of abstinence and emphasized the
usefulness of this type of assessment. In January 1964, the Motley test was
46
100.0
22
47.8
9
19.6
11
23.9
4
8.7
520
replaced by the much more sensitive and accurate procedure of thin-layer
chromatograph}' for detecting narcotics {2) . This type of analysis will detect the
administration of as little as 15 milligrams for a period up to 36 hours.
RESULTS
Court-referred narcotic addicts. A sequential presentation ot the clinical impres-
sions resulting from the dailj' analysis of urine begins with the court-referred
narcotic addicts. These studies extend from 1960 to 1964, inclusive. During this
period 46 male narcotic addicts were referred. Their periods of hospitalization
ranged from a minimum of 1 month to over a year in some cases. Little could be
provided in terms of treatment other than the routine care available in a state
psj'chiatric hospital. Against this background an attemjit was made to assess the
deterrent effect of a daily urine analysis. The meager results are indicated in table
1. Inly 11 m;inaged to remain sufficiently motivated and coojjerative to reach a
point in their hospitalization where they could be recommended for discharge
and referral to an outpatient clinic. Only two of these 11 patients reported to an
outpatient clinic for continuing treatment, although all had been referred. The
remaining patients were either returned to the court because of their continued
sociopathic acting out such as drug usage, disinterest, resistance to hospital
routines, lack of motivation and attempts to elope from the hospital. During
hospitalization, each patient at one time or another j'ielded a positive reaction for
narcotics.
TABLE 1.— DISPOSITION OF COURT-REFERRED NARCOTIC PATIENTS
Number Percent
Referrals, 1960 to 1964 inclusive -.. - -
Ret u rned to cou rt .,.^.
Eloped from hospital IJ./.'.L'.
Discharged from hospital ' --
In hospital, ^.
The presence of a positive reaction was not brought to the attention of the
patient during the phase of study (1960-63) in which the Motley spot test had
been utilized, since there was uncertainty concerning its reliability. Following the
introduction of thin-layer chromatography, they were informed, but this did not
appear to influence the occurrence of sporadic narcotic usage.
Voluntary narcotic admissionf!. — As attempts to treat the narcotic patient at the
Spring Grove State Hospital became public knowledge in the metropolitan
Baltimore area, more requests were made to enter the hospital on a vohmtarj-
basis. It was soon observed that the great majorit,v of such patients stayed a
relatively short period of time (see table 2), the hospital being utilized primarily
for detoxifying purposes. Very few of these patients displayed withdrawal sympto-
matology which could be considered of moderate severity. The initiation of
urinalysis for opiates by thin-layer chromatography of all admissions in 1964
revealed the rather puzzling observation that 24 percent of the patients were
negative for opiates on admission (see table 2). A review of the case histories of the
patients with multiple admissions seemed to indicate that their hospitalization
had little effect on their subsequent usage of drugs.
TABLE 2.— CHARACTERISTICS OF VOLUNTARILY ADMITTED NARCOTIC PATIENTS
Number Percent
Admissions (Jan. 1, 1964 to Dec. 31, 1964) ,.
Patients without symptoms ot withdrawal .'...'....'j ......
Patients with negative urine on admission.. .--
Patients with previous admissions ^-.
Patients remaining 1 week or less
The lirief stay of the voluntary narcotic addict confronted the hos])ital adminis-
tration with a question as to the significance of the theraixMitic coutact. This led
to an attempt to obtain more control over these patients. It was anticii)ated that
this would result in a longer stay and jji-ovide an opportunity for increased thera-
peutic effort. The hospital administration began to request the use of court orders
54
100
26
48.1
13
24.1
9
16.7
26
48.1
52)1
and medical certificates on those patients with a history of multiple admissions
seeking readmission. The wisdom of this was imcertain, since, as time went on, it
became more apparent that the hospital did render assistance to these patients by
allowing some degree of detoxification to occur, thus preventing a compounding
of their difficulties and perhaps allaying the development of a state of panic with
the resultant acting out of additional antisocial behaviour.
Parolees from correctional institulions (the outpatient group). — In order to investi-
gate the deterrent effect of daily laboratory control in an outside environment,
arrangements were made with the Deimrtment of Parole and Probation of the
State of Maryland to select inmates with a history of narcotic usage or addiction
whose homes were in Baltimore City and who would agree to accept the condi-
tions of parole associated with this experimental program. The conditions were:
Daily attendance at the clinic to provide a urine specimen, attendance at the
weekly group psychotherapy meetings, maintenanace of a job and complianc
with the other usual parole requirements.
On release, the patient reported to the clinic within a day or two. In the clinic
he was seen initially in an individual interview by the psychiatrist and informed
of the schedule he was to follow in providing his urine specimens. The importance
of dailv attendance at the clinic for the purpose of providing a urine specimen
was also emphasized. In the event of illness or emergency, the patients were
instructed to telephone and give the reason for their absence and these absences
were reported to the probation officer on the following morning. The readiness
with which these patients gave in to minor illnesses and the unending excuses
presented concerning the difficulties they encountered in getting to the clinic
made it necessary to take the position that an unauthorized absence would be
considered as equivalent to a positive reaction.
This unit, which came to be known as the narcotic addiction clinic, began to
function in June 1964. In its first 10 months of operation from June 1964 to
April 1965, a total of 31 patients were referred to the cUnic. Of these, two never
reached the clinic. They apparently obtained narcotics immediately after release
from the correctional institution and died from an overdose. The remaining 29
patients have attended the clinic for varying periods of time ranging from a few
weeks to 9 months. Six of these 29 patients have had to be referred back to a
correctional institution as control failures after varying periods of time in the
clinic ranging from 3 weeks to 9 months, and two have absconded.
The overwhelming majority of these patients fell in the sociopathic diagnostic
category. They presented histories of narcotics usage over varying periods of time
and many had previous arrests for narcotic violations. Their response to the
program was evaluated from several standpoints, namely: Laboratory control,
the meaningfulness and course of the group therapy and the impact of this
program on the probation officer.
Laboratory con^r-o/.— Initially, the urine testing was on a daily basis. This fre-
quency was decreased depending upon the level of abstinence achieved by the
patient; there was usually a "night oflf" after several weeks in which his record
had remained "clean." Specimens were collected under direct observation by a
psychiatric aide and delivered to the laboratory for analysis the next day. A
breach in the abstinence of a patient was promptly brought to the deviant's
attention by the probation officer and in the weekly meeting with the psychiatrist.
The occurrence of these deviations raised many challenges in terms of the course
to be taken with the patient. He was informed of the laboratory findings and asked
for an explanation of his drug use. The decision as to the patient's subsequent
course in the program rested on the degree of control he was manifesting over a
10-day period with day one beginning with a deviation. If over a 10-day period
the breaches reached a level of 50 percent, the patient was taken into custody by
the parole oflScer and returned to a correctional institution. Often a decision could
not be made as to whether the patient should remain in the program or l)e returned
to the correctional institution since the patient would again reestablish his control.
In most cases he was allowed to remain in the program. Subsequently, some of
these did well for a time while others decompensated again and had to be returned.
The problem of the failing patient raised many issues. One was whether the
patient should be transferred to a hospital or retruned to a correctional institution.
It was decided for the time being that all failures would be returned to a correc-
tional institution. This decision was based to a large extent on the meager thera-
peutic achievements resulting in the court-referred narcotic addicts and the ex-
periences with the voluntary admissions group. There was also the feeling that the
correctional institution could provide greater work and rehabilitative opportunities
522
than a State psychiatric hospital for this t\-pe of pcrsonahty, since the great
majority of these patients refused to see themselves as sick. Furthermore, for some
of the patients, the hospital setting led to development of unrealistic therapeutic
expectations. Their subsequent disappointment tended to reinforce their ever-
present antogonisms while increasing their sense of the liopelessness relative to
any attempt to treat their addiction.
Group therapy. — The group psychotherapy sessions turned out to be a helpful
medium for the psychiatrist to obtain a better understanding of the patient. A
group just getting underway was one in which there was a great deal of discussion
about drugs, their urge for drugs, complaints, and many demands and expressions
that the doctor do something for them rather than that thej' do something for
themselves. Subsequently, as a group identification mechanism began to malie
itself apparent, discussions evolved which generated much feeling concerning
their living and working conditions and their family problems. An increased sense
of awareness developed, relative to the significance of the discussions of their
problems, which frequently found expression in such remarks as, "After talking
about this last week I wasn't angry anymore." Some of the members dropped out
of the group, with a subsequent return to a correctional institution. The remaining
members seemed to focus on the more complex aspects of their immaturity and
impulsiveness. The therapist's attempts to point out some of their manipulative
behavior and channel their thinking into approaches which might provide some
insight seemed to become more meaningful.
The parole officer. — The parole officer made arrangements with the parolees to
see them once weekl3^ However, the occurrence of a positive reaction or an un-
authorized absence from the clinic led to an immediate confrontation as soon as an
interview could be arranged. Continuing failure to complj-- with the program at a
level which was considered satisfactory (and this varied somewhat from patient
to patient) could lead to the patient's return to the correctional institution.
The most difficult issue confronting the parole officer was the return of the bread-
winner of a family to a correctional facility. Quite often his release had resulted in
his family being taken off the relief rolls. In addition, the patient might be doing
quite well on the job and getting along with his famil.v. It was especially difficult
to make a decision in some of these cases, particularly when the decompensation
had been gradual and occurred only over a rather long period of time. However, as
the frequency of narcotic usage increased and the possibility of physical dependence
became accentuated, a decision was made to return the indiviudal to a correctional
institutioi' .
DISCUSSION
The attempts to achieve maintenance of abstinence in the narcotic addict or
user have in the great majority of such patients been so imrewarding that con-
troversy still continues relative to the usefulness of this concept {1, 11). This is
emphasized by the observations in the study; namely, that sporadic deviations
occurred in practically all. However, the observation that laboratory control
seemed to be of value in helping many of the parolees quickly regain their control
and in extending their period of abstinence was repeatedly made. This program,
which required an almost dailj^ report on themselves, nevertheless allowed the
patients on parole to carry out their daily lives in the context of their social setting,
famil}^ and work relationships. It was found that such control could be carried
out over a period of months, as indicated by the duration of this study to date.
Many of the patients, in their efforts to bypass this system of control, oc-
casionally reverted to alcohol, amphetamines, and barbiturates. The degree to
which these were utilized in dealing with their recurrent dysphoric states is as yet
not known. As far as could be learned during the present period of study, even as
the narcotic exit was being closed, there did not appear to be any increased anti-
social behavior in terms of further arrests or infractions of the law. On the other
hand, this does not mean that while these patients were restricting tlieir usage of
narcotic drugs the.y did not have disturbances in their social relationships, work
activities, and within themselves.
The opportunities for stud.ving nascent deviant behavior in drug users have not
been as rewarding as anticipated. This may be due to the fact that the processes
involved may be much more conqjlex than is superficially indicated by the banality
of the explanations offered and the difficulties in probing beyond these. While
confrontation of the patient with a deviation from abstinence in most instances
523
brought back a return to abstinence, there were patients who ultimate!}' de-
compensated and in whom this repeated confrontation seemed to lose its impact.
The factors responsible for this are as yet not clearlj- understood.
Although our experience is still limited, there is evidence that a deterrent effect
is being exerted. This is indicated by the subjective expressions of the participants
in the outpatient group. It was repeatedly pointed out by many of the participants
that without this progi'am the.v would be back on narcotics. It helped them by
implementing their own control. The procedure also gave them security in protect-
ing them from cliallenges by the police concerning their abstinence. Objectively,
this deterrent effect could also be seen in the rapidity with which control was
regained in many patients who sporadically deviated. Fmall\', there was the ever-
present threat, which cannot be discounted, of being returned to a correctional
institution.
CONCLUSION
The use of laboratory testing of urine obtained daily in an inpatient and out-
jjatient setting indicated sporadic consumption of drugs in practicall}' all patients.
The outpatient group, despite their exposiu-e to all the factors in an environment
which might create pressure for drug usage, seemed to oflfer the most promising
possibilities for management. The laboratory data also indicate varying and
fluctuating degrees of control which offer a point of departure of new studies.
ACKNOWLEDGMENTS
Acknowledgments are made to the following for their assistance, cooperation,
and services, without which this project coidd not have been carried out: Dr.
Isadore Tuerk, commissioner. Department of ^Mental Hygiene, State of Maryland;
Mr. Paul Wolman, director. Department of Parole and Probation; Mr. John \ .
Rohr, probation officer assigned to this project; and the facilities of the Crowns-
ville Outpatient Clinic, under the supervision for Dr. Addison Pope.
REFERENCES
(1) Chein, I., Gerard, D. L., Lee, R. S., and Rosenfeld, E.: The Road to H:
Narcotics, Delinquency and Social Policy. New York: Basic Books, 1964.
(2) Cochin, J., and Daly, J. W.: Rapid Identification of Analgesic Drugs in Urine
with Thin-laver Chromatography, Experientia 18:29, 1962.
(5) Elliott, H. W.,'Nomof, N., Parker, K., Dewey, M., and Way, E. L.: Com-
parison of the Nalorphine Test and Urinarv Analysis in the Detection of
Narcotic Use, Clin. Pharmacol. Ther. 5:405-513, 1964.
(4) Elliott, H. W., aiid Way, E. L.: Effect of Narcotic Antagonists on the Pupil
Diameter of Non-addicts, Clin. Pharmacol. Ther. 2:713, 1961.
(5) Foldes, F. F.: The Human Pharmacology and Clinical Use of Narcotic
Antagonists, Med. Clin. N. Amer. 48:421-443, 1964.
(6) Eraser, H. F.: Human Pharmacology and Clinical Uses of Nalorphine (N-
Allyinormorphine), Med. Clin. N. Amer. 41:383-403, 1957.
(7) Halbaeh, H., and Eddy, N. B.: Tests for Addiction (Chronic Intoxication)
of Morphine Type, Bull. WHO 28:139-173, 1963.
(5) Kolmer, J. A., and Boerner, R.: Approved Laboratory Technique. New
York: Appleton-Century-Crofts, 1945.
(9) Poze, S. R.: Opiate Addiction I. The Nalorphine Test II: Current Concepts
of Treatment, Stanford Med. Bull. 20:1-23, 1962.
(10) Terry, J. G., and Teixeria, T. C: Nalorphine Testing for Illegal Use in
California: Methods and Limitations, J. New Drugs 2:206-210, 1962.
(11) Zusman, J.: A Brief History of the Narcotics Control Controversy, Ment.
Hyg. 45:383-388, 1961.
Attachment No. 3
The D.\ily Testing of Urine for Opiates as a Deterrent to Opiate Usage:
THE Results of a 5- Year Study (Supported by Public Health Service
Grant No. 07616, N.ational Institute of Mental Health, and All Pur-
pose Grant No. RR-05.546, Administered by Friends of Psychiatric
Research, Inc.)
(By Albert A. Kurland, M.D. (Director of Research, Maryland Psychiatric
Research Center, and Assistant Commissioner for Research, Marjland State
524
Department of Mental Hygiene), Roljert Kokoski, Ph. D. (Chief, Drug Abuse
Laboratory, Friends of Psychiatric Research, Inc.), Frances Kerman, R.N.
(Research Nurse, Outpatient Narcotic Clinic, Friends of Psychiatric Re-
search, Inc.), and Gene A. Bass, M.S. (Research Psychologist, Outpatient
Narcotic Clinic, Friends of Psychiatric Research, Inc.), Maryland Psychiatric
Research Center, Baltimore, Md.
(Presented at 32d annual meeting of the Committee on Problems of Drug De-
pendence, National Academy of Sciences-National Research Council, Wash-
ington, D.C., February 16-18, 1970)
INTRODUCTION
Narcotic abusers remain a formidable management and theraputic problem.
Contributing to this difficulty in no small measure is their continuing to resort to
manipulative and deceptive behavior in their efforts to conceal their deviant
behavior (1). The development of techniques for detecting the deviant behavior
relating to narcotic abuse through the testing of opiates in the body fluids has
focused attention on the possibility of controlling such behavior through the use
of daily monitoring. This study, initiated in June 1964, on a group of subjects
with a history of narcotic abuse over whom mandator}^ supervision could be main-
tained, employed this approach. From time to time during the period from June 1,
1964, to May 31, 1969, progress reports have been submitted (^-5), with the
present report summarizing the experiences with this system of management
over this 5-year period.
METHODOLOGY
The subject participating in this study came from the correctional institutions
of Maryland and were limited to those residing in Baltimore. They were referred
to a special outpatient clinic operating only in the evening hours between 6 and
9 p.m., 7 days a week. The treatment program consisted of supervision by parole
agents, the maintenance of abstinence, daily monitoring for opiate usage, with an
incident of use resulting in a confrontation, and weekly sessions of open-ended
group psychotherapy.
The parolees were from working class families primarily, and were composed
of a mixture of approximately 40 percent whites and 60 percent blacks. Their
ages ranged from 17 to 53, with most in the 20-30 age bracket. With few excep-
tions, the educational level was some degree of high school education or less. In
a relatively small number of subjects there were episodes of alcoholism. Occa-
sionally, a few resorted to the use of other drugs, such as the amphetamines or
barbiturates.
Supported by Pubhc Health Service Grant No. 07616, National Institute of
Mental Health, and All Purpose Grant No. RR-05546, administered by Friends
of Psychiatric Research, Inc.:
( 1) Director of research, Maryland Psychiatric Research Center, and assist-
ant commissioner for research, INIaryland State Department of IMental
Hygiene.
(2) Chief, Drug Abuse Laboratory, Friends of Psychiatric Research, Inc.
(3) Research nurse, Out-Patient Narcotic Chnic, Friends of Psychiatric
Research, Inc.
(4) Research psychologist, Out-Patient Narcotic Clinic, Friends of Psychi-
atric Research, Inc.
The monitoring tochniciue employed the collection of daily urine specimens
obtained under direct observation by trusted attendants. These were analyzed,
employing thin layer chromatography (6). A positive urine test led to the parolee
being confronted by the parole officer, usually within 48 hours, and a brief inter-
view with the clinic psychologist or one of the attending psychiatrists. If, despite
these challenges, the individual persisted in the intermittent usage of opiates
and this exceeded the clinical tolerance level of the program, the subject was
returned to a correctional institution. This tolerance level had been established
as the occurrence of five positive urine tests within any 10-day period. The parolees
were never informed of this criterion, since this would have implied an allowance
of a limited amount of opiate usage. They were aware, however, that the sporadic
utilization of a narcotic did not result in their immediate return to a correctional
institution.
DATA
An opportunity to determine on a daily basis the presence or absence of the
U.SC of narcotic drugs as the subject moved from a relatively drug-free environ-
525-
ment into the free society, made it possible to construct a number of charts as to
the course the sub.ject pursued in the study. The following have been selected to
provide a perspective on a number of issues that emerged from the data generated
by the study:
Table 1 — Course in program.
Table 2— Failure: trend.
Table 3 — The occurrence of the first positive test for opiates.
Table 4 — First positive test for opiate use and subsequent course.
Table 5 — Subjects maintaining complete abstinence.
Table 6 — Subjects achieving expiration of parole during first admi.ssion.
Table 7 — Subjects remaining in program for 6 months or longer.
Table 8 — Subjects achieving expiration of parole during second admission.
Table 9 — A subject achieving expiration of parole on a third admission.
Table 10 — -Comparison of older and younger subjects as to their stay in
program.
TABLE 1.— COURSE IN PROGRAM
Year 1st 2d 3d 4th 5th Totals
First admissions .^...
Readmissions. ...„'—.. — .:..
Total admissions.. -..
Total in program '_..
Total days in program
Average daily census..
Average participation, in days^
Parole expired
As 1st admission, 29 ..-...'."..L.
As 2d admission, 12 --. _-_
As 3d admission, 0. _
Returnees 6 49 66 62 30 213
As 1st admission, 148
As 2d admission, 53_
As 3d adinission, 12
Absconders -. -. 5 17 49 46 30 147
As 1st admission, 97 _
As 2d admission, 39 .-_
As 3d admission, 8
As 4th admission, 3 _
Newarrests 1 6 7 9 8 31
Deaths 0 0 0 2 1 3
43
63
112
111
48
68
32
397
0
25
50
155
43
43
4, 764
88
118
11,315
31.5
95
6
162
196
21,857
59.6
111
9
159
223
25, 565
69.3
114
10
100
171 ...
28,064 ...
552
13.2
110
0
82 ...
164 ...
16
"■"^Tf
1 Subjects whose period of participation extended into a subsequent year utilizing the 1st of June as a dividing line were
counted as a new subject for that year beginning with June 1, 1964, to IVlay 31, 1965, as the 1st year.
2 This figure was obtained by dividing the number of subjects for the year into the total number of days for the year.
TABLE 2.— FAILURE: TREND
Year Subjects i Failures' Percentage
2d 118 66 55.8
3d 196 115 58.5
4th 223 108 48.4
5th ..... 171 60 35.1
' The total number of subjects in the program and is obtained by totaling the new adminissions, readmissions, and the
carryover from the previous year.
2 Those returned to prison for failure to maintain abstinence or absconding.
60-296— 71— pt. 2 13
TABLE 3— COMPARISON OF THE 1ST POSITIVE TEST FOR OPIATES IN 300 ISl ADMISSIONS
1st 100
2d 100
3d 100
Positive reaction within day:
1st 4 weeks:
lto7
8to 14..
15 to 21
22 to 28
2d 4 weeks:
29 to 35
36 to 42.
43 to 49.
50 to 56..
3d 4 weeks:
57 to 63
64 to 70..
71 to77_
78 to 84.
Total
44
46
33
11
22
13
4
6
8
7
3
5
4
4
3
5
2
10
4
1
4
0
2
1
1
1
2
1
1
3
4
2
1
0
4
1
85
94
84
TABLE 4.-RELATI0NSHIP BETWEEN 1ST POSITIVE TEST FOR OPIATES AND SUBSEQUENT COURSE
Discharges from program— 1st admissions (397)
1st positive test for opiate usage i
administered)
(1st 300
Returned to
prison for
narcotic use
Absconders
Othe
rsi
Total
Days
Number
Percent
Percent
0to28
202
40
21
67.3
13.3
7.0
17
17
18
22
20
13
2
5
6
41
42
37
10.3
29 to 56
10.5
57 to 84
9.3
weeks...
Total 12
263
87.7
52
55
13
120
30.1
1 Removed because of violation of parole or new arrest.
TABLE 5.— PAROLEES MAINTAINING COMPLETE ABSTINENCE UNTIL EXPIRATION OF PAROLE
Parolee
Age
Days>
Positives
Absences Foliowup
142.
128.
308.
274.
160.
158.
190.
361.
2....
413.
264.
200.
24
883
0
0
27
866
0
5
29
651
0
0
38
594
0
6
27
571
0
0
44
544
0
1
22
522
414
0
9
26
0
1
24
393
0
0
22
359
0
0
29
257
0
1
40
220
0
3
On methadone.
Doing well.
Do.
Using drugs.
Doing well.
Using drugs.
Doing well.
< Table is arranged from the longest to the least period of abstinence in days.
TABLE 6.— IN PROGRAM 6 MONTHS OR LONGER
As 1st admission 135
As 2d admission 20
As 3d admission.. 3
52i7
TABLE 7.— EXPIRATION OF PAROLE ON 1ST ADMISSION
Parolee
Age
Days
Positives
Absences Followup
142.
113.
128.
29.
22.
105.
308.
274.
160.
298.
247.
158.
190.
77..
34_.
185..
144..
361..
2..
413_.
278..
337..
4..
429_.
264..
55..
200..
82..
229..
24
883
0
5
30
869
17
36
Doing well; drug free.
27
866
0
5
23
764
2
12
27
762
39
18
Doing well; drug free.
23
677
27
7
On a methadone program
29
651
0
0
38
594
0
6
27
571
0
0
25
556
3
0
Returned to drug use.
21
554
30
13
44
544
0
1
22
522
0
9
33
520
6
5
In correctional institution,
30
493
22
37
21
741
48
3
Doing well.
42
467
7
0
26
414
0
1
24
393
0
0
22
359
0
0
39
355
4
22
Doing well.
25
347
4
5
35
328
32
42
Readmitted to program.
21
295
2
1
29
257
0
1
24
246
28
3
40
220
0
3
38
183
13
2
22
126
31
5
TABLE 8.— EXPIRATION OF PAROLE-ON 2D ADMISSION
Course, 1st admission
Course, 2d admission
Parolee
Age Days Positives Absences Days Positives Absences Followup
(74)126B 37 119 4 5 1,015 2
(11)44B. 27 159 25 31 243 8
(348)477B 29 16 8 0 238 2
(354)5046 25 323 22 9 132 3
(109)3526 29 456 40 20 119 19
(373)5196 20 185 1 2 107 4
(103)2936. 28 415 42 7 104 12
(123)2056 24 134 25 3 91 7
(6)686. 23 399 31 36 79 3
(26)896. 22 136 18 13 52 6
(147)2596 32 157 10 3 42 15
(24)1306 32 445 26 27 38 5
Note: Number in parenthesis refers to 1st admission.
TABLE 9.— EXPIRATION OF PAROLE-ON 3D ADMISSION
5 Returned to drugs.
33 On methadone.
2 Doing well.
1
4
0
2
0
0
6
0
2
Parolee 463C
Age
Days
Positives Absences
Course on 1st admission
27
28
28
184
11
36
11 11
5 2
10 1
Course on 2d admission
Course on 3d admission
--
TABLE 10.-RELATIONSHIP OF AGE TO DAYS IN PROGRAM (AS 1ST ADMISSION)
Parolee
Age
Days
Pos.
Abs. Average.!
17 to 23 year age group (N=45):
385
135..... _.
368..
48
492
230
440
See footnote at end of table.
17
17
17
18
18
18
18
18
420
125
169
226
58
56
0
30
9
29
10
8
2
10 1^=3-
^\ |Average= 187.67.
3 In =4.
1 fAverage= 127.25.
4
528
TABLE 10— RELATIONSHIP OF AGE TO DAYS IN PROGRAM (AS 1ST ADMISSION)— Continued
Parolee
Age
Days
Pos.
Abs. Average '
e group (N=45)—
17 to 23 year ag
Continued
84 ..■:
19
19
49
121
6
6
4
4
502
390
19
74
11
0
256 pJ
.ryr-li ■; 1- ---
19
58
8
7
240
J^_ --'--
19
32
15
6
373 -
19
185
1
2
N = 12.
411
19
19
10
0
Average = 129.67.
28-
19
86
9
11
289.......
19
552
1
2
481
19
278
0
0
251
19
66
14
1
335
19
36
20
4
184..
20
21
0
8
327
\i
20
10
0
4
333
. ;.-'-r!..?
20
641
28
3
193.
20
469
7
3
288
20
73
18
8
154.
20
21
2
7
295
20
92
20
8
529
20
89
0
0
N-17
38.
479
20
20
86
17
18
3
9
6
Average=152.41.
371
20
548
0
4
392
20
95
1
4
296
20
140
19
15
320
20
98
8
8
56
20
42
16
3
30
20
139
21
8
431
20
10
4
0
406
21
39
13
0
324
21
142
3
3
247
21
554
30
13
28
21
136
18
13
I\J— Q
31
323..
21
21
149
649
8
0
^l /Average=255.55.
185
21
471
48
^ 1
272..
.^^?::S-.
21
81
9
^
299
ge group (N=44):
21
79
5
5 1
35- to 53-year a
366
53
108
1
0) N=2.
312
47
267
10
Ot Average=187.50.
168
46
22
11
1
546
44
25
0
0 N=4.
151
44
1,030 .....
Average=405.25.
158
44
544
6
1
319
43
98
0
11^
116
43
71
13
4
144
42
467
7
0
302
42
524
11
U
283
42
448
4
2
153
42
20
11
3
2
1
N = 12.
908
41
41
33
86
0
10
Average =239.42.
360
397_.
41
284
11
4
200
40
220
0
3
233
40
578
28
8
459
40
39
8
8
454.
39
9
6
2
278
39
355
4
22
or-
281
39
39
150
U
0
1
486
39
274
38
594
0
8
82
38
183
13
2
221
38
365
32
16
245
38
16
12
0
N-17
248
531
38
38
170
72
0
1
6
0
Average =220.41.
74
fc ' '<IcUi.'--'^-i---
37
37
37
119
10
1,062
4
1
5
8
136
137
0
6
176 L
..jjA..^:iA
37
127
»SA 5
6
422
37
37
437
19
1
0
0
0
547
380
37
20
13
2
59
-'rrsDV|-.-
37
259
31
12
23 ,
81 1
36
36
113
29
26
5
10
9
131
iji
36
51
8
3
N— 9
156
534 .
36
36
35
252
8
32
15
0
13
15
5
4
Average=152.44.
231
1 •
469
36
321
0
, 1
472
36
307
0-
"' 1/
'In days.
J
929
DISCUSSION
' 1 i J
Although the approach was originallj^ delineated as a studj' in deterrence, it
became apparent as the study progressed that other elements were playing a role,
the impact of which would be difficult to define without a control group of non-
monitored subjects. Although this was considered, it was not attempted because
the scope of the problems were bej'ond our capabilitj^ Nevertheless, from the data
elicited it was possible to obtain an overall view as to the courses the subjects
followed. From this information, year by year comparisons were made, as shown
in table 1. These comparisons displayed changes indicating that the program was
becoming progressively effective in retaining the subjects for increasing periods
of time. This was manifested in several ways, namely, that despite a growing
average daily census, there were decreasing numl^ers of subjects returned to a
correctional institution because of additional narcotic abuse or absconding from
the program. There was also the fact that the number of new arrests remained
relatively low and were nondrug related. Considering the highly recidivistic nature
of the group, this appeared to be an encoui-aging development. In the three deaths
reported, all were accidental and not associated with the use of narcotic drugs.
The comparative data of table 1 were analyzed in table 2 from the standpoint
of comparing the total number of admissions to the program with the failures.
The total number of admissions included new admissions, readmissions and the
number carried over in the program from the preceding year. The failures were
composed of returnees to the correctional institutions because of increasing drug
usage, and the absconders who were disqualified for any further acceptance. In
calculating the percentage of the failures in relation to the total number of ad-
missions, the percentage gradually decreased over the fourth and fifth years.
This would seem to suggest tiiat the program was becoming much more effective
in retaining subjects, since no changes had been made from the original experi-
mental design.
With the opportunity to determine on a daily basis the use of narcotic drugs,
a question arose as to the relationship between the occurrence of the first positive
test and subsequent course. Table 3 compares the occurrence of the first positive
test for opiates in 300 first admissions. The interesting observation was made
that this occurs in a very liigh percentage of the subjects within the first 12 weeks
following their release. No definite explanation for this behavior has been de-
lineated, although the phenomenon has been attributed to a variety of factors,
such as a need to celebrate release from custody; reassurance that response to the
drug effect has not changed ; and to reinstate their social relationships. Surprisingly,
there is little overt expression of any initial anxietj^ over the problems thej^ faced
in reintegrating themselves into the community.
With the high incidence of an earh- initial exposure, it became of interest to
compare this event with the incidence of failure in the program over the first
3 months. Evaluation of the data from this aspect revealed a failure rate for the
first 3 months averaging approximately 10 percent per month. This would appear
to indicate that most of the subjects were making some effort to control their
desire for the drug experience. The 10 percent that immediately relapsed, of course,
raises questions as to their motivation or the presence of other factors. These
experiences emphasized the critical significance of the first few months in the
program and the necessity of intensive scrutiny and study for a more detailed
clarification of those factors bringing this about and their resolution.
The number of parolees who managed to maintain complete abstinence during
the period of ])articipation in the program was very small. Table 5 tabulates the
course of the 12 subjects out of the 397 first admissions who managed to achieve
this. There was little in this initial approach to suggest any special factors as
contributing to their course. The issue, however, is complicated in that a number
of subjects regressed once they left the program, and the length of participation
in the program seemed to have no significant relationship to this occurrence. ^
Since a major goal of the program had been the endeavor to maintain the
subjects in the program for as long as possible, the data were reviewed to deter-
mine the number of subjects who had been able to remain in the program for a
period of 6 months or longer. The 6-month period had been somewhat arbitrarily
determined as "the l^reak-even point" in that the subject who was able to maintain
himself for this period of time or longer made the justification of the resources
invested in this approach in bringing about his release from a correctional insti-
530
tution and his involvement in the program meaningful. The subjects accomplishing
this are tabulated in table 6. Among the first admissions, 135 managed to achieve
this period of participation, or longer. However, only a relatively small number of
the second admissions were able to achieve this — 20 out of 155. This would seem
to suggest that the subject's best opportunity for making out well in the program
occurs during the first admission, and this failure may be associated with an
attenuation of their motivation on subsequent admissions. The exception to this
is those patients who on their first admission, because of insufficient motivation,
very quickly relapse into narcotic at^use. When these patients are given an op-
portunity to return to the program at a later date, they do better in terms of
length of participation, since their first admission apparenth" presented them
insufficient challenge.
There was a continuing interest in the subsequent course of those individuals
who had left the program. Although the research design had no provision for a
systematic foUowup, information did reach the clinic via the "grapevine", con-
tacts and chance meetings, information originating in other programs, and from
former subjects visiting the clinic or reappearing in institutions. This information
was recorded and noted as foUowup in tables 5, 7, and 8. Where there was no
information available, the space was left blank. Table 7, that tabulates the expira-
tion of parole on the first admission, indicates that in the small sample of infor-
mation reported, the number remaining abstinent and the number returning to
drug use was about equally divided.
The information tabulated in table 8 provided an opportunity to compare a
second admission who had achieved expiration of parole during this admission
with his course on the first admission. Inspection of this table reveals the variabil-
ity and the difficulties in attempting to come to a conclusion as to the factors
responsible.
The course of a third admission is presented in table 9. The subject who achieved
the exi)iratiou of parole on his third admission again reflects the variability which
may occur and for which there are no specific explanations. It also emphasizes
the problem that emerges when an individual is admitted to the program with
only a brief period of time remaining in his parole status.
Of consideralile interest was the relationship of age to the length of time spent
in the program. The literature gives the impression that the youthful narcotic
user has a n^ore difficult time in participating in the program. To some extent
this would seem to be true as indicated in table 10. However, there is a great deal
of variability for which there are no apparent explanations.
CONCLUSION
It would appear that a program of this nature is feasil)le and meaningful and
may well be a preamble to other forms of treatment concerned with the manage-
ment of the narcotic abuser. This impression arose from repeated observations
despite the polarity of the program; that is, its punitive and therapeutic aspects
with the overwhelming majority of the participants tending to view the program as
being supportive. Furthermore, the relative lack of complaints from his family
appeared to be significant.
Aspects of the program which were difficult to assess, but nevertheless related
to the support it provided, touch upon such issues as the reassui'ance it provides
first for an employer knowing tliat his emploj'ee is participating in such a pro-
gram; second, the relief it provides the parolee's family from a chronic preoccu-
pation with the exercising of policing the subject; and third, the invaluable
service it provides the parole agent by allowing him to function with an increased
sense of effectiveness by his knowledge of the daily status of his charges. The ap-
proach provides a mechanism by which a productive relationship is established
between the parolee, his parole supervisors, and the clinic staff. It also provides
opi^ortunities for detecting periods of stress leading to narcotic abuse. The prompt
confrontation and the assistance provided, prevents an accelerated regression into
another cycle of narcotic dependency in many of the subjects. The fact that no
patient became addicted while ])articipating in the i)rogram, and that the numljer
of aiTests were relatively small for a group as liighly recidi\istic in nature as this
one, was a most encouraging finding.
References
(1) Kurland, A. A. The deceptive communication and the narcotic abuser. Rutgers
Symposium on Commimication and Drug Abuse, Rutgers University, The
State University of New Jersey, New Brunswick, N.J. (1969), Sept. 3-5.
531
(2) Kurland, A. A., Wurmser, L. & Kerman, F. Urine detection tests in the man-
agement of the narcotic addict. Am. J. Psychiat. (1966), i^;g:737-742.
(3) Kurland, A. A., Kerman, F., Wurmser, L. & Kokoski, R. Intermittent pat-
_ terns of narcotic usage. In, Drug Abuse, Social and Psychophannacological
' Aspects, J. O. Colt and J. R. Wittenborn, Eds. C. C. Thomas: Springfield
^(1969), pp. 129-145.
(4) Kurland, A. A., Kerman, F. and Bass, G. A. Laboratory control as a deterrent
to narcotic usage — a case study. In, Drugs and Youth — Proceedings of the
Rutgers Symposium on Drug Abuse, J. R. Wittenborn, H. Bill, G. P. Smith
and S. A. Wittenborn, Eds. C. C. Thomas: Springfield (1969), pp. 372-384.
(5) Kurland, A. A. Outpatient management of the narcotic addict. In, Drugs and
the Brain, P. Black, Ed. Johns Hopkins Press: Baltimore, Md. (1969), pp.
363-370.
(6) Kokoski, R. A practical application of thin-layer chromatography in the
detection of narcotic drugs in the urine. Psychopharmacol. Bull. (1966),
3:34-36.
Attachment No. 4
PERIOD OF RETENTION OF PAROLEES IN AN ABSTINENCE PROGRAM
-Attrition-
A£ST1\'E?JT
STATUS
[Prison]
.28 DAYS_^^.
6 MOS-
FHght
-Unmotivated-
(10%)
Usage -^
(57o)
-Unsteady State-
^Increasingly Motivated
Flight
" (25%)
Usage
(50%)
1 YR
V
(35%)
\/
aintaining Complete Abstinence (/j%).
Indefinite-
Attachment No. 5
;r\ N-CH,-CH=CHo , , :i-CH,-CH«CH,
3 u/ \ 6/ X, h/
N-CHj-CH-CHg
C. LEVALLORPHAH
Figure 1. The structural formulas of nalorphine (W-allylnor-orpIiine), lavallorphan
(li'-allylnorlevorphan) and naloxone (Il-allylnoroxymorphone).
Attachment No. 6
Naloxone in the Management of the Narcotic Abuser Employing a System
OP Partial Blockage — A Pilot Study
(Albert A. Kurland, M.D., Assistant Commissioner, State Department of Mental
Hygiene, Superintendent, Maryland Psychiatric Research Center, Medical
Director, Friends of Ps3^chiatric Research, Inc.)
code
0= Specimen negative.
Blank Space == Authorized absence.
X= Unauthorized absence from clinic.
N/S=No specimen — could not void.
-= Specimen combined with previous day's specimen.
/= Clinic closed.
D = Deceased.
H= Hospital.
?= Incomplete data from laboratory.
F= Absconding,
J= Jail.
illicit drug usage
A= Positive for amphetamines and methamphetamines.
B= Positive for barbiturates.
C= Positive for codeine.
CC= Positive for cocaine.
Di= Positive for dilaudid.
M= Positive for heroin or morphine.
Me= Positive for methadone.
Q— Quinine in specimen.
naloxone
1 = 200 Mg.
11 = 400 Mg.
111 = 000 Mg.
1111 = 800 Mg.
.= Naloxone rejected.
:= Naloxone discontinued.
t= Placebo.
*= OS all medication.
533
TRANSFERS
(These were parolees who, on the abstinence program, were beginning to de-
compensate into increasing opiate usage and under ordinary circumstances
would have begun to become considered as possible returnees to the correctional
institution for violation of their parole, were transferred to the Naloxone
program.)
Chart No 11 (case No. 546)
Displays the course of a parolee who had two admissions to the abstinence
program. On his first admission in May 1969, within a few months he decom-
pensated into increasing drug usage of a frequency that led first to his hospitaliza-
tion in a desperate effort to interrupt it. Within a few days after he was released
from the hospital, he was once more using drugs and was returned to a correc-
tional institution.
On a second admission (case No. 607B) he did quite well for a period of several
months and then began to show evidence of drug use, bringing about his transfer
to the naloxone program. Very promptly he reverted back to his abstinent status
and during this course he was changed from the naloxone medication to a placebo
and continued to do well. The placebo medication was discontinued after several
weekrs and he has received no medication at all and has continued to do well.
TRANSFER ■''■00^00 CHART NO. 1 1
Name: McC.W. 1st Adm, Case No. 5^
Adtir, 5-6-6a- iis. 9-.3a-;v3
'o3 May .
I 2 3 4 5 6 7 S 9 10 11 i2 13 I'tlS 16 17 18 19 20 21 22 23 24 2S 26 27 12 29 30 31
000000000000000000000
0 0 0 0
Juni 000000000 0
0 0 0 0 0 0
0 0 0 0
0 0 0 0
July. 0 0 0 0 0
Q. -
Aug. Q-'sXClQHHHH H H H HH H H
d 0 0 Q 0
H 0 0 0 a X d
Sept. OOOOCOOXQ Q Q, Cj X Q 0
M FT
Q a M Q a
M K I". ;v
a X Q 0 0 0 0
Q 1 n 0. g '.: 'S X J
- Q ^
2nd Adn. Case No. 607B Adm. 11-4-69- Naloxor- 5-7-7C
1 2 3 4 5 6 7 3 9 10 11 12 13 14 15 16 17 18 19 20, .21 22 23 24 25 26 27 28 29 3C 31
'69 Wov..
0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
/
0
0 0
Dec.
00000000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
c c
*70 Jao,
.0000 0 0
0
0
0
0
0
0
0
0
0
0
0
0 0
Feb,
0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
i'>ar.
0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0 0
0 0
0 0
Q ^
Q a 0 0 Q
0 0 0 0
sy nC^-OQClQ^O 0 0 0 0 0 0 0 0 0 0 0 0
0 000000000
J'.ly
C
C 0
0
0
0
0
0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Aug.
c
0 0
c
0
0
0
0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0:
to
0
0
0
0
0
0
0
Sept.
0
0 0
0
0
0
0
0 0
0
0
0
0.
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Oct.
0
C 0
0
0
0
0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Nov,
■0
c
0
o-->
0
0
0
0
0
0
0
0
0
/
0
0
Dec.
0
0
0
0
0
0
0
0
0
0
0
0
/
/
0
0
0
/
'•)rJar(.
/
C 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Feb.
0
0
0
c
0
0
0
0
0
0
0
0
0
0
0
i'.ar. .
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Apr. .
0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
534
Chart No. U (case No. 672)
Displays the course of the patient who, shortly following his admission to the
abstinence program, began to use drugs, was admitted to a hospital where he
remained for almost a month, and following his release did well for several months.
As evidence began to appear of intermittent opiate usage, he was placed on the
Naloxone program with some indication that his course was beginning to once
more stabilize toward the maintenance of abstinence.
TRANSFER
Name: K.R.
Chart No. \h
Case No. 672
Adm. 5-19-70
Naloxone; 7-23-70
1 2 3 4 5 6 7 8 9 10 11 12 13 I't 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1970 May OOOOOOMOOOOOO
; fT '- ii M Me
June 0000(iOOOOOOQX(lQ(iXXXQOOOOHHHHHH
July HHHHHHHH HHHHHHHHHHHHHH I) 00000000
Aug. 0X00000000000000000000000000000
Sept.
000000000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
0
0
0 0
Oct.
OOQOOOOOO
0
0
0
0
0
0
0
0
X
0
0
0
0
0
0
0 0
0
o'
0 0
0
Nov.
•'000000000
0
0
0
0
0
0
0
0
0
0
0
u
0
0
0 /
u
w
.
Dec.
QOOOOOOOO
0
0
0
0
0
0
0
0
0
n
n
0
A
0
/
/ 0
0
0
0 0
/
0
0
0
X
M
0
X
0 DI
0
0
0 0
Jan.
/oooooooo
0
0
0
0
0
X
0
0
0
Feb. 0 0 0 0 0
'S Me^fe
00000000X00000000X00
March
hpr.
000000000 000000X00 XX 00000000000
AOOO 0 00000000000000 0000X00000
535
DIRECT ADMISSIONS (SELECTED PRIMARILY ON THE BASIS OF YOUTHFULNESS)
Chart No. 2 {case No. 592)
Illustrates the course of an individual, who despite the partial blockade system,
could not maintain his abstinence and was eventually discharged from the pro-
gram, since his parole expired, with the recommendation that he pursue his
treatment in a methadone program.
DIRECT ADMISSION
CHART NO. 2
Name: O.D.
Case No. 592 Adm. 9/23/69
) 2 3 ^ 5 6 7 8 9 10 11 1.2 13 li* 15 16 17 18 20 21 22
23 2k 25 26 27 28 29 30 31
1969 Sept.
MM M
OOQQOQQO
M M
Oct OOAOOOOOOOOOOOOOOOOOOBBOOOOQMOX
M'MM M M M M M M M M
Nov. OOOOOOQQQ Q Q Q CI Q Q Q " *
Case No. 628B
1
2 3 L,
5
6 7 8 9
10
11
12 13
\h
15
16
17
18 19
20
21
22
2?
2k
25
26
27
28
29
30
31
M 0 0 0
0
0
0
Q
0
0
0 0 0
0 M
0
0
0
0
0
0
1970 Jan
0
0
0
0
0
0
0 0 0 Q O+O 0 0.
0
0
0-
0
M
0
M
0
0
0
0
Feb
0
0
0 0 0
0
0
0
0
Mar
0
OOOX QOOO
0
0
0
0
0
0
0
0
0 0 0
0
0
0 0
0
X
0
0
0
0
0
DOOOX QOO
0
0
0
0
0
0
0
0
0 0 0
0
0
0 0
0
0
0
0
H
c
M
Apri 1
0
0
0 0 0
0 0 0 0 X
Q
M
n
0
0
X
M
, Q
M
0. 0
0
0
0
0
M
May
0 0
0
0
0
0
0
-i
M
Q
D 0 0 0 0 0 0 0
0
X
0
M
Q
0
Q ti
<k
0
0
0
0
0
June
(i
0
0 0
X
0
Q
July
0
M
OQQOOOOO
0
X
M
Q
0
0
0
0
0 0 0
0
0
0 0
0
0
0
0
X
0
0
Aug.
0
0000 XOOO
0
0
M
0
0
0
0
,.^,.
0 0 0
0
0
0
I
0
0
0
0
0
0
_0_
Sept.
0
00000000
0
0
0
0
0
0
0
0 0 0
Q
0
0
0
X
0
;/
0
H
Oct.
1
:; 0 0Di2i0 0 0
0
0
0
0
0
0
0
Di
M3 Di
DiC; Q
0
0 Di Di
Di
w
0
Q
0
Li
0
:.'ov .
0 :
3iO 0 0 0 DiO DI
0
Di
Di
Di
Di
Di
Di
Di
Di Di X
0
0
Di Di
Di
/
Di
0
0
0
Dec.
DiO
Di Oi Di Oi DiDi J<
M
M
H
P
0
Di
0
Di
0
01 0 0
X
0
Di /
/
Q
X
■ M
CL
0
/
'71 Jan.
/ X
0 X 0:X 0 0 0
0
0
PE
536
Chart No. 4 (case No. 694)
Illustrates the course of an individual who has continued to remain abstinent
from opiate drugs although there have been episodes of unauthorized absences.
Direct Admission Chart No. U Adm. 9/23/69
Name: B.J. Case No. 59'*
1 23't56789 10
11
12
13
\k
15
16
17
18
1?
20
21
22
23
2i»
2';
26
27
28 2S 30
3t
1569 Sept
0
0
0
0
0
0 0
0
Oct.
000000000 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
0
0
Nov.
000000000 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
0
Dec.
000000000 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
0
0
J 970 Jan.
000000000 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
:+0 0
0
0
Feb.
000000000 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
u
0
Mar.
000 00000 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
0
Apr.
'0000 0 0 '0
0
0
0
0
c
0
0
0
0
a
0
0
May
0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
c
0
0
June
0000c
0
0
0
0
0
0
0
0
0
0
c
0
0000c
0
0
0
0
0
0
0
0
J
0
0
c
Aug.
0 0 0 0 0 c
• 0
,0
;0
,0
0
0
.0
• 0
0
0
,0
.0
Sept.
0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
0 0 0-0 0
n
n
0
0
0
0
0
0
0
0
0
c
0
Cct.
0 0 0 0 0
0
0
n
n
%
0
0
0
0
0
0
0
/
0
0 0
0
Mov .
Dec.
0 0 0
0
0
0
0
0
X
X
/
/
/
•71 Jan.
/oooooxoc
0
0
0
0
X
0
0
0
X
0
0
X
0
0
0
0 0
0
0
oooOxooxo
0
0
0
0
0
X
X
0
0
0
Feb.
0
0
0
0
0
0
0
0
0
March
000000000
0
0
0
0 *0
0
0
0*
0
0
0
0
0
0
0
0
0
0 0
0
Apr. _
000000 00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
0
537
Charts No. 8, 9, and 10 ( ^^-'^ .
Illustrate the course of subjects who. were apparently poorly motivated since
they absconded from the program without any evidence of any extensive use of
drugs.
3i;^iCT AD>;.ISSIO,N Chart No. 8
.\cr-o: C.Z.
Case No. 617
5 o 7 S 9 10 II 12 n 1^ 15 16 17 18 19 20 21 22 23 24 2; 26 27 2S 29 30 31
oi; ooc. '^0000000
0
0
0
n
0
0
0
0
0
0
0
0
0
0
0
^
0
0
0
0
0
y
Vu '^-i..') 'i 3 0 u 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
0
0
0
0
n
"~^^' 200000000
0
0
M
0
Q
'i
0
0
0
0
X
0
0
0
0
0
0
0
X
X
X
Q
a
X
X
F
^\ >: M c 's d (1 X (i
X
Q.
DIRECT ADMISSION Chart No. 9
Nar.-.e: S.F. 'Case No. 622
1 2 3 '^ 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 2^* 2S 26 27 23 29 30 3I
Dec.
CI
X
0
0
0
0
0
0
0
0
X
0
0
0
0
0
.3r..
COOOOOQ.OXO
?
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
A
Fib.
000000X000
X
0
0
0
0
0
0
0
0
0
X
X
X
X
X
F
DIRECT AO.niSSiON Chart No. 10
:;s-e: E.L. Case No. 616
' 2 3 ty 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 2k 25 26 27 28 29 30 31
1565 .".-v.
xJq
ci ■>$
c
Dcc.
C;:;o 0 0 X 0 0 0 0
0
0'
■Q.
Q.
0
0
X
0
X
Q
N/
0 ^S
Q. 0
.■'i X
X
0 X
X
X
"i37C -=n.
X X X X X F
Chart No. 29 {case No. 682)
Illustrates the course of a subject who has pursued a stable course on the
naloxone program.
DIRECT ADMISSION
Name: S. R.
Chart No. 29
Case No. 682
Add). 6/9/70
, 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 23 29 30 31
1 970 June
0^0000000000 0000000 0, 00
July 000000000 0 OOOOSOOO 00000000 /; 0000
Aug. 0 0 0 0 OOP 0 0 0 0 0 % 0 0 0 0 0 0 / 0 0 0 0 0000000
...^_ I" 0 0 0 0 /so oooooooQ^oooooo oliilo 0 -^ --y n 0 Q
Cot.
0 0/3 0 CS Q.-S 0 0 0
0
Cf 0
5-
0 0 '3 0. 0
0 0 0 0 0 0 0
0 0
0
0 0
Nov.
0 0/? 0000000 0
0
ot
0 0 0 0 0
0 0 0 0 0 0
0 0
0
0
Dec.
0000000000 0
0
0 a.-
0 0 0 0 0
0 0 0 0 / / 0
0 0
0
0 /
'71 Jan.
/OOOOOOOO 0 0
0 0
0 0 0 0
0 0 0 0 0 0
0
0
0 0
Feb. .
0 0 0 0 0 0 0
0
0
0 0 0
0 0 0 0
0
March
0 0 0 0 0 0
0
0
0 . 0 t 0
0 0 0 0
0
0
■•■Q
Apr.
0 0 0
0 0
0 0
0 0
538
Chart No. 35 {case No. 697)
Except for one morphine positive, the record of this subject has been abstinent.
Di rect Admi.s'sion
Name: T. R.
Chart No. 35
Case No. 697
Adm. 7/l'*/70
1231+56789
10
11
12
13
11*
15
16
17
18
19
20
21
22
23
Ik
25
26
27
28
29
30
31
1970 July
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Aug.
000000000
0
0
0
0
0
0
0
0
0
0
X
0
0
0
0
0
9
Q
0
1
0
n
000000000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Sept.
0
0
Oct.
000000000
0
0
0
Q
Q
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
>.'av.
000000000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
/
0
0
0
0
Dec.
0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
/
/
0
0
0
/
71 Jan.
/ 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
Feb.
0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
Mar.
0 0 0 0 0
0
0
0
0
0
:'t
0
0
0
0
0
0
0
"0
Apr.
0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
Chart No. 38 {case No. 709)
Reflects the course of a subject who initially did well then decompensated into
an episode of increasing opiate usage which was interrupted by hospitalization. On
return to the program, he was again placed on naloxone and despite this he again
decompensated into a episode of opiate usage, extending over a period of approxi-
mately 2 weeks and was then able to recover and has maintained an abstinent
course, as indicated on the chart.
DIRECT ADMISSION
Name: F. J.
Chart No. 38
Case No. 709
Add. 7/29/70
1 2 3 it 5 6 7 8 9 10 11 12 13 l^t 15 16 17 18 19 20 21 22 23 2h 25 26 27 28 29 30 31
1970 July
10 0 0
Aug.
00000000000000000 00000000000000
Sept.
00000000000000000 0000000000000
Oct.
Nov.
Dec.
'71 Jan.
Feb.
March
Apr.
00000000000000000 00 000000000000
c ;rt
0 0 0 0 0 0 X M ooooccooo
0 0 0 0 0 0
000000000 0 0 0 0 0 0 0
0 0 0 0 0
0 0 0 0
F
VTTTTTTT/
/ Q a
M M MN^MMMMMMMMMN^
Q. ft Q. Cl^ Q. Q. CL Q. Q. (i d (i .<!• '^S
0 H H H II H
0 0 0 0 ft X
M M M M M
XXXXftftftftft
M
ft
M
ft
M M M
ft ft ft
M M M
ft ft ft
ftO OiOOOOO 000
000000000
0
0
0 0 0
0 0 0
00000000000000
0 0 0 0 0 0 0
0
0
0.0 0
0000 0 0000"o:to
From January IS, 1971, to January 20, 1971, inclusive, the patient was excused
by a parole agent from taking his naloxone, since it was making him sick and he
was planning to enter the hospital for the interruption of his use of opiate drugs.
589'
Chairman Pepper. Our last mtness today is Dr. Richard B. Res-
nick of New York. Dr. Resnick is head of the addiction services unit
of MetropoUtan Hospital Medical Center, where he also serves as
assistant attending psychiatrist.
Dr. Resnick received his medical degree in 1958 from New York
Medical College and was formerly chief resident in psychiatry at
Montefiore Hospital in New York.
He is the author of numerous articles on the treatment of heroin
addiction using narcotic antagonists.
Dr. Resnick is a colleague of Drs. Max Fink and Alfred Freedman
of New York Medical College, and has worked ^\dth them on signifi-
cant research on the narcotic antagonists cyclazocine and naloxone.
While these drugs have not yet been perfected for use in treating
addiction, they offer real promise and the committee looks forward
to your testimony Dr. Resnick.
Mr. Perito, you may proceed.
Mr. Perito. Thank you, Mr. Chairman.
Dr. Resnick, you have a prepared statement; is that correct?
STATEMENT OF DR. EICHARD B. RESNICK, ASSOCIATE PROFESSOR,
DEPARTMENT OF PSYCHIATRY, NEW YORK MEDICAL COLLEGE
Dr. Resxick. Yes, sir.
Mr. Perito. Would you care to read it or summarize it as yoii
wish?
Dr. Resnick. Well, I would Hke to read it with some amendments
from the original statement.
Mr. Perito. Fine, Doctor. With the chairman's permission, please
proceed.
Chairman Pepper. You go right ahead.
Dr. Resnick. Mr. Chairman and members of the committee, I am
going to discuss with you my experiences in the use of narcotic an-
tagonists in the treatment and also in the eventual potential use of
these substances in prevention of opiate dependence.
I believe that we are now on the threshold of a very important
medical breakthrough in both the treatment and the prevention of
narcotic addiction. As you are aware, until now the prevailing treat-
ments of addiction have been either rehabilitative techniques alone
or together mth the use of opiate substitutes such as methadone and
that the development of the orally effective narcotic antagonists now
provides a basis for a new and a different model of treatment.
During the past 5 years at the New York Medical College we have
used and investigated these antagonists, substances such as cycla-
zocine and naloxone, for the treatment of opiate dependent
individuals.
Our treatment has focused mainly on cyclazocine because of its
relatively longer duration of action and its more ready availability/.
Cyclazocine is an effective nonaddicting narcotic antagonist
which, when taken daily m does of 4 to 5 milligrams a day, will block
all the physiological and subjective effects of about 20 or 25 milli-
grams of intravenous heroin and this action persists over a 20-26-hour
period.
540
This amount of heroin is roughly equivalent to about $20 or $30
worth of heroin as available in the streets.
In our studies we have treated addicts who have volunteered for
admission in the inpatient treatment center of a municipal hosj)ital
in the East Harlem section of New York City. This population is
predommantl}^ low income, predominantly Negro and Puerto Rican,
with low educational levels, and many are receiving extensive welfare
assistance.
Our patients range in age from 17 to 54 years and the duration of
their addiction has been from 2 to 30 years.
After these individuals are admitted to the hospital, they are
withdrawn from heroin over a period of about a week. They are then
kept in the hospital in a drug-free state for about another week and
they are then inducted on cyclazocine to the mamtenance dose of
generalh' 4 milligrams a day.
Now, you have heard about side effects of cyclazocine and it is true
that during this induction period, during the buildup, patients do
experience side effects. However, these side effects do gradually sub-
side and completely disappear after the maintenance doses are
reached.
During our very early studies, we used a 21 -day period of induction
in order to try to minimize the side effects. More recently, however,
we have developed and employed a rapid induction technique wherebj"
we have been able to build patients up to the 4 milligrams of cyclazo-
cine in a period of onl}^ 4 days. And of more than 70 patients that have
been inducted in the maintenance levels by this rapid method, there
has only been one patient who did not complete the induction and we
have had no patients at all who have discontinued treatment because
of any secondary drug effects.
Mr. Perito. Doctor, excuse me. How is it that we have heard
so much about the alleged agonistic or side effects of cj'clazocine? How
did it get a bad name, so to speak?
Dr. Resnick. Whenever you start with any new drug and there is
anxiety about it, this anxiety is transmitted to the patients and I
think that even if you are given an orange sugar-coated pill that
you were concerned about, the patients would have bad side effects.
When you are familiar with the drug and you are comfortable with
it and you can tell the patients in advance that you know about it
and you know what is gohig to happen and you tell them in advance
what they can expect to happen, it is true they do get these side
effects but they are able to tolerate them, particularly -when they know
that once they reach this maintenance level, all of these effects wDl
disappear.
Chairman Pepper. How often do you give the doses to them when
you reach the maintenance level?
Dr. Resnick. The cyclazocine is effective for approximately a 24-
hour period and, therefore, for it to continue its effectiveness, it has
to be taken once a day.
Chairman Pepper. Once every 24 hours.
Dr. Resnick. Once every 24 hours.
Chairman Pepper. And hoAv much does it cost nov>?
Di'. Resnick. How much does cyclazocine cost? I have not the
vaguest idea. Sterling-Winthrop Laboratories is kind enough to supply
541
it to us for nothing and I do not know what it costs them but it does
not cost us anything.
Chairman Pepper. Very well.
Dr. Resnick. After the patients are discharged from the hospital,
they return to the clinic generally once or twice a ^^■eek, sometimes
more frequently, at which time they get a sufficient sujjply of medica-
tion to take every day to last until their next visit.
In 1969 we presented a t^'pological classification of opiate dependent
individuals which was based on characteristics of patients who con-
tinued successfully with cyclazocine as compared to those who dis-
continued treatment. We found that those patients who sustained
cyclazocine treatment successfidly were those who usually rated
themselves as not needing narcotics in order to alleviate symptoms of
anxiety or in order to increase their capacity to function when they
were clean.
These were also individuals who usualh^ had an ongoing and
consistent relationship with a girl, either a Avife or a girl friend.
These were individuals who apparently used heroin principalh^ as
part of their social interaction, as part of their culture, as contrasted
with other individuals who seem to need narcotics in order to feel or
to function normally.
Since the summer of 1970, all patients who have requested cycla-
zocine and who did not have an active, acute medical illness, have
been accepted for cyclazocine treatment.
Now, in our evaluation of our treatment results, any patient who
discontinued cyclazocine without our supervision we regarded as a
failure whether or not we had any information with regard to his having
become readdicted. In other words, individuals who stopped because
they moved out of the area or who stopped for some other reason, we
counted him as a failure.
Currently, we are treatirig more than 75 outpatients who have been
receiving cA^clazocine for periods of between 1 to 4 years. Almost all
of these patients who have sustained this treatment have extricated
themselves from the drug culture and are leading rehabilitative lives
as judged by either their working or attending school.
Mr. Perito. Doctor, excuse me for one moment. Yesterday we
heard testimony concerning the number or approximate number of
patients under treatment nationally on narcotic antagonists and it was
a very small figure. Do you have an estimate of the total number of
addicts, throughout the country, that are under treatment on narcotic
antagonists?
Dr. Resnick. In June of last year we conducted a clinical conference
which was attended by investigators who were using cyclazocine and
other narcotic antagonists clinically and at that meeting, approxi-
mately 400 patients were reported upon which indicated a successful
induction and maintenance rate of about 40 percent.
Mr. Perito. Thank you. Please continue.
Dr. Resnick. Now, during our most recent 2-year evaluation,
which is from January 1969 until December 1970, we have inducted
59 new patients on cj^clazocine. Of this group, 37 remain in treatment
and 22 have discontinued treatment.
Now if we eliminate those patients who have been on cyclazocine
for less than 6 months — it is very hard to say whether a patient is
60-296 — 71^pt. 2 14
5m
successful or not in that short a period of time and we define success
as someone who has been on it for more than 6 months — we are com-
paring 17 patients receiving cychizocine out of this group for 6 months
or longer, with 22 patients who dropped out of treatment and on
that basis our treatment success rate is approximately 50 percent.
Virtually all the patients who are on cychizocine learned of tliis
treatment only after their admission to the hospital. In other words,
they did not come into the hosjntal in order to volunteer for this
treatment. Few of them had heard about cyclazocine or know it to be
available as a treatment prior to their admission.
Now, these experiences with narcotic antagonists are based on a
theory that views narcotic addiction as analogous to a conditioned
response — the addict responding to stressfvd stimuli in his environ-
ment with drug-seeking behavior. And in this theory the repeated
use of heroin without liis anticipated relief of stress or without ob-
taining the euphoric high should lead to extinction of this learned
drug-seeking beha^dor.
In fact, most of our patients who have been successfully treated
with cyclazocine have, during the course of their treatment, tried
heroin on one or more occasions while they were out on the streets.
Having done this, and then not experiencing the high, they report
to us feeling relieved at being protected from heroin effects wdiich then
enables them to clear their minds from either thinking about it or
being tempted to use heroin, knowing that it will have no effect, and,
therefore, wdll be a waste of money.
Now, the principal shortcoming of cyclazocine as a treatment
for those addicts in whom it might otherwise be useful is its short
duration of action, not the side effects. Effective heroin blockade
rareh^ wdll exceed 20 hours, so that in the face of some acute symptoms,
it is easy for a patient to skip a dose of cyclazocine on a particular day
and become high on heroin, and even a patient who is highly moti-
vated, who is symptom free, is on occasion ambivalent about taking
cyclazocine on a particular day, having in mind that he can use
heroin perhaps just that once or use it once in a while, and his
occasionally^ skipping cyclazocine and using heroin typicalh' would
reestablish the cycle of an increased craving and then an eventual
readdiction.
So, in an attempt to avert this cycle, we have assigned some family
member the responsibility of administering each day the cyclazocine
to the patient.
Chairman Pepper. Excuse me. How is cyclazocine administered?
Dr. Resnick. By mouth. It is available as a tablet or as a liquid.
We use the liquid.
Now, when a person in the patient's family or another person who
is responsible in his life has the responsibility of seeing whether or not
he takes the cyclazocine, he is much less likely to miss taking it
because he knows that not taldng it on a particidar day is tantamount
to announcing in advance on that da}', todaj' I am going to go out
and shoot heroin.
Of course, this })rocedm'c also serves as a reassurance to the family
so that they arc relieved of having to look fur signs of ch'ug use in the
patient, to look for needle marks, to search him for possession of drugs
54^
when they know that the cyclazocme was taken on that particidar
day.
One sohition to this problem of drug dehvery would be the develop-
ment of a long-acting antagonist, preferably one which ^\ould be
efi'eetive for periods of weeks or months, which would both prevent
readdition and also extinguish his conditioned deju-adence on opiates
without the need for his daily cooperation. Such long-acting com-
pounds have been developed for other medications. Bicillin is a form
of penicillin which lasts for up to a month. Prolixin enanthate is a
tranquilizer which is effective uj) to 3 weeks. And there are other
kinds of medications in other fields of medicine that have been de-
veloped in long-acting forms. And a long-acting narcotic antagonist
would not only vastlj^ increase its therapeutic usefulness but also it
would provide the possibility^ of immunization against addiction if it
would he used in patients who are subjects of a high-addiction potential.
Mr. Perito. Is this m terms of a vaccine, Doctor?
Dr. Resnick. You might call it a vaccine. I do not like the term
"vaccine" because vaccine implies something different than what I am
talking about. Vaccine implies the development of antibodies within
the system and I am talking about a medication that is effective over
a long period of time.
Now, it is of special and particular interest that a long-acting
formulation could serve both as a prophylactic as well as a therapeutic
use. As you are aware, heroin use has become so rampant in some urban
centers that it is progressively affecting younger and younger can-
didates. Deaths in teenagers ^hich were once rare, are now becoming
commonplace. And a long-acting narcotic antagonist — perhaps im-
bedding it m a plastic-like substance which can be imbedded in the
body and then gradually release the medication — could render it
effective for periods of up to months.
By using such a formulation early in highly exposed populations, it
could drastically reduce both the deaths and the addiction rates and
also provide a basis for active prophylaxis, particularly in young
people.
Recently the New York Times reported that among the 300,000
U.S. servicemen m Southeast Asia, 1,000 became newly addicted to
opiates, to heroin, during 1970.
I have with me an article from this week's Time magazine, dated
June 7, and I would like to quote from this article.
Between 10 percent and 15 percent of U.S. troops in Vietnam have developed a
heroin habit. That represents from 26,000 to 39,000 Americans hooked. Some
estimates are even liigher, 20 percent or more, which means upward of 50,000 GI
addicts. These figures were brought back by retiring Army Secretary Stanley
Resor from a recent visit to Vietnam and were repeated last week in a study
conducted by the House Foreign Affairs Committee bj'^ Republican Congressman
Robert H. Steele.
Chairman Pepper. And Mr. Murphy of Illinois, who is a member
of our committee, and is here with us today.
Dr. Resnick. How do you do, su\
Now, I would suggest and recommend strongly the distribution of
cyclazocine to all soldiers in the narcotic endemic zones as a means of
effectively curtailing this epidemic of addiction. This can be done in
a fashion similar to our use of atabrine for malaria during World
War II.
544
Chairman Pepper. Would you repeat that statement, Doctor?"
That last statement.
Dr. Resnick. I would suggest and recommend the distribution of
cyclazocine to all soldiers in these narcotic endemic zones as a means of
effectively curtailing this epidemic of addiction in a fashion similar to
our use of atabrine for malaria during World War II.
In November of 1970, a 1-year contract in the amount of $66,000
to develop such a long-acting formulation was granted to the Food
and Drug Research Laboratories of Maspeth, N.Y., by the depart-
ment of psychiatry of the New York Medical College with funds from
the New York State Narcotic Addiction Control Commission. This
contract has focused on naloxone rather than on cyclazocine, naloxone
being a compound which is more potently effective in antagonizing
opiate effects and also which is free of any toxic effects. Unfortunately,
however, additional funds are not currently available.
The only other study of a long-acting formulation that I am aware
of is that of Seymour YoUes at the University of Delaware and his
work is impeded by some nontechnical problems.
Another narcotic antagonist which I believe you have already heard
about, M-5050, which has been tested only in animal studies, has been
shown to be between eight and 16 times more effective in its narcotic
blocking capacity as naloxone and also is free of any toxic effects. This
compound was tested in England and funds for its continued study
in the United States are not available.
Chairman Pepper. Doctor, you are telling us the shocking story
that three of the drugs which seem to hold the greatest promise of
being antagonistic drugs or immunizing drugs or blockage drugs, in
respect to their longer duration, are the subject of insignificant ex-
penditure for research?
Dr. Resnick. Yes.
Chairman Pepper. And here we are dealing with a problem of the
magnitude in terms of lives and money and ruined careers and
criminal acts, et cetera, deriving from this problem of heroin. It is
shocking to hear a man of your knowledge and repute to have to make
such a statement as that. I wonder what has happened to our country
that we have ignored the scientific communit}' instead of stimulating
them to try to do something effective about it. It looks like we would
\)e out looking for you and Dr. Yolles and others who are working
in these fields and telling 3^ou, for goodness sake, hurry up and try to
save more lives and do more about this problem.
Dr. Resnick. I agree.
Mr. Murphy. Mr. Chairman?
Chairman Pepper. Yes, Mr. Murphy.
Mr. Murphy. Doctor, have jou made any attempt to bring this
testimony j^ou are giving today to the attention of the medical authori-
ties of the U.S. military forces?
Dr. Resnick. No. This has not been done because these reports
about the epidemic of addiction in Vietnam are very recent reports.
Mr. Murphy. They are recent reports as far as we are concerned
here in the United States, but the Army has known about the cpiilemie
proportions.
Dr. Resnick. I did not know about it.
545
Mr. Murphy. Well, nobody from the Army has made an attempt
to contact you regardmg your studies?
Dr. Resnick. No.
Chan-man Pepper. Go ahead, Doctor.
Dr. Resnick. Now, another reason for increased efforts at develop-
ing and supporting narcotic antagonists is our view that the present
enthusiasm for the legal distribution of methadone or heroin is
really a doubtful long-range solution and can
Chairman Pepper. Doctor, I am sorry. I want to interrupt you
there. We saw in the paper the other day that one of the members of
the New York commission or authorities had suggested that heroin be
made available as a maintenance drug for the addicts of heroin. And
one of our members, Mr. Rangel, made some public comment about
this. And others, some of my colleagues in the House, have suggested
that this committee should recommend that heroin addicts be pro-
vided the necessary herom in a lawful manner without expense to
them throughout this country.
Would you for the record, give us the benefit of your opinion on
this suggestion?
Dr. Resnick. My personal opinion is that it is very doubtful that
this is going to be a helpful solution to the problem. My personal
opinion also is that it is likely to create more problems than it is
going to solve.
However, as a scientist, I would certainly be willing to support in
a ver}^ limited way a stud}^ of that approach in order to be able to
really test whether or not it is helpful, it is harmful, or it has no effect
at all. I do not like to sit back in my armchair and have preconceived
opinions that really have not been tested out. 1 doubt it personally,
but 1 certainly would have no objection to it being tried under close
research medical auspices and supervision.
Chairman Pepper. Are you famihar with the British program?
Dr. Resnick. I have heard about it, yes; and I have also heard that
it has aggravated their problem, that it has made it worse, but I do
not know the details of the British program and I do not know how
any program of a research nature that might be implemented or
started here could improve on it and perhaps have different results. I
just do not know.
I doubt it, but I am willing to try anything as long as it is done
carefully and under proper supervision.
Chairman Pepper. Is it not true that the heroin addict generally
requires an increasing number of shots a day to satisfy the urge?
Dr. Resnick. He requires an increasing number of shots a day in
order to continue to get the high. It reaches a certain point as with
methadone whereby he requires it only to feel normal, does not get
high from it.
Chairman Pepper. Go right ahead with your statement.
Dr. Resnick. As I was saying, another reason for increased efforts
at developing and supporting narcotic antagonists is our view that the
present enthusiasm for the legal distribution of either methadone or
heroin is really a doubtful long-range solution and can only be a tem-
porary expedient at best. These maintenance schemes provide for an
increase in the number of addicted persons and an increase in the
number of delivery centers. And we would expect that when thousands
of addicts inhabit the cities of this Nation, that there will be an in-
54^
creased amount of licit as well as illicit drugs in the community and
most discouraging, however, is the general failure to consider the
means of eventual withdrawal from narcotics or the complacent view
that treating these opiate dependent individuals with legal opiates is
going to be a life-long process.
Narcotic antagonists provide a logical therapeutic and prophylactic
possibility and in the face of this need, further experimentation should
or must be encouraged and to that end we recommend that the
Congress authorize the establishment of a special study unit or com-
mission analogous to the Commission on Marihuana to re^dew all the
available data, and should this commission agree with our view of the
data, they shovild firstly stimulate the development of a long-acting
formulation of an antagonist with a period of action of at least 30
to 60 days; second, support the testing and development of other an-
tagonists; and also to utilize currently available antagonists in South-
east Asia as a prophylactic for the personnel who are daily exposed tO'
heroin in tliis highly endemic area.
I would think that to this end the commission should be funded
with a sum to be determined by Congress. Probably the modest
amount of $3 million shoidd suffice initially.
Chairman Pepper. We thank you very much for your able
statement.
Mr. Perito, do you have any questions?
Mr. Perito. Just two questions. Doctor.
Assuming proper funding, how long do you think it would take tO'
develop an effective long-lasting antagonistic drug?
Dr. Resnick. Well, with a million dollars we could do it in a year;
$3 million, in 6 months; $5 million, maybe in a month and a half.
You see, we have the technical means to do this. It is merely a matter
f the chemists going through the procedure of testing it out. I mean,
it does not require any new, unusual discoveries. It is merely a ques-
tion of trying out different vehicles to see which one works and what
the dangers are.
Chairman Pepper. Excuse me, Doctor. This committee, I think,
was among the first groups in the Congress to reconunend a commis-
sion to study marihuana. We called on the Department of Health,
Education, and Welfare to have the Surgeon General make a study,
a thorough authoritative study of marihuana, some 2 years ago and
later on we supported the setting up of the Commission, and that is a
very desirable procedure in many resjjects.
Do you think the same job could be done in perha[)s a shorter
length of time if we provided the money to the National Institute of
Mental Health, an existing agency, and gave them the j^ower to en-
courage these researchers that you ai'c talking about?
Dr. Resnick. Yes. I would think that if some subgrouj) within the
NIMH was dedicated to this pur])ose; yes.
Chairman Pepper. Mr. Mann?
Mr. Mann. Doctor, your ])rograin has been conducted as a nuiinle-
nance-type of program. Have you cxperiment(Hl Mith the termination
of treatment and supervision of the individual to see about a perma-
nent cure? , ^;,ii.i
Dr. Resnick. Yes. We have experimented with it. There have been
a number of individuals who have been on our cyclazocine program
-in in ,n<' ff >o (o
S47
over a period of time, from 1 to 3 years, who have then come to us and
stated that they feel they have during this period of time, been free of
using narcotics, stabihzed in their hves, do not have the need for
narcotics and would like to try ^^'ithout the use of cyclazocine.
There are seven such individuals who we withdrew from cycla-
zocine, none of whom have become readdicted to date. There were two
individuals who requested withdrawal from cyclazocine who shortly
after they were off cyclazocine came back and said, "I have the urge
to use tlrugs again; please put me back on cyclazocine," and we did so.
Mr. Mann. So, there is definite potential for the reordering of
one's life, perhaps, while under a sui)ervised program?
Dr. Resnick. No question about that. I think the biggest hope about
cyclazocine is that it is not addicting. The individual does not get
any kick from it. There is no illicit market for it and he is not addicted
to it. It is a very useful tool or crutch for him to be able to conduct his
life without heroin and hopefully to be able to reach a point where he
no longer has the need to use heroin.
Mr. Mann. Thank you.
Chairman Pepper. Mr. Blommer?
Mr. Blommer. I have no questions.
Chairman Pepper. Mr. Steiger?
Mr. Steiger. Thank you, Mr. Chairman.
What are the side effects of cyclazocine?
Dr. Resnick. The side effects of cyclazocine depend upon how fast
we give it.
Mr. Steiger. What is the worst that can happen? I mean, in the
4-day period.
Dr. Resnick. The usual, most common side effect in the 4-day
period is the patient experiences what he describes as a high and he
likens this to being similar to a pot high. Some of them say it is like
LSD. Most of them enjoy it. They do not find it uncomfortable or
unpleasant.
It is of some interest that we offer them naloxone as a means of
reducing the intensity of these side effects. Now, naloxone has that
propoerty. So that the procedure is to tell the patient that he is going
to be built up on cyclazocine in increasing doses over 4 days and that
during this 4-day period he will experience some side effects, none of
which are harmful or dangerous, that if he finds that these side effects
are too strong for him, if he wishes, he may request tablets, naloxone,
which will help to reduce the intensity of these effects, and about 50
percent of the patients go through the induction without using
naloxone. The other 50 percent will use naloxone sometime during
these 4 days and they do report after they take the naloxone, ^vithin
about a half hour to an hour the intensity of this feeling- subsides.
Mr. Steiger. If there is an interruption in the administration of
cyclazocine and they get back on it in a month, after being off it a
month, do they experience this again? Would you anticipate that they
would?
Dr. Resnick. If they have been off cyclazocine for a month and
then need to be reinducted on it?
Mr. Steiger. Yes, sir.
Dr. Resnick. Exactly the same thing happens.
Mr. Steiger. Knowing the research community as you do inf this
particular area, and also knowing the cumbersomeness of this body
54S
and the bureaucracy and the apparently headless effort that is being
conducted to develop these drugs, do you think there would be any
merit on a very pragmatic basis of a prize established — a bonus or
reward of a significant amount of money, a million dollars, perhaps —
for the achievement of an antagonist that would last not less than 30
days and whatever the other criteria are that logic would dictate? Do
you think that that would produce a response from the research
community?
Dr. Resnick. Yes; I think if they were paid for their efforts they
would do the job.
Mr. Steiger. Assuming they would only be paid if they were
successfid, obviously, and if they were first. I do not mean a contract
now.
Dr. Resnick. I would not presume to answer that question.
Mr. Steiger. All right. Winthrop is furnishing you with the
cyclazocine; right?
Dr. Resnick. Yes.
Mr. Steiger. Do j^ou know if Winthrop is doing anything to make
cyclazocine a longer acting substance?
Dr. Resnick. To my knowledge, no.
Mr. Steiger. Would it be reasonable to assume that if there were
some commercial incentive for them to do so, that they would do so?
Dr. Resnick. It is reasonable. ,,f I y-j
Mr. Steiger. Have they the research capability to do so?
Dr. Resnick. I do not know.
Mr. Steiger. Do you know of any laboratory that has the experience
or any research organization that has the experience, to make cycla-
zocine a longer acting substance?
Dr. Resnick. Oh, yes. I know, as I stated, that we have arranged
a contract with a particular biochemical laboratory for this purpose.
I am sure there are many throughout the country who have the
personnel and the technical know-how to be able to proceed with
such studies. I am not a chemist but I do not think the chemical
problems are that difficult.
As I said, I think we have the knowledge. We just need the funds
to pay people to go through the rigor of testing the different vehicles.
Mr. Steiger. You apparently have not discussed this possibility
with Winthrop but you are in a position to, at least speculate. Why
isn't AVinthrop interested in extending the effectiveness of this drug,
the effective timespan of cyclazocine? Is it not commercially valuable?
Dr. Resnick. I wish you would ask Winthrop. I can only guess.
Mr. Steiger. I suspect we might. (See exhibit No. 32.)
Dr. Resnick. My guess is that it is economic considerations. It is
an expensive thing to have to do and if they want to do it, then they
want to feel that there is some remuneration for it.
Mr. Steiger. I have no further questions, Mr. Chairman.
Chairman Pepper, ^^r. Murphy.
Mr. MuKPHY. Thank you, ^lr. Chairman.
I agree with Mr. Steiger's suggestion that we give an inducement to
some chemist or doctor or some laboratory to come up with a cure for
this. I am all for taking the lady down from the Cai)itol and replacing
her with whoever comes up with that cure, as it is such an important
problem. And I cannot understand why none have not pursued this
549
with more vigor and funded the program if what you say is true, Doc-
tor. I think a lot of us here in Congress are derelict in our duty and
have been derelict in our duty in the past. I know this may sound
self-serving because I am a member of this committee, but I commend
the chairman, Mr. Pepper from Florida, and the members of the com-
mittee for undertaking this study because it is long overdue. I com-
mend you, Doctor, for your work and I agree with 5*!r. Steiger that it
is about time the Federal Government took a lead in this program.
We owe a responsibility to a generation of young Americans that we
are not only losing in Vietnam but we are losing back here. This sounds
like a Fourth of July statement, but I really feel it and I know that
members of the committee feel it. Again, I want to congratulate Mr.
Pepper for providing the leadership for this study and this testimony.
Dr. Resnick. I will second that.
Mr. Steiger. I wonder if the gentleman will yield. I thought the
gentleman might pursue the military aspect of this.
In issuing cyclazocine to the military — much as you made the equa-
tion of Atabrine, and, of course, we did it as far as venereal diseases,
et cetera; so it is not a unique idea — I wonder what would be the
practical difficulties? Is cyclazocine, for example, readily available as
far as you know? Would it be available in sufficient quantities?
Dr. Resnick. To my knowledge cyclazocine is available and could
be easily made available. We have not had any trouble. I mean,
Sterling- Win throp has supplied us with as much cyclazocine and other
individuals throughout the [country who are fusing fit, with as much
say we need. There has never been any problem with that.
Mr. Steiger. All right.
Now, A\dth your clinical knowledge of cyclazocine in its present
state of the art, and recognizing the side effects as you do probably
better than anybody in the country, do you anticipate that when given
to a great number of people as you are suggesting, it would create any
particular problems? The side effects, the high, whatever it is?
Dr. Resnick. I can only answ^er the question on the basis of my
experience and my experience has been ^^dth all of the individuals
whom I have treated, all of whom, of course, are addicts. I do not know
how a nonaddict is going to react to cyclazocine. These are all addicts
who have withdrawn from heroin, who have been drug free for a
period of time ranging from a week to several weeks and have been
placed on cyclazocine. If we build them up on the cyclazocine very
slowly they experience minimal or no side effects. If we build thorn up
on the cj^clazocine more rapidly they do experience these side effects.
But in 100 percent of the cases these side effects diminish, disappear.
We have not had a single case of anj^ patient who stopped taking this
drug, once he has been built-up, because of side effects. What the
results mil be in some other population I do not know.
Mr. Steiger. And there have been no deaths ; is that correct?
Dr. Resnick. No deaths. No illness. No harmful effect.
Mr. Steiger. Thank you.
Chairman Pepper. Mr. Winn?
Mr. Winn. Thank you, Mr. Chairman.
Along that same line, in a paper that I beHeve you and three other
doctors presented February 16 and 17 of this 3'^ear in Toronto, Canada^
550
you have used some of the same information in your testimony
todaj'. You made the statement or the statement was made here:
Efforts at developing a long acting antagonist are imperative until a more
logical means of preventing opiate addiction is developed. The present enthusiasm
for the legal distribution of methadone or heroin is a spurious solution. Methadone
or heroin maintenance substitutes a legal addiction for an illegal one, reducing
neither the risks of addiction nor of death.
In other words, methadone is not safe; right?
Dr. Resnick. I cannot give you the exact figures but in New York
City there have been a number of methadone deaths.
, ,Mr. Steiger. Here, too.
Mr. Winn. Yes; there have been some here, too, of course, and I
suppose the other large cities where there is a methadone program.
Dr. Resnick. I want to emphasize I am not knocking methadone. I
think it is very useful.
Mr. Winn. No. I understand you are not knocking it, nor am I,
but at the same time I think what you and the other doctors have
pointed out in that paper which ycu gave, and what I am tr^nng to
bring out, is that the risks of methadone maintenance are about the
same as heroin maintenance as far as deaths are concerned.
Dr. Resnick. I am not sure that statement is true, Mr. Winn.
It is true that )3atients do take overdoses of methadone and die.
It is true that individuals who are not bonafide members of methadone
maintenance programs get methadone from people who are on these
programs, and die.
Mr. Winn. They also secure them from licensed physicians, Avhich
would ]3ossibly give them the overdose that would cause them to die.
Dr. Resnick. That is a possibility. Now, it is also true that many
heroin addicts die not odIj from an overdose of heroin but they die
from concurrent illnesses that result not directly from the heroin
but from other illnesses that they contract as a result of their using
heroin.
,Mr. Winn. Now, the gentlemen that testified with Dr. Kurland,
who were on naloxone, testified that they had a loss of appetite. That
was about the main reaction they felt. Is that same loss of appetite
prevalent with users of cyclazocine?
Dr. Resnick. Loss of appetite is one of the side effects but it is
also, as all the others, one that goes away, does not persist. It does
not occur in every patient. It does occur with some.
Mr. Winn. I am sorry.
Dr. Resnick. It does not occur with eveiy patient. But anj" patient
who has been on cyclazocine maintenance, taking it regularly over a
period of time, in my experience, whatever side effects he experienced
initially, all of these side effects disappeared and they tell us the}^ take
this cyclazocine and have the same effects as if they drank a glass of
water.
Mr. Winn. Then should there be, or do 3-ou in your experiments,
have a nutrition substitute to counteract that loss of ai)petite or are
we really talking about anything that is that serious?
Dr. Resnick. It is not serious.
Mr. Winn. Not that serious.
Dr. Resnick. No.
55)1
Chairman Pepper. Dr. Resnick, again, I want to repeat our deep
thanks to you for the magnificent contribution on this subject and to
this hearing. We thank you very much.
Dr. Resnick. Thank you.
Chairman Pepper. The Select Committee on Crime of the House
has now concluded the second phase of our public hearings on the
research aspects of heroin addiction in the United States. What we
have heard for the past 3 da3's both saddens me and gives me reason
for hope. I am saddened by the low priority research that heroin
addiction has had in the past. I am saddened that at the present we
can only offer such limited hope to those addicted to heroin, their
families and their connnunities, but I am hopeful that the testimony
we have received today and throughout this hearing bolsters this hope.
That with the necessar}^ commitment on the part of Coiigress, we can
rapidly increase our capacity to deal with the heroin epidemic.
I have found from a good many years' experience in the Congress
and as a citizen of this countr}- that this great countrj" can do almost
anj'thing it wants to. When we wanted to find the atom bomb, the
President of the United States gave almost unlmiited spending power,
and so did the committees of the Congress and the Congress to that
effort. When the President committed us to go to the moon, we did
not ask how much it was going to cost. We said we were going there,
and we went. So, I found that if we make a commitment, a determined
commitment, this great country can do almost anything it wants to do.
I believe that that commitment must be expressed in terms of dollars
to finance research, and an expressed national will to solve this problem
now, not 10 years from now after so many more have died; but now.
Far too much lip service is paid to fighting heroin addiction and a
lot of it is made on the part of the Government of the United States.
We need action, and a real sense of continuing urgency until this
problem is solved, not some momentary flurrj' of excitement when
periodic disclosures gain currency in the press.
I am also hopeful that we can conquer this menace because the testi-
mony we have received mdicates that scientists are developing some
potentially successful leads that ma}' make heroin addiction a thing
of the past.
Look at the exciting prospects that are revealed here by Dr. Resnick
today, that we might develop a prophylactic to give the young people,
the way they get a vaccination for smallpox or typhoid, give them an
inocvdation and some prophylactic drug like this that would prevent
them from ever being hooked on these terrible drugs.
We must support these scientists to the fullest. The general cutback
in Federal funding of scientific research — and incidentall}', my
information is that the Russians are not cutting back on any aspect
of scientific research — which is causing great harm to all fields of
research is a pitiful example of false economy. Wliat I meant to refer
to is that they tell me in the field of space and oceanography, in build-
ing a great navy and building a maritime power, and many other
areas with which we are comjjetitive with them, their expenditures
are not being reduced. I understand they are going right along on an
inclined plane.
Cutting back as we are cutting back in so man}- areas of scientific
research is false economy, and failure to make wise investments in
552
so many areas is also a pitiful example of false economy. If heroin
costs this Nation almost $4 billion a year in direct and indirect money
costs — I am not talking about life costs, the latter largely a cost of
crime which is an economic saving — and not at least doubling, trip-
ling or even quadrupling our research efforts, clearh* is a short-
sighted and very costl}^ economy.
It is my hope that the Congress will not be a party to such short-
sightedness.
After we have had an opportunity to review the transcripts of
these hearings and stud\' the valuable suggestions we have received
and, of course, consult with knowledgeable people, this committee
M-ill make recommendations to the House of Representatives on what
we can do according to knowledgeable people to combat drug addic-
tion— how we should spend our money, what our prioritif^s should be,
and what we should do. A quarter of a milUon drug addicts — these are
American citizens — their families and the Nation demand that wc do
no less. Not to speak of the danger that these addicts constitute to
the lives and the property of other citizens of our coimtrv.
Now, just one announcement I want to make. One of the fine groups
in the greater Miami area, part of which em.braces my congressional
district, has been one group we call Operation Self-Help. Those
people have gone out and begged and tried to persuade people to put
np mone}^, voluntary contributions. They have appealed to the State
of Florida, to the Government of the United wStates, for aid and they
have received some assistance, very small, through the State of Florida,
from the Federal Government, but they have done a magnificent job
in the treatment and rehabilitation of many heroin addicts in the
greater Miami area, and that operation is Operation Self-Help, and
the founder of it and the great leader of it has been Father O'Sullivan,
who honors us with his ])resence here today.
I will ask if you will stand up, Father O'Sullivan. I would like them
to see you. [Apphiuse.]
He is accompanied by the Honorable Mr. Matthew Gressen, who is
the president of the Concept House, which is an integral part of
this great treatment and rehabilitation program.
I will ask you to stand up. [Applause.]
And he is also accompanied by two others who have had a large
part in this program, have been founders or cofounders with them, the
Rev. Clint Oakley, one of my fellow Baptist. I will ask you to stand
up. [Applause.]
And the other one, a cofounder and leader in this drug program,
Air. Roger Shaw. [A])plause.]
I thank the committee and I thank all those who have been here with
us.
The committee will adjourn.
(Whereupon, at 1:10 p.m., the hearing was adjourned, to reconvene
at 9:45, June 23, 1971.)
NARCOTICS RESEARCH, REHABILITATION, AND
TREATMENT
9ili if
WEDNESDAY, JUNE 23, 1971
House of Representatives,
Select Committee on Crime,
Washington, D.C.
The committee met, pursuant to notice, at 10 :10 a.m., in room 2359,
Rayburn House Office Building, Hon. Claude Pepper (chairman)
presiding, ^n 'd^fll ■w:t vn<ir,1 '■■^' ^ . ^ ,. . -r.
• Present : Representatives Pepper, Brasco, Mann, Murphy, Kangei,
Wiggins. Winn, Sandman, and Keating.
_,. Also present: Paul Perito, chief counsel; and Michael W. Blommer,
associate cliief counsel.
Chairman Pepper. The committee will come to order, please.
The Select Committee on Crime today concludes a series of hearings
which have examined virtually every aspect of the drug addiction and
abuse crisis in America today. We have examined the possibilities of
banning the importation of ci'ude opium into this country, and the
availability of synthetic analgesics to replace opiate drugs. We have
examined the difficulties of halting the smuggling of heroin into this
country, and the possibility of using our space age teclinology in this
fight. We have examined the successes and failures of methadone as a
maintenance drug, and the new antagonist drugs still being developed
and tested. >;■ ^iii
From its creation in 1969, the Select Connnittee on Crime has had a
continuing keen interest in drug abuse. We have often been asked why
a crime committee should concern itself with drugs. Aside from the
obvious rejoinder that drug abuse is usually by definition a criminal
act, we believe there are far more pressing reasons for our interest
and work in this area. The nexus of drug abuse to other criminal be-
havior, only alluded to when we first began our investigations, has
now been testified to by every respected law enforcement authority.
Wliile statistics in this area are inexact, it seems clear that in major
cities about half of all property crimes are committed by addicts who
are compelled to steal to supply their daily fix. And Dr. Robert Du
Pont, director of the District of Columbia's Narcotics Treatment Ad-
ministration, told our committee recently that perhaps half of all
homicides are committed by addicts. So when we are talking about
drug abuse we are talking about what is proba;bly the largest single
cause of crime in Ajnerica today. , q,;^,,;
Our investigations and hearings have taken us across the length
and breadth of America, and everywhere we have heard much the
same plea : Help us fight this grave menace to our society. The mag-
(553)
55,4
nitiide of heroin addiction in America knows no jurisdictional bound-
aries; local, State, even national borders, provide no shield to this
deadly traffic.
There are those who say that there will always be a supply of heroin
as long- as there is a demand for the drug ; others claim that as long
as heroin is available, the demand for it can always be created. In fact,
both statements are true, and we must take this into account in any
effort to deal with the problem.
It is clear, in the first instance, that we cannot reasonably expect
substantially to halt the smuggling of heroin into this country. Short
of the imposition of police state techniques, a virtual sealing of our
borders, heroin will reach its customers on the streets. We have been
told by the authorities of our Government that we are able to seize
only about 20 percent of the heroin that is smuggled into this country.
But the same supply, as well as satisfying demand, also creates addi-
tional demand. For the classic way for the heroin addict to support
his habit is to become a heroin pusher himself. And as long as addicts
have enough heroin to push in order to pay for their own habits, we
will see an ever increasing number of new addicts, for the market is
virtually limitless.
What can we hope to do to fight this menace? Last year, this com-
mittee urged that the United States take the lead in working for the
eventual elimination of opium poppy production wherever such pro-
duction takes place. We were told we were dreamers. Well, if to work
toward an admittedly long-range goal that holds some promise of
success means to be dreamers, we gladly accept the title. But is this goal
so impossible of attainment, or has our own skepticism worked to en-
sure our failure in this endeavor ? I was pleased to read the other day
that the Prime Minister of Turkey has offered his legislative or par-
liamentary body legislation that would substantially reduce the opium
crops, something we recommended long ago. We are pleased to learn
that one house of the Turkish Parliament has already passed the pro-
posed legislation. We applaud liis actions as a new awareness of the
world wide nature of heroin abuse. So are we dreamers after all? A
positive approach by the United States may well be one of the kev in-
gredients in fostering a similar attitude by other members of the
world community.
A substantial portion of our energies have gone to an examination
of the research underway to produce drugs for treating addicts. Al-
though we must be mindful of the distinction between curing an addict
of his addiction and reintegrating him into society, as a committee
on crime, we are obviously anxious to fully explore any treatment
modality which offers the hope of reducing crime.
We have carefully examined the use of methadone as a maintenance
drug, and while we believe it is far from a panacea, we do believe that
it is the best drug now available on a large scale for treating a substan-
tial segment of the addict population. But we have also received testi-
mony about the new antagonist dimgs, which curb an addict's craving
for heroin. We believe these significant drugs have been slighted by
those who have the funds to foster the development of treatment
modalities. We have heard testimony that for about $5 million— a mere
pittance given the magnitude of the problem — we could possibly de-
velop a long-lasting nonaddictive antagonist. You will recall Mr. In-
gei-soll of tlie Bureau of Narcotics and Dangerous Drugs testified te-
fore our committee recently that he estimated that herion costs our
country between $3,5 and $4 billion a year. I say this $5 million is a
mere pittance given the magnitude of the problem. Not to spend this
inoney verges on malfeasance. When we submit our report to the Con-
gress, we intend to ask for a crash program to develop such an antago-
nist. I believe this would be an investment that would pay im-
measurable dividends.
The President, in announcing his new drug program last week, has
wisely recognized the national drug abuse and drug dependence crisis
to which our committee has devoted a substantial portion of its time
during the past 2 years. Certainly the administration is to be com-
mended for recognizing that drug abuse lias "assumed the dimension
of a national emergency." The President is also to be commended for
recognizing that the drug user, if submitted to proper treatment, can
be reclaimed as a responsible member of society. However, I am serious-
ly concerned that the process of reclamation will fail unless more
money is committed to the building and adequate staffing of treatment
and rehabilitation facilities on a nationwide basis.
Our committee was particularly pleased that the President chose
Dr. Jerome H. Jaffe of Chicago to head this new office in the executive
branch of the Government and that he was given the authority that
Dr. Jaffe was given. We all heard and were substantially impressed
with Dr. Jaffe's presentation before our committee on April 28, 1971.
I am especially pleased that the President has chosen a man of impec-
cable academic credentials who is not inextricably associated with a
limited rehabilitation philosophy or treatment modality. Dr. Jaffe's
sagacity in establishing a multimodality treatment approach is well
known to our committee. Additionally, Dr. Jaffe is a researcher, who
by his own admission, longs someday to return to his laboratory.
I sincerely hope that the President, in light of Dr. Jaffe's expertise,
w^ill especially earmark additional moneys for basic opiate research. It
is my personal judgment that the moneys presently earmarked for
research would not enable diligent and committed scientists to do the
type of research that is necessary to develop more effective and longer
lasting blockage and antagonist drugs. The President has failed to set
forth, as specific line items in his appropriations amendment of June 21,
1971, such amounts as I feel will be necessary to expand on and accel-
erate the study of drug effects, abuse, prevention, and treatment. I
take note of the fact that the President has reputedly told Dr. Jaft'e
and publicly announced that if more money is needed, it will be
provided. I think indeed it would appear to be imperative and I hope
that the President will recommend to the Congress adequate funding
for this program.
The President has, however, seen fit to request specific sums for
research into plant eradication and opium detection. It is my fervent
hope that the President will request additional sums for the explicit
purpose of carrying out more substantial basic research into the basis of
opiate addiction and the effects of diTig dependence upon the body.
Furthermore, our committee has found that additional research
must be done, and must be done immediately, to develop safe and effec-
tive nonaddictive synthetic substitutes for morphine and codeine. It
seems to me that in a country where last year the gross national product
556
reached $976.5 billion, we can well afford to spend something more
than the $11 million in new money presently scheduled by the Office of
Management and Budget for pure research conducted under the direc-
tion of the new Special Action Office for Drug Abuse Prevention. If
our country can tolerate a defense budget which reached $76.4 billion
during the past fiscal year, we can obviously support basic drug
research far in excess of the relatively paltry sums presently requested
in the recent appropriations message which the President has for-
warded to Congress.
I am deeply concerned that we must leave na rock unturned in our
efforts to answer some of the basic (questions regarding drug abuse
and drug dependence. The state of our knowledge in this area has been
shockingly described as primitive by Dr. William Martin at our last
healing. How can we possibly justify to our constituents and to our
Xation the fact that we have for so long denied basic science the money
and tools to answer so many of the unanswered questions about this
menacing epidemic ? How can we in this Congress intelligentl}^ legis-
late in these areas when we don't know basic answers to so many basic
questions about how herion, cocaine, amphetamines, and barbiturates
affect the brain, the central nervous system and the f mictioning of the
basic body organs? I sincerely hope that this Congress will aid the
President and his outstanding nominee for the office of Director of tiie
Special Action Office for Drug Abuse Pre\ention by providing ad-
equate funding which will enable Dr. Jaffe and his associates properly
to direct, simulate, encourage, and accelerate the type of i-esearch
winch is necessary if we are seriously committed to solving this national
calamity.
I am indeed pleased that the President has recognized that there is
a need for overall coordination and planning of the present multiple
Federal efforts in the areas of treatment and rehabilitation. At present,
nine Federal agencies unevenly share this responsibility without the
benefit of a comprehensive plan of attack. A comprehensive approach
on the Federal level is absolutely necessary if our Government is seri-
ously committed to a national drug abuse offensive. To the best of my
knowledge, the administration is only requesting $91.3 million in new
money for treatment and rehabilitation for fiscal year 1972. This sum,
added to funds already provided for treatment and rehabilition,
amounts to a totfil of $195.3 million for the coming fiscal year. It is dif-
ficult for me to understand how this limited amount of Federal money
can possibly be truly responsive to our national drug addiction crisis.
However, the President has said, as I have said, that if additional sums
are needed after an analysis of the problem by Dr. Jaft'e, such sums will
be requested by the administration. I for one, think the Congress has a
substantial responsibility in this regard. I see no reason why the
Federal Government slionld not be able to say that it will be able to
offer treatment to every drug dependent ])erson who desires such
treatment. At the present time we cannot make good on this representa-
tion. I seriously doubt whether the present request for $91.3 million in
new money will allow us to make that representation next year. How
can we possibly explain to the Nation that persons requesting medical
aid for their addiction are denied such aid because we have not ])ro-
vidcd sufficient treatment aiul rehabilitation facilities 'i
557
Our investigators have reported to us several instances througliout
the country where addicts have sought treatment at hospitals _ and
clinics, buthave been denied treatment because of inadequate facilities.
How can we possibly explain away the crimes which these addicts ares
forced to commit in order to feed their voracious habits ? How can we
possibly justify the overdose deaths of addicts who have requested,
but have been denied medical aid? A humane society cannot justify
such inequities.
: I respectfully submit that Congress cannot shirk from its respon-
sibility in this regard. Our record is replete with evidence showing the
need for a tremendous expansioii in our medical facilities to handle
drug dependent persons who seek help. Since the need is clear, Con-
gress must respond adequately. . . . /r.x'J
Today we will examine various State and local rehabilitation pro-
grams for heroin addicts, and wliat more the Federal Government can
do in this area. The need for adequate rehabilitation programs and
facilities cannot be overemphasized, for any success we enjoy in de-
creasing the supply of heroin on the streets, or finding drugs that
block the craving for heroin, only intensifies our need for massive and
effective rehabilitation programs.
"Wlien we talk of rehabiliting addicts, we are again talking of re-
ducing crime. What lasting benefit does society receive when we simply
detoxify an addict and send him back into the streets of his past, with-
out the ability to earn a meaningful livelihood, without a decent place
to live, without, in short, those ingredients Americans view as essen-
tial to self-respect? A lack of self-respect has often been cited as a
causative factor in drug abuse. Will the detoxified addict, without a job.
without a decent home, long remain a former addict? There is little
reason to expect that he will. And if he returns to heroin, he also re-
turns to crime.
It is with this in mind that we are today examining these programs
and the involvement of the various States in this endeavor. While I
believe that the Federal Government must play a significantly larger
role in combating the addiction crisis, the important role ]:>layed by the
States cannot be overemphasized. Therefore, we are today seeking the
advice of Governors and other State officials. We will lean heavily
upon the advice of these men as we draw up our recommendations to
the Congress. We are honored that Gov. Linwood Holton of
Virginia, Gov. Jimmy Carter of Georgia, Gov. Milton Shapp of
Pennsylvania and Lt. Gov. James H. Brickley of Michigan have come
here today to share with the committee the experience of their States
in dealing with narcotic addiction. We will also hear from Commis-
sioner Howard Jones, vice chairman of the New York State Narcotic
Addiction Control Commission, a man charged with grappling with
the highest incidence of heroin addiction in the Nation.
We will also take testimony from Dr. Jolin Kramer, a distinguished
psychiatrist who has devoted much of his time and energy to the prob-
lems of drug addiction and abuse, through various programs in
the State of California.
Our first witness this morning is Commissioner Howard A. Jones,
vice chairman and I believe designated chairman of the New York
State Narcotics Addiction Control Commission.
60-296 — 71— pt. 2 15
558
Mr. Jones was appointed to the commission by Governor Rocke-
feller in May 1970, became vice chairman in November. He is now
the chairman designate of the commission.
Mr. Jones Avas a member of the State board of parole from June 1063
until May 1970. He served from 1961 to 1970 as a member of the
Temporary State Commission on Revision of the Penal Law in the
Code of Criminal Justice. From 1960 to 1963, in New York County,
where he gained considerable experience as a trial law^^er in criminal
jury trials and was also in charge of narcotic investigation and
prosecution.
Commissioner Jones attended the City College of New York and
New York University and obtained his law degree from Saint John's
University Law School in 1951.
Mr. Jones, we are veiy grateful for your appearance here today.
Our chief counsel, Mr. Paul Perito, assisted by our associate chief
counsel, Mr. Blommer, will inquire.
Mr. Perito. Thank you, Mr. Chairman.
Mr. Jones, you are accompanied by two gentlemen. "Would you
kindly introduce them to the chairman and members of the committee ?
STATEMENT OF HOWARD A. JONES, COMMISSIONER, NEW YORK
STATE NARCOTIC ADDICTION CONTROL COMMISSION: ACCOM-
PANIED BY DR. CARL CHAMBERS, DIRECTOR, DIVISION OF
RESEARCH; AND RAYBURN F. HESSE, SPECIAL ASSISTANT TO
THE CHAIRMAN, FEDERAL-STATE RELATIONS
Mr. Jones. Yes, Mr. Perito. On my right is Dr. Carl Chambers who
is the director of our division of research in the New York State
Narcotic Addiction Control Commission, Dr. Chambers brings with
him a lone-er list of credentials than I think we have time for, as vou
will see when you get into the various reports that we will submit to
3'ou for your consideration as part of this presentation.
On my left is a gentleman familiar to you, I think, Mr. Rayburn
Hesse, who is the special assistant to the chainnan for Federal-State
Relations of the New York State Narcotic Addiction Control Com-
mission.
It is a privilege, Mr. Chairman, to have this opportunity on behalf
of Governor Rockefeller, the State of New York, and our commission.
to present our views to you on the urgent problems of narcotics de-
pendence and addiction.
Our commission congratulates you, Congressman Pepper, on the
leaderehip, the imagination, and the dedication you have given to
this complex cause, especially your efforts to control the various
psychotropic substances, for these, as you know, are the principal
drugs of abuse in the Nation ; also for your efforts to bring about more
efl'ective controls over the production of narcotic substances.
We are particularly proud, even though he is absent, that a New
Yorker, Congressman Rangel, is a member of this committee. As you
Iniow, he represents perhaps the most highly impacted area of crime-
related drug abuse in the country.
Chairman Pepper. Mr. Jones, I accept your compliment on behalf
of our committee. We have a very dedicated committee. We appreciate
your kind words.
559
Mr. Jones. With your permission, Mr, Chairman, I would like to
depart from the usual practice, that is followed, I supj)ose, at these
hearings, to the extent of abondoning the text of the testimony
that we have prepared, copies of which were sent down in advance.
Mr. Perito. Excuse me, Commissioner.
At this point, Mr. Chairman, may the entire text of Commissioner
Jones' statement be submitted as part of the record ?
Chairman Pepper. Without objection, it will be admitted in the
record.
Mr. JoxES. For the record. I would like to mention that there
were some slight revisions made in the copies that were sent down
previously. Revised copies have been submitted this morning and I
ask your indulgence and express an apology for the late submission.
We are especially pleased, Mr. Chairman, that your committee is
confining its attention at these hearings not just to the problem of
addiction and treatment, but to the larger problem of the overall
manifestations and ramifications of narcotic dependence and drug
addiction. As you know, we are confronted with a nationwide
Chairman Pepper. Excuse me, just a minute. We have two very fine
members from New York, Mr. Frank Brasco and Mr. Eangel. Mr.
Rangel was detained. He will be along shortly.
Mr. Jones. I am sure I did not mean to
Mr. Brasco. That is perfectly all right.
Mr. Jones. I think, Mr. Chairman, it will be helpful in our presenta-
tion, mindful of your tight schedule this morning and tlie fact that
several Governors will be appearing to testify, if we simply simimarize
the presentation that we would like to make, following which, and
again with an apology, we have submitted an addendum to our testi-
mony which we thought would be necessary and helpful in connection
with the recently announced programs that emanated from the White
House this past week.
I would like, therefore, to present our testimony in these four main
categories : First of all, a summary of the text that we have submitted ;
some comments that are contained in the addendum with regard to the
President's new proposals ; next, the implementations that we think are
reasonable, perhaps even feasible, for this Congress to consider ; and
finally, to submit the various studies and reports that we brought along,
authored largely by Dr. Carl Chambers, and with your indulgence, I
would turn over the latter part of the presentation to Dr. Chambers.
I think it will be helpful if we focus the discussion, Mr. Chairman,
on the excellent frame of reference that the President made in his news
releases recently. I am referring, of course, to the promise of the admin-
istration that the effort indeed the highest priority, will be given at all
levels of Government, not just to drug addiction as it affects returning
veterans, but as it affects the Nation as a whole. At the time we pre-
pared our text, our testimony, we did not have the details of the
President's new program and that is why, as I said, the addendum
was prepared. I think it is absolutely essential that the Federal Gov-
ernment provide for the treatment of returning veterans because State
progranis do not currently have the capacity to absorb this new group
of addicts. As you will see in the materials that will be submitted to
you, there is an estimated total of some 1,200 veteran addicts among
the drug addict population in New York today, and I think it is signifi-
560
cant when you consider that Out of the total, the estimated total of
about 110,000 addicts in the State of New York, already 1,200 of them,
again an estimate, are returning veterans. It is our fondest hope, Mr.
Chairman, that the promise of policy that has recently been enunciated
will be transformed by this administration and by the Congress into
the performance pi-ogram. We, of course, have some pretty fixed ideas
as to the directions in which these programs should move and to things
that should be done, perhaps to quickly implement the programs that
Jiave been announced, willi the help, of course, of this Congress.
Chairman Pepper. Mr. Jones, do you loiow that one of our members,
Mr. ^lorgan Murphy of Illinois, was one of the Representatives who,
with Representative Steele, made the i-epoit on the world heroin prob-
lem; his particular interest is the pro}:)lem of addiction among our
veterans in the Indo-China war ?
Mr. JoxES. Yes, I heard of Mr. Murphy and his trip and his report.
I look forward to some meaningful exchanges, as a matter of fact,
between our commission and the Congressman.
Because of the large number of heroin addicts in tlie State of New
Yorlc and, indeed, in the country and because of the fact that the matter
of heroin addiction carries with it such a large impact on the rest of
society with regard to crime and the effect of crime, understandably,
much of the concern, both at the Federal and State levels, has been
directed toward the heroin addict. The first observation we would like
to make, of course, is one that I am sure is familiar to the gentlemen
of this committee. That is that heroin addiction is merely a tiny frac-
tion of the total problem of drug abuse in the Nation. I think it would
be helpful, therefore, if generally speaking, we thought in terms — that
is, for defining program differentiations — if we thought in terms of
four main categories of drug abusers : The experimenters, the recrea-
tional or social users, the involved users, and the disfunctional
abusers — ^tlie latter group, of course, including but not limited to nar-
cotic addicts.
Certain essential facts, I think, must i-emain in the forefront of
our thinking and our planning. One outstanding fact, Mr. Chair-
man, is that the drug abuser today is younger, much younger than
he was even 4 or 5 years ago. He is much more inclined' to take risks
and more importantly, he has been found to be a multiple drug user.
Just 4 years ago, for example, when our commission first began
operations, the average age of the heroin addict in New York was
29. Today, that median age is estimated at 21. Today, 35 percent of
the 12,000 addicts under our direct jurisdiction — and by "our," I
mean the commission itself — are under age 20 in the State of New
York. Similarly, I think your own studies will show that whereas
only 15 percent of the addicts admitted to the Federal hospital at
Lexington in 1936 were 20 years or yomiger, today 53 percent of them,
as I am sure you know, are under age 19.
I think these statistics simply highlight what we all know to be
the clear evidence of a growing epidemic, really a pandemic, in the
country today.
Mr. PePvIto. Based upon your vast experience do you believe that
pandemic would be a more ])roper classification than epidemic?
Mr. Jones. Indeed I do, and I think recent developments will bear
that out, especially with the incidence of returning veterans, com-
561
ing back from overseas, going back to various parts of the country
that hitherto, perhaps, did not have the sad experience of having
among their population young drug addicts, especially the hard-core
drug addicts.
■; Another change that has taken place, gentlemen, is the change
ill the nature of the drugs that are being used and abused, also sub-
stantial changes among the various types of users. These users today-
include top corporate executives, middle management, clerks, sales-
men, white- and blue-collar workers, housewives, as well as young
people. And as you will see again, referring to studies that we have=
made, the matter of drug use and drug abuse by people actually on
the job is a really startling fact to consider. We have defined a major
problem of drug abuse in business and industry at all levels of work,
including a significant percentage of employees who abuse drugs
while actually on the job. Now that business and industry are in-
volved, we look for added involvement from that sector of the public
in the fight against drug abuse.
Another major change, gentlemen, that we have found to have oc-
curred over the past few years is that more and more people are be-
coming involved with drugs as a matter of recreation, believe it or
not. Hence, it is no longer entirely a medical problem with which we
have to deal ; it is becoming more and more also a matter for social
workers and other disciplines to address themselves to.
These are essentially some of the changes in direction and pro-
grams that we are undertaking in New York at the moment and urge
for your consideration, a similar change of direction and focus on
the part of the Federal Government.
We must recognize, gentlemen, that there are adaptive as well as
escapist abusers, persons who use drugs to cope with life and to ad-
just to the ordinary problems of society, aside from the thrill seekers
and other types that we are used to discussing. Not all drug abusers,
as you know, are criminals. As a matter of fact, the National Insti-
tute of Mental Health predicts that 65 percent of the experimenters
with marihuana will use the drug only once or twice, and the majority
of the remainder, not more than 10 times in their lifetime.
Eecent research by our commission suggests that of 100 students
in a given high school, 50 will experiment with drugs at some time
or other during their school career. As a matter of fact, the study
further reveals that 50 percent of the average graduating class from
high school has liad drug experience. So that if this number, this
large number of high school graduates going out into business and
industiy or going on into college, where the figures are substantially
the same as those people going out into business and industry, there
is no reason to assume that they are suddenly going to discontinue
their experimenting with drugs. So that what we are doing, gentle-
men, is we are graduating 50 percent of our classes these days right
into business and industry as drug experimenters, some of whom,
of course, will later on become disf unctional addicts.
^- As I said, gentlemen, there are a number of studies that we will be
submitting to you. I do not want to burden you with mere recitation
of what each one contains. But one study that you will see indicates
from facts developed by Dr. Chambers and our research unit that of
every addict that was studied, every single one had engaged in some
562
criminal act in his lifetime. Yet only 79 percent had arrest records.
I think that is significant in terms of the total projection of what drug
abuse and drug experimenting means with regard to crime statistics.
The fact is, of course, that there are mitold numbers of crimes that
^o unreported. Even among those are are reported, the studies in-
dicate that they are largely unrecorded. It is estimated, as you will
see, that perhaps only once out of every 120 times that a convict-
addict, if I can use that phrase, is arrested and convicted of a crime,
only once out of 120 times that he actually commits a crime will such
an arrest and conviction be actually recorded — a startling disclosure,
as you will see when you examine these submissions.
Mr. John Ingersoll recently estimated that the total drain on the
national economy by reason of heroin addiction is as high as possibly
$3.5 billion, including, of course, the cost of crimes committed and
the law enforcement costs. The Urban Center of Columbia University
said in a recent study that the cost of narcotics-related crime in Har-
lem alone runs as high as $1.8 billion. Now, we do not suggest that
these conclusions or these figures are contradictory; we do suggest
that they again emphasize the importance of reexamining our prior-
ities, particularly since the traditional cost of crime estimates, let us
call them
Chairman Pepper. Mr. Rangel of Harlem has just come in. Would
you repeat that statement you just made, Mr. Jones?
Mv. Jones. I am sure it comes as no surprise, but the reference,
Mr. Rangel, was to a recent statement by Mr. John Ingersoll to the
effect that the total drain on the national economy caused by drug
addiction is e.stimated at some $3.5 billion, including the cost of crime
and the law enforcement costs. In a similar study, I just stated, the
Urban Center of Columbia University reported that the cost of nar-
cotics-related crime in the Harlem area alone nms as high as $1.8
billion.
Now, this is exclusive of the costs of law enforcement and crime
prevention.
Mr. Murphy. Commisisoner, may I ask one question at this point?
What percentage of the total crime in New York do you think is drug
related ?
Mr. Jones. Dr. Chambers?
Dr. Chambers. It would be impossible to estimate. We feel com-
fortable with the estimates that have been made, 50 to 60 percent of
all crimes attributed to the addict. I would feel more comfortable
talking about what we do know as opposed to what we do not know.
What we do know is that each of the addicts who is on the street,
excluding the hidden user — the individual who still maintains em-
ployment, ct cetera — the street addict is committing 120 crimes for
every one that he is being arrested for. For every one that he is ar-
rested for, only half of those result in a conviction. We feel more
comfortable with that. You can take and multiply by the number of
street addicts that are cuiTently being projected, but it is impossible
to estimate the dollar cost of this, because the individual may be
stealing things that today sell for more than they will sell for
tomorrow.
I think more important than the dollar cost, or at least as important,
is that there appears to be an evolution in the type and amount or
563
crime being committed. The same study involving the hidden, unre-
ported crime, also indicated that 65 percent of this group had crimes
against the person in their history. We have traditionally grown up, I
think, with the idea that the heroin addict is a passive, dependent
individual who commits property crime. He does indeed commit prop-
erty crime, but he also commits crimes against the person. What ap-
parently is happening, and I use "apparently" advisedly, he leaves
his house in the morning and he commits that crime which presents
itself. If it happens to be a mugging, that is what gets committed.
If it happens to be a purse snatching, that is what gets committed.
We can no longer predict and, therefore, assign enforcement on the
basis of what we knew about the old heroin street addict.
Mr. Murphy. Thank you very much.
Chairman Pepper. Excuse me just a minute. Dr. Robert Dupont,
director of the narcotics treatment administration in the District,
also estimated about 50 percent of the homicides were committed by
drug addicts. Have you any comment on that ?
Dr. Chambers. Yes, sir; I heard you mention that earlier. I was
not aware of that figure. We do not have a comparable figure, but it
will not be long until we do, now that you have mentioned that.
Chairman Pepper. Thank you.
Mr. JoisTES. With regard to the cost of crime estimates, the added
point that I would like to make is that most of these estimates, gentle-
men, fail to include the incalculable losses suffered by the victims
of these crimes — whatever the percentage might be. Congressman
Murphy, of those crimes that are committed by addicts. In New York,
we recognize and try to reflect a growing concern for the innocent
victims of crimes, whether they be committed by addicts or nonad-
dicts. They help swell the figures, you see, that I think reasonably
should be considered in assessing estimated costs of crime.
In Xew York, for example, in the current fiscal year, we have ap-
propriated $2.2 million to aid the victims of violent crimes under a
program that was recently launched.
Just a few more observations with regard to the text, Mr. Chair-
man. As you will see, further studies indicate, and this one is some-
what startling, that among the numbers of students in a ninth grade
class — and if I am not mistaken. Dr. Chambers, this was not a class
in New York City, this was a surburban area — but among the mem-
bers of a ninth grade class, 27 percent of them used drugs or drugs
and alcohol. Some 24 percent of them used alcohol alone, and the rest
either had no drug abuse or different kinds of drugs. Altogether, there
were 12 different kinds of drugs that were admittedly used by mem-
bers of this ninth grade class that was surveyed, indicating that the
problem is not only spreading outward, but it is seeping further
downward among the age groups like a deep, heaA^ fog settling over
the lives of blighted youngsters in the metropolitan area where this
survey was made.
Mr. Perito. Commissioner, was that study made in Westchester
County ?
Dr. Chambers. These figures do not relate to Westchester County.
We actually did 65,000 instruments in the State, in counties through-
out the State. This happens to be an upstate suburban area.
564
Mr. Perito. Would it be fair to describe this area as an iipper-
middle-class community ?
Dr. Chambers. Yes ; it is.
'Mr. Perito. Please continue.
Mr. Jones. I have already alluded to the significance of the new
phenomenon of multiple use and multiple-diTig abuse, multiple addic-
tion. In 1944 there was 8 percent of the population at Lexington that
had concurrent use of opiates and barbitura.tes, with 1 percent ad-
dicted to opiates: By 1966, that figure had swelled, believe it or not,
to 54 percent, from 8 to 54 percent in 22 years, that showed concur-
rent use of opiates and other types of drugs, M'ith 35 percent addicted.
I think it is important, gentlemen, that in all your deliberations, you
focus upon not only what drugs do to an individual, but what they
do for an individual. I made some reference to this earlier when I
said that increasingly larger numbers of drug users find themsehes
involved as a matter of recreation, as a matter of, almost, survival in a
very hectic, teeming sort of way of life.
There are other statistics, as I said. I fall victim myself to the thing
I keep saying I will not. but as you can see, whenever j'ou get in-
volved in studies of this kind, you do tend to get overwhelmed by the
facts and figures that are revealed. I w^ill try not to burden you any
further with these statistics.
The next categor}' I would like to discuss generally, gentlemen, is
a comparison of the Federal and State efforts. There was much dis-
cussion when we were putting this together because of the fear, don't
you see, that whatever we say in this context might be construed —
and w^e hope not — as critical of the Federal Government or the pres-
ent administration. It is not intended to be, per se. It is done only and
entirely in the hope that further cooperative effort will be generated
and further meaningful channels explored of cooperation between Fed-
eral and State Governments.
Chairman Pepper. Mr. Jones, let me make it clear for the record
that the purpose of this committee is not to be critical but to be com-
mendatory of the effort being made, and to try to find out from
knowledgeable sources the magnitude of the problem and the magni-
tude of the effort that will have to be made to cope with the problem.
Mr. Jones. Thank you, sir ; as commendable as the Federal efforts
have been, gentlemen, they are simply not enough. Comparisons are
odious, I know, but when you consider, sirs, that in 4 years, the State
of New York has spent almost a half billion dollars in its entire drug-
effort, the figure is actually $475.3 million, almost half a billion dollars
in 4 3'ears operation, I think you can understand the point I am trying
to make.
Mr. Perito. Commissioner, excuse me, are you referring to all re-
lated drug-abuse activities ?
Mr. Jones. That is right. This is not just operational budget figures
for the commission itself; these are also for funding of agencies, pri-
A'ate agencies that are treating drug addicts.
Mr. Perito. Is that excluding the cost of law enforcement ?
Mr. Jones. Yes.
Mr. Hesse. Yes ; it is.
l\fr. Jones. That is excluding law enforcement: right.
Mr. Brasco. But that includes all the administra(ivi> coMri'f
565
Mr. JoxES. True, part of our operational budget is included. But
keep in mind, Mi*. Brasco, that of the total, the total operating budget
year by year, out of that, we fund ]Drograms that are designed for
treatment, including our own. So it is not just salaries and
Mr. Brasco. No, no; I was not — you see, we get to that area all
the time. To echo the words of the chainnan, I am trying to find a pos-
ture, not to be critical. I was just curious, when we give tlie figure —
you know, sometimes, when presented, it sounds like a very large
amount. But when you have to take into consideration that of neces-
sity, you need administration in all of these programs and the ad-
ministration, obviously, is part of the treatment, but it does eat into
that $475 million that has been spent over the, 4 years.
Mr. Jones. That is right. r fvi -
Mr. Brasco. I am just wondering whether there was a breakdown
on what it costs to administer the programs, inchided in the $475
million.
Mr. Jones. Oh, yes; we have figures that we will be glad to submit
to you. Even with the extensive cuts that were made, budgetary cuts
that were made by our own legislature this year, gentlemen, the op-
erating budget alone for the current fiscal year is $91.7 million as com-
pared with a figure of $20.7 million 4 years ago, when we started. As
I said, I will be happy to submit a breakdown to show you just where
tliose moneys go that we label generally operational budget, with the
assurance that a large part of it does go for treatment.
(The budget breakdown referred to follows :)
The Commission's present fiscal plan calls for the following' allocation of its
$91.7 million State purposes appropriation for fiscal year 1971-72 :
Dollars
in millions
Administration $3. 7
Centralized support services 22LuJJ : 2. 6
Residential treatment and rehabilitation . ij^. ■ ;24. 6
Community based and aftercare treatment and rehabilitation .^^^ -^23. 6
Treatment and rehabilitation contractual services^ . 9.2
Methadone ^ . 20. 6
Research and testing 1. 7
Prevention and communications 2. 5
Total =* 88.5
^ Excludes detoxification services expected to be financed through medicaid and Includes
Hart Island.
-To be supplemented by approximately 10 percent in medicaid funds.
3 Limit of current expenditure plan.
Mr. Rangel. Commissioner, there is no question that New York
State has really provided the leadership in the attempt to rehabilitate
the addict, and certainly those here in Washington are looking for
some of the answers, whether it be medically or in the area of rehabili-
tation. Now, could you, representing the State's program, give us
tiny idea^ — notwithstanding the amount of money that has been spent —
as to what ]')ercentage of drug addicts went through your program and
are presently drug free ?
Mr. Jones. Well, I am sure Dr. Chambers has the figures more
readily at hand than I do, but I do have one figure here that in 4
years, 38,933 addicts have been through our program of which total
there are something like 10,000, if I am not mistaken, currently in
treatment.
566
Now, Dr. Cliambers, can yon respond to the further part of the
question relating to wliat percentage of that total remain drug free?
Dr. Chambers. I think we can say this for you : We have a 3- to
5-year commitment process. Those who are processed through the
entire civil commitment, the 3 or the 5 years, are a relatively small
number of people thus far. Of those who have gone all the way
through the program, roughly 25 percent are currently abstinent,
according to a physical followup. I have a followup division which
goes to the field at periodic times after decertification to physically
locate, interview, and request a urine specimen from our decertified
clients.
That is not to suggest that 75 percent are now nonabstinent indi-
A'iduals. Roughly 25 percent have either recertified themselves to us
or have entered other treatment programs. They are not currently
addicts in the classical street sense. We have, therefore, a residual
of approximately 50 percent who are in jail as a result of a new
offense, drug related, or have returned to drugs.
I must emphasize, though, that we are still talking about a rela-
tively small population because of the length of history of the com-
mission itself.
Mr. Rangel. Well, notwithstanding the small number that you
are dealing with, is it safe to say that New York State does not have
the answer to rehabilitating drug addicts ?
Mr. Jones. Oh, that is a safe statement; absolutely.
Mr. Rangel. The doctor was thinking about it.
Dr. Chambers. Well, I do not think anyone has the answer, because
I do not think there is an answer to drug addiction. For example, if
I may give you a personal bias, the longer I am around people who
use drugs, therefore around people who subsequently abuse drugs,
the more I become convinced that drugs do large numbers of things
for people — not one thing. You do not handle only depression with
drugs ; you do not handle only anxiety with dru^s ; you do not handle
only the loss of a job with drugs or the inability to get a job with
drugs. So as long as there are multiple reasons that drugs do some-
thing for the individual, or even that he thinks drugs are doing some-
thing for him, then I do not have an answer to the treatment of those
people.
Mr. Rangel. Well, what would you suggest, Doctor, if you had the
responsibility of creating a Federal program and the Congress gave
you the money to do what you thought had to be done? What areas
would you go into ?
Dr. Chambers. Well, I think I share the same treatment philosophy
that most drug professionals have today, that since we do not know
the answer, since what we do know is that each of the modalities that
has been tried has been successful and each one has also been a failure,
and until which time we use a multimodality approach, using all of
the modalities, evaluating all of them with the same yardstick, that
is w^hat I will have to recommend. I must have substitution programs,
lioth the antagonist programs and the maintenance programs. I must
have detoxification facilities; I must have halfway houses; I must
have purely abstinent residential centers.
I guess I want everything we have tried and anything else I can
think of to try, put all of them in an experimental fi-anu> wIumv L
567
can do controlled evaluation and actually see which is working best
with which type of client.
Mr. Rangel. What, if anything, has New York State done in the
area of research since we have not really found an effective rehabilita-
tion modality as yet? Is there any research being done with the,
millions of dollars that are being spent?
Dr. CiiAiMBERS. Of course there is research being done. There are^
several levels of research. I would suggest that the commission has en-
gaged in most, if not all, of the levels of research. For example, I have
great faith tliat Dr. Mule's laboratory science work is a marked con-
tribution to the field. In the otlier i-esearch areas, we have been fortu-
nate within the commission to be able to randomly assign people to
the various kinds of facilities, the various kinds of programs that we
operate internally. These are being carefully monitored. In addition, I
also have the data from the systems for all of the programs which
we fund, rather than only for our civil committed clients. Those are
all being evaluated now, with the same yardstick that I applied to the
commission.
Mr. Rangel. Have you had any experience at all with a substitute
drug which is not addictive ?
Dr. Chambers. It is my impression, and it is only that, that we have
not had a pure antagonist yet, which is what j^ou are asking for. Even
naloxone and cyclazocine have some agonistic characteristics which
suggests they do have some abuse potential.
Mr. Rangel. Does the drug Perse means anything to you ?
Dr. Chambers. Yes.
Mr. Rangel. Have you had any opportmiity to study its effects
on drug addicts ?
Dr. Chambers. No ; I have not.
Mr. Rangfx. Is there anyone with the New York State commission
that is preparing to investigate the feasibility of using this drug ?
Dr. Chambers. That question has to be directed to the commissioner.
Mr. Jones. Yes ; there is. That is why I interrupted. Dr. Chambers
may not have even known yet about recent developments, as recent as
last week.
A committee, Mr. Rangel, finally has been appointed to examine
this drug, the one to which you referred. Perse. It is one that, an effort
that started a year ago and finally culminated in the formation of this
committee^ — I might say a committee of veiy highly critical medical ex-
perts, but I think the more critical they are, the better, frankly, from
the point of view of results that may obtain. Some of the names of the
members of that committee. I am sure, will be familiar to you. They
have agreed upon a protocol to be followed. I have been assured that
the requirements and the requests that the committee will make shortly
on Dr. Revici will be met ; namely, submission of his own protocol, a
submission of quantities of the drug that he has developed for analysis,
and other inputs which they will shortly ask him to provide. He has
assured me that he will provide them and this committee will then start
working on the first indepth analysis of the whole theory and testing of
the product that he has put forward.
I might say that Dr. Mule, who is head of our laboratory, is the head
of that committee.
568
Mr. Raxgel. Our distinguished chairman has provided congres-
sional leadership in assisting Dr. Revici to have a fair review of some
of the assumptions he has made to us thixjugh other doctors, so I would
hope tlie commission might be able to work very closely with this
committee to make certain that whatever areas we explore, we can do
it witliout duplicating. I am very excited to hear that my State, too, is
involved.
]Mr. Jones. Right.
Mr. Br.\sco. Would the gentleman yield for a moment ?
Mr. Rangel. Yes.
Mr. Brasco. I wanted to echo the words of Mr. Rangel. Certainly,
I, too, am very happy that the commission ha,s decided to take a look
at this drug. Not being a medical expert and lisfening to all of tlie ex-
perts Avho come before us and tell us, as we already know, how complex
the ])rob]em is, I find it often very distressing that Avlien we have any
kind of a lead in terms of some drug that might ])rovide a medical
answer, such as Pei-se — and from what I understand, in New York
alone, there are some 1,200 people — is that correct, Charley — in the
program ? Some ]>eople are being treated.
Mr. Rangel. Some 2,000 liave gone tlirongh his program. But the
question of folloAvup woidd be for agencies such as j-ours to sub-
stantiate.
Mr. Bkasco. The point I make is I find it very distressing that we are
just getting around now to take a look at it. We had people from the
FDA who indicated that we had to go through some tests on monkeys
and other animals, I just find it absolutely no answer to say that we
cannot provide Dr. Revici or any one else with the monkeys and the
other animals to be tested in a hurry when we are all in agreement that
we are groping up some kind of a lilind alley in finding a solution to
this problem. I am happy that we in New York State are finally get-
ting around to ap])ointing a committer, or a subcommission under your
leadership to take a \ery good look at tliis. I think we should take a look
at every lead that comes along today.
Thank you.
]Mr. jNIurphy. Would the gentleman yield ?
]Mr. Brasco. Yes.
Mr. Murphy. What Mv. Rangel and Mr. Brasco are talking about
here is pure research. I am wondering about the President's program —
and I do not mean to be unnecessarily critical — but $11 million for re-
search ])urposes to me is a drop in the bucket when we can spend $400
and $500 million in missiles and I do not know how many billions
in the Defense Department. With the type of statistics that you have
quoted here today. Commissioner, about crime and you. Doctor, about
the ramifications of crime in New York, I am wondering if we are ap-
propriating enough money for pure research with $1 1 million ?
Dr. Chamrers.As a researcher, you have asked the wrong individual.
You will have to ask the commissioner. Of course, it is an inappi-o]iri:ite
amount of money. The State of New York, for example, recently spent
in excess of a quarter of a million dollars to do a survey of the incidence
of drug ufe in the general population, the results of which are being
shared with the Nation today. We are tnlkincr about, simply tp go to
the streets and look at a relationship, a behavioi-al science relationship
between crime, the addict, and its victim as a quarter-of-a-million-dol-
569
lar project. So if you are going to include all basic research, the bio-
chemical, the pharmocological, where laboratory equipment is very
expensive and time is of the essence
Mr. MuEPiiY. Doctor, do you share the opinion of Dr. Resnick, who
testified before this committee, that a concentrated research effort with
enough money to do a good job and a collection of the finest minds we
have in this country devoted to this research would produce in a
year's time some type of prophylactic or immunization program that
would prevent drug addiction in the future among tlie youngsters?
Dr. Chambers. Not with the certainty that he does. I wish I could.
Gentlemen, I am sure Dr. Martin from the Addiction lies(nirch (^enter
in Lexington must have been before you. I have no idea who the other
clinical pharmacologists or toxicologists are who have been before
you. These gentlemen have been doing precisely this kind of work for
7, 8, 9 years that I personally know of.
Money is not always the only answer. It certainly provides us with
the means for addressing issues and isolating questions, bvit money
will not guarantee you an answer in (! months. It certainly would allow
you to look at more appropriate questions in a short period of time, but
I personally can't guarantee you a pure antagonist that would have
the effect of measles vaccination, mumps vaccination, et cetera. I just
do not share that faith.
Mr. MuRPiiY. But if we do not look. Doctor, obviously we will never
know.
Dr. Chambers. You are right. But that was not the question, as I
understood it.
Mr. Murphy. No; it was not. But it seems to me that where we
should be concentrating our efforts, and I ask you as a medical man, I
think is in the pure research area, because obviously, all the customs
officials, all the special leverage that the president has with foreign
governments, have not produced any satisfactory results as of today.
The problem becomes worse and worse as the days go by.
Dr. Chambers. Point of clarification : I am not a physician, I am a
behavioral scientist. That may temper my judgment in some of the
areas.
Mr. Murphy. Thank you.
Chairman Pepper. May I get back, Mr. Jones, to your figures a little
bit ago. I want to get a clear statement as to how much the State of
New York or the city of New York is spending toward trying to treat
and rehabilitate narcotics addicts. You have given us the figure that
the State of New York has spent about $475 million in the last 4 years.
You are spending now at rate of about $91 million a year. Is that
correct?
Mr. Jones. That is in our operational budget alone.
Chairman Pepper. That does not include any money for law
enforcement ?
Mr. Jones. No.
Chairman Pepper. Now, what else are you spending? I am trying to
get some idea of how much the State of New York and the city of New
York are spending on treatment and rehabilitation of heroin addicts.
Mr. Jones. Our operational budget, as I indicated —
Chairman Pepper. Total expenditures, leaving out law enforcement,
related to treatment and rehabilitation ?
570
Mr. Jones. That is correct. Our operational budget is $91.7 million
a year, this current fiscal year.
There is an additional $51.9 million for youthful drug abuse pro-
grams alone. The reason for this separate appropriation is that when
our commission was first established, the mandate from the legislature
was to treat adult drug addicts. It soon became obvious that the man-
date was not broad enough, that we needed additional authorization.
Chairman Pepper. So you are spending $141 million a year.
Mr. Jones. No ; there is more.
.There is an additional $20 million that was appropriated just in the
past 2 weeks to be added to the figure of $51.9 million for youthful
drug abuse programs alone. I mention these separately because the
$51.9 million is a carryover from last year. In addition to that carry-
over, there is a new $20 million that has been added this year for
youthful drug abuse programs alone. So that the total figure for
youthful drug abuse programs as of this minute, the total appropria-
tion is $71.9 million.
Chairman Pepper. To be added to the $91.7 million ?
Mr. JoxES. That is added to the $91.7 million operational budget.
And there is more.
There is an additional $23 million appropriation for methadone.
These are listed separately, gentlemen, because they were appropriated
separately, but tliey do give an entire picture. If you add those up,
gentlemen, I think the figure is $186.6 million.
Chairman Pepper. New York is now spending for those various pur-
poses related to drug addiction or education against it about $186
million per year ?
Mr. Jones. That is right.
Chairman Pepper. How much is the city of New York spending in
addition, if any ?
Mr. Jones. The only independent moneys that are expended by the
city of New York, to my knowledge, are the moneys that come through
special grants from the Federal Government.
Chairman Pepper. They are not spending any additional money ?
Mr. Jones. No ; they adjninister funds that we appropriate or desig-
nate for the city.
Chairman Pepper. Very good.
Now, how much money do you get from the Federal Government ;
that is, in the same area as the $186 million a year that New York
State is now spending ?
Mr. Jones. All right, I will refer the answer, if you do not mind,
sir, to Mr. Hesse, who is our Federal-State relations man.
Mr. Hesse. At the current time, Mr. Chairman, we have two research
contracts from the National Institute of Mental Health which total
$107,000.
Chairman Pepper. $107,000 total?
Mr. Hesse. Right. We have an authorization of up to $60,000 in
support of an on-the-job training program for rehabilitating addicts.
That basically is the amount of money that the Federal Government -
is contributing directly to the New York State program.
Chairman Pepper. You are not getting any money from the Federal
Government for your treatment and rehabilitation program?
Mr. Hesse. No, sir; we are not.
571
Mr. Jones. Not a pemiy.
Chairman Pepper. In the last 4 years, you said you spent about $475
million. During that 4-year period, how much money did New York
State get from the Federal Government for narcotics treatment, re-
habilitation, or research?
Mr. Hesse. My records show the total over a 4-year period, including
the current budget year, to be tlie $167,000 1 have just mentioned.
Other contracts nearing execution, which are also research oriented
would bring the total to $200,000.
Chairman Pepper. Not over $200,000 ?
Mr. Hesse. Not over $200,000 in direct grants approved by the Fed-
eral Goxernment. We have received an additional $143,000 in Federal
iunds, again for research. But this was not approved under any
Federal grant programs. The Law Enforcement Assistance Adminis-
tration allows the New York State Office of Crime Control Planning
to take 25 percent of its bloc grant and to dispense it for "State pur-
poses." This agency provided the money to conduct the survey of
■drug abuse in New York State. It was actually from a State agency
using its bloc grant funds.
Chairman Pepper. Now, you estimate, I believe, Mr. Jones, that
the State of New York has about 110,000 heroin addicts?
Mr. Jones. That is right.
Chairman Pepper. So you gentlemen are telling this committee
that New York has almost entirely, itself, borne the total cost of the
treatment and rehabilitation programs for heroin addicts.
]\[r. Jones. That is correct, sir.
Mr. Hesse. But, Congressman, just a comment I would like to make
because our two Congressmen from New York have asked some ques-
tions here.
The money that New York State has spent can be evaluated in
many, many ways. But in terms of what you are trying to accomplish
here, which is to put the Federal Government into this ballgame, you
should bear in mind that our increase this year in operating budget
alone amounts to more money than this Congress gave to the National
Institute of Mental Health to support Public Law 91-513.
Chairman Pepper. By the way, if you have the figure, just state
for the record what the Federal Government has been spending in
the whole country in the area for which you gave figures just now?
Mr. Hesse. This may be an implied criticism, but in Public Law
91-513
Mr. Perito. This is the Comprehensive Drug Abuse Prevention and
Control Act ; that is, Public Law 91-513.
Mr. Hesse. The Comprehensive Drug Abuse Prevention and Con-
trol Act of 1970 had an authorization of $189 million over 3 years —
with $23 million to be provided in the current Federal fiscal year. The
Department of Health, Education, and Welfare appropriated $6.5
million.
Mr. BpvASCO. I just wanted to interject at this time because we get
involved in implied criticisms. I think what we really have to do in
this situation is to take the gloves off to a great extent in terms of
being able to criticize each other constructively. I think unless we do
that, we are never going to get any place. I think it is very simple,
The figures are that New York is going to spend, as I understand from
572
the commissioner, $186 million in all of the programs for the next
fiscal year. Is that correct ?
Mr. JoxES. That is correct.
Mr. Brasco. And it seems to me that notwithstanding this expendi-
ture, we are all in agreement that we need more and tliat we do not
have any answers yet; notwithstanding the fact that Xew York is
considered to be one of the leading States in this area.
Then when you get the program before us, the President's progi^am,
which is supposed to be a war, which allocates for 50 States to use
$105 million in various categories, and then you have to divide that
105 by 50, plus all of the jurisdictions in those various 50 States, this
is a war that is being fought by throwing marshmallows. I think
that very simj)ly, if we are going to go along those lines and say that
this is a major breakthrough, then I think we do a disservice to our-
selves and to the millions of Americans who are looking at the Con-
gress and this particular committee to come up with some answers.
So when you ai-e ready to criticize, please do it, because I think
that is what we need here. This is not a partisan thing. There has
to be constructive criticism across the board; otherwise, we are not
going to get any place.
Chairman Pepper. Following that line of inquiry, Mr. Jones, if I
understand your conclusion, the State of Xew York in its next year's
budget, the 1972 budget, is spending $186 million on a treatment and
rehabilitation program for narcotics addicts, and you are telling us
that the Federal Government, without considering the President's
present reconmiendations, is spending $88 million for the whole
United States of America, where it is estimated that there are between
200,000 and 300,000 heroin addicts?
Mr. Jones. Right.
Chairman Pepper. The Federal Government is presently spending
$88 million and if the President's additional $105 million is added to
that, that will make a total of $193 million. And you are spending $186
million in New York alone.
Mr. Jones. That is correct.
Chairman Pepper. My next question : Is the amomit that New York
is spending, the $186 million, adequate to deal with a heroin addiction
crisis of such magnitude ?
Mr. Jones. Absolutely not. As a matter of fact, it represents a sub-
stantial cutback from the amomit we actually asked for for the current
fiscal year.
Chairman Pepper. Have you and your associates made any estimate
as to how much it would cost to effectively offer treatment and rehabili-
tation to all the heroin addicts of New York State ?
Mr. Hesse. I can say this much on that question, Congressman Pep-
per. We anticipated at a point last November that we would require
$117 million in our operating budget from State purposes funds; that
we would need approximately $71 million in local assistance funds. We
estimated our needs from the National Government for just basic pro-
grams to give us an additional impact in certain areas, particularly in
New York City, for certain types of programs for which we could not
get the additional funds from the legislature, at approximately $27
million. Unfortunately, the money was not put into Public I^aw 91-513
573
and we could not get them to entertain the applications that we had
prepared for them.
On that particular point, when you talk about a disservice to the
people of this country — and forgive me, Congressman, if I am some-
what cynical ; I am a political scientist — the people of this country re-
sponded to what this Congress did last year in approving Public Law
91-513 and Public Law 91-527. You promised them an opportunity
for drug education programs and the Office of Education received ap-
plications totaling $70 million. And they only had $6 million to spend.
You should read the letters that the Office of Education had to send
out.
Mr. Brasco. That is what we should be hearing.
Mr. Hesse. Right.
At the same time, NIMH had $6.5 million to implement the com-
prehensive drug abuse treatment program under the special program
grants section. They received 79 applications totaling $26 million and
they had $6.5 million.
Now, the initial estimate of $23 million in the first year that was
made by this Congress when they drafted the bill was fairly precise,,
because you got just about that much. $3.5 million more, from pro-
grams around the country. But regardless of what kind of program
dollar estimates you make here, Congressmen, or regardless of what
people may think about New York and what we have accomplished
with our $475 million, if you put forth programs and you put forth
bills, there must be a general consensus here in this Congress, and with
the administration, that you will actually fund the programs that you
make available to the country. You cannot repeat what you did in
1970-71.
Mr. Brasco. I agree with you and that is why I am rather con-
cerned about this present declaration of war on drug addiction. It
would seem to me that, if we come up with the figure of $3.5 billion,
it is costing in one way or another because of the scourge of drug addic-
tion ; then for openers, we ought to at least get to that point where we
are talking on a war level — give the program $3.5 billion. Unless we
do that, I just do not think that you can draw up any guidelines that
make any sense ; I agree with you. I think in the rhetoric of speeches,
the American people have been told so much and expect so much and
receive so little ; that is why we are involved in the kind of situation
that we have today, where there is just great disbelief in government,
period. And I think that is what we want to hear, that kind of criticism
Avhich — well, it is not criticism, it is the truth. And I think it is con-
structive. If we are continually saying "I do not mean to criticize,*'
then we are not going to get anywhere.
Mr. JoxES. There is only one thing wrong with it, of course, and
that is that assuming the money were provided, the tendency would be
a year from now to say, "Well, let us see what you have done with it;
how many of the people that you have treated now remain drug f ree ?"
Questions like that are awfully hard to answer, you see.
Chairman Pepper. Mr. Jones, let me ask you one question. Have you
any recommendation out of your wide experience in this area as to the
type of treatment and rehabilitation agency or facility there should
;be? I mean by that do you contemplate that the treatment should be
given, for example, by j)rivate physicians or do you contemplate that
60-296—71 — pt. 2 16
574
there should be something in the nature of a clinic? It need not be
large. It might be private as well as public. But do you agree with
others who have testified here that there needs to be not only the ad-
ministration of a drug to counteract the heroin addiction, whatever
the accepted drug may be, but in addition to that, there needs to be
theiapeutic care, occupational assistance, general aid and consideration
given to the addict ? What kind of facility do you find from your ex-
perience to be the most desirable one for the treatment and rehabilita-
tion of heroin addicts ?
Mr. JoxES. As Dr. Chambers mentioned, Congressman Pepper, I
would be wary of trying to isolate any one program as the most effi-
cient or the most efficacious that we should pursue. I think the only
rational approach has to be the one that we have followed; namely,
a multimodality approach. Even with regard to methadone, which is
i-eportedly the most successful to date, it speaks in terms of quiclaiess
of easing the problem that we are addressing, you see. But even the
most ardent supporters of the methadone approach, I think, will admit
that it is a modality that is suitable for no more than 25 or 30 percent of
the total population, you see. So that it would be a mistake to say, well,
we ought to go all out for methadone, because it simply can't be applied
successfully to the bulk of people that we are addressing.
The same thing would hold true for the therapeutic treatment, the
therapeutic community approach. Not all addicts, of course, will re-
spond to that kind of modality or treatment. It is awfully difficult to try
to isolate one method and sell it to this Congress or to the administra-
tion as the one that should be followed.
Mr. Rangel. It is true. Commissioner, that most people who are un-
aware of wliat is going on in the drug addiction area do ask for results.
But it seems to me that there should be a Federal program which would
dissiminate the results that are coming in from all of the States rather
than having any one mimicipality or any one State ask what they are
doing with their particular addicts. But we are now listening to this
administration declaring war on addiction and everyone is being apolo-
getic. But on page 18 of your prepared statement, you indicate that the
National Institute of Mental Health, in setting up its recent 25-target
city programs, did not include a single city in New York State. Well,
I would like to direct my question to the liaison here and ask how can
you avoid being critical ?
Mr. Hesse. With a great deal of difficulty. Congressman.
I am sorry ; that is a facetious answer and I should not give it.
No, we were rather upset at the guidelines which were incorporated
into Public Law 91-211 by the Congress when it passed that bill and
the guidelines that were adopted by the National Institute of Mental
Health, because it did not give us what we thought was a meaningful
opportunity to participate and we very much hope that in the future,
such opportunities will be forthcoming.
We would like to see the National Institute of JNIental Health, if I
may take just a second here, implement the provision of Public Law
91-513 whicli requires the Secretary of HEW to establish priorities for
the States having the more significant problems of drug abuse. To the
best of our knowledge, that has not been done. Possibly if the money
had been forthcoming, it would have been done. But ceitainly, if you
575
are going to spend these large sums of money that are being talked
about in the various bills, we would hope that a system of priorities
would be worked out, not just because New York State has the largest
problem and we need a lot of money, but to address the national effort
in a coordinated response with our own toward those areas having the
iiighest incidence of drug abuse.
Mr. Rangel. May I suggest this, that certainly, this is not a social
gathering. The Chair has made it abundantly clear that the committee
is looking for direction and certainly not attempting to embarrass any-
one. It seems to me that with the great amount of money New York
State has spent — honestly admitting that they are still searching for
the answer — your commission might be able to give some very strong
suggestions and recommendations to this committee as to how the Con-
gress can be more responsive to the problem of rehabilitating drug
addicts. If this includes being critical of programs that are suggested,
this committee will accept it from the experts making the recommenda-
tions. So I hope that we can look forward to some very strong sugges-
tions, not only as it relates to the needs of the people in the State of
New York, but certainly as to the Nation as a whole.
Mr. Brasco. And with respect to that problem, I wish you would
•communicate with Mr. Rangel's and my ofhce, in connection with New
York being left out as one of the 25 target areas. We should know
about things like that.
Mr. Jones. Well, the guidelines, Mr. Brasco, as presently written,
seem to impose a penalty on those States in areas where programs and
facilities and services are provided. So that the more New York does,
you see, the more we are likely to be excluded. This is actually what has
happened.
Mr. Brasco. I appreciate that, except we would like to know about it
in writing and we will see what we can do about it.
Chairman Pepper. Mr. Winn ?
Mr. Winn. Mr. Jones, just one quick question. Do you have any idea
how much foundation money and how much medical school money has
been made available for fighting the drug problems in the State of
New York?
Mr. Jones. I know we have contracts with the New York Medical
College. Dr. Chambers can give you more precise details.
Mr. Winn. Could you give the committee just a round figure? We
have been batting figures around.
Dr. Chambers. Those are funds that we provide to the medical
schools. The medical schools do not provide funds.
Mr. Winn. I am talking about foundation money that they may
have that they are spending on their own, medical schools and founda-
tion money.
Dr. Chambers. I do not have that figure.
Mr. Winn. Could you supply the committee with that figure ? I have
heard of several programs where foundations are supplying funds to
the medical schools for fighting drug abuse in the State of New York.
Thank you, Mr. Chairman.
Chairman Pepper. Mr. Keating ?
Mr. Keating. I have heard a lot of talk this morning about the
expenditure of funds and I was happy to hear from the doctor with
regard to behavioral sciences that he also is concerned with the quality
576
and the way in which the funds are expended and how we approach
the problem. I personally feel that President Nixon has increased that
fund considerably, doing- a better job, really, than the Congress has
at this point in providing leadership so far as the drug problem is
concerned. I ho])e. and I certainly will support a larger expenditure
of money until we get the job done, every penny that is necessary to
do the job. But I do think we have to go about it wisely and have a
planned program to operate under.
Now, let me aL k a couple of questions, If I may. You are using the
methadone program in New York ?
Mr. Jones. That is correct, sir.
Mr. Keating. And I am sure you are aware of Dr. Jaffe's efforts
in this direction to make a longer lasting blockage drug so as to avoid
treatment every day. Do you have any of that methadone in your
hands for treatment that is longer lasting or is that only with Dr.
Jaffe?
Mr. Jones. As far as I know, we do not have the new derivative that
Dr. Jaffe is reportedly using — not that we do not have it, but we are
not using it as an integral part of our program effort. There is research
being done with respect to this new drug which, incidentally, is, as
I understand it, also addictive. It is longer lasting, allegedly, in the
sense that it does not have to be administered as frequently as the
methadone-type that we are using.
Mr. Pp:rito. Mr. Keating, just to clarify the record, you are referring
to acetyl-methadone, the drug Dr. Jaffe has been using.
Mr. Keating. Right.
Now, do you think this has some pluses from your standpoint, this
longer lasting drug? Can it help you so that the addicted person does
not have to come in every day ?
Mr. Jones. It certainly sounds exciting. It is because of the possi-
bilities here that we are making some of the recommendations that are
contained in our submitted text, as a matter of fact.
Mr. Keating. Now, recently, there were two deaths from overdoses
of methadone in New York. We traced it through our office that the
deaths were due to methadone, although we were advised in Washing-
ton and other places that it was not methadone. I am sure you are
familiar with the 16-year-old girl and 22-year-old fellow who died
together outside tlie hospital in New York. We only have our informa-
tion. I could still be wrong. I wonder if you investigated that and if
you know if that was a methadone overdose in fact.
Mr. Jones. I understand it was and as Dr. Chambers will tell you,
this is part of the reason for our caution in wholesale use or adaptation
of any of the known chemicals. The fact is, for example, that metha-
done is much more dangerous on an experimental basis than is heroin ;
believe it or not.
Mr. Keating. I am not surprised and I am concerned. I can see,
with regard to the crime rate, methadone does have some positive, plus
effects. Rut it is not the answer, and I am not satisfied that it is the
answer, because total rehabilitation must be our goal. I am very happy
to hear you say that there are some reservations about its use and we
have to look for something better.
Have you ever used naloxone or have you over had an opportunity
to use naloxone ?
577
Mr. Jones. We are doing considerable research with cyclazocine as
well as naloxone. Again, Dr. Chambers will enlarge if you wish, but my
iniderstanding is that with regard to cyclazocine, although it's effec-
tive for the purposes along which research is aimed, it has been found
to be awfully short term. In an effort to overcome that defect, effort
was concentrated on the other drug, naloxone. The one difficulty was
overcome only to find that other disturbing side effects appeared. Per-
haps it was the other way around. There is always this complex of
problems and related considerations before we can move wholesale on
any one substance.
Mr. Keating. The first time I heard the suggestion that naloxone had
some addictive characteristics was this morning. I wonder, Doctor,
if you could enlarge on that comment ? >
Dr. Chambers. These are trials that of course have been done at the
Addiction Research Center. With the exception of the new numbered
■antagonists that I am sure Dr. Martin shared with you
Mr. Perito. You are referring to M-5050 ?
Dr. Chambers. Yes. They have not isolated a pure antagonist as
yet. If you have a pure antagonist, there is some liability — abuse and
dependency can be produced for it. If we are thinking of the same
thing, you say addictive possibility, dependency could be produced
with naloxone. It is not a high liability ; for example, it is not like a
narcotic.
Mr. Keating. I have in my file some indication on the use of mari-
huana and Mr. IngersoU made some comment on the use of marihuana.
I am wondering how the commission views that use and its relation-
ship to the heavier drugs — heroin and so on ?
That is a little ambiguous. Let me put it this way. The indication
was that the use of marihuana creates the environment into which
you can move to heavier drugs such as heroin and £o on. Do you look
upon it in the same way ?
Mr. Jones. I think this would be a good point to introduce
Dr. Chambers so that he can present officially to this Congress the re-
sults of the first statewide survey of narcotic dependence and drug
abuse, I think, that has ever been undertaken in this country. It is an
outstanding accomplishment, Mr. Chairman and gentlemen. I think
the answers are contained in this study. Perhaps Dr. Chambers would
like to make a formal submission at this time.
Chairman Pepper. Would you summarize it for us. Dr. Chambers?
Dr. Chambers. I can do that, sir, or I can relate only to the mari-
huana section and leave both the summary and the full report with
you. It is a very lengthv report.
Chairman Pepper. Whatever Mr. Keating would like.
Mr. Keating. I am very happy I stumbled on this. We are most
anxious to hear it. Dr. Chambers.
Dr. Chambers. Let me answer your question first before I present
data for you.
I, as all drug professionals, have been interested, I think, in the
"progression hypothesis" for some time now — does marihuana smok-
ing or the use of cannabis in any preparation set a stage or lead to or
cause the use of other drugs?
Mr. Keating. That is not really my question, but I would like to have
the answer to that one, too.
57S
Dr. Chambers. I think wliat you have is undoubtedly a correlation!
or relationship. If I may, it is the same one we have had in behavioral
science in criminology for a long time. JNIost adult criminals were
first juvenile delinquents. That is not to imply that most juvenile de-
linquents become adult criminals. Most heroin addicts have marihuana
histories. That is not to imply that most marihuana smokers become
heroin users or addicts.
May I share with you the marihuana figures ?
We did a stratified representati^-e sample of the population in New
York, age 14 and above, which gave us a base population to study in
excess of 13 million people. We did face-to-face interviews on this
representative sample in their homes and looked at all forms of drug
use, whether it be aspirin or heroin and everything in between — looked
at attitudes, behaviors, what they thought about other users, people
who sold drugs, how you prevent drug use, whether you get all your
drugs with prescriptions, et cetera. What we found in the area of mari-
huana was that roughly 1,032,000 people in the State of New- York
smoked marihuana in the last 6 months. Of those, some 487,000 are
regular users of marihuana, having smoked marihuana at least six
times during the past 30 days.
Of those 487,000 regular smokers, some 175,000 are employed: they
are not students, they are not hippies, they are full-time emplo3^ed
people. Some 90,000 of those people are using it on the job.
So we have in effect now established, I think, a data base for all of
the forms of dnig use w-hich should allow us to look at some of the
questions that Mr. Ingersoll addressed with you.
We are very proud, it must be apparent, in New York of the survey
and the results it gave us. '\^nien you begin to relate that some 110.000'
people in the State of New York are regular users of prescrip-
tion pep pills, some third of them get none of them by legal scrip, and
some 40 percent of the people who are regular users of pep pills are
using them on the job, then we are talking about an even greater prob-
lem than we have alluded to earlier this morning.
Mr. Keating. Do you have enough copies for all of us or is it permis-
sible that we duplicate these ? I would love to have them.
Dr. Chambers. I would be most pleased if you would duplicate
them.
Chairman Pepper. We can Xerox them.
Dr. Chambers, will you kindly submit your summary for the record
so we will have the full benefit of it ?
Dr. Chambers. Yes, sir.
(Dr. Chambers summary of the report follows. The report itself was
retained in the committee files. It was published by the Narcotic Ad-
diction Control Commission and is entitled "An Assessment of Drug
Use in the General Population^ — ^Special Eeport No. 1 : Drug Use in
New York State," May 1971.)
[Exhibit No. 21(a)]
State of New York,
Narcotic Addiction Control Commission.
New York, N.Y., June 22, 1071.
Select Committee on Crime.
House of Representatives, Congress of the United States,
Washington, D.C.
Dear Mr. Chairman : You win And enclosed a report prepared by NACC's
research director, Dr. Carl Cliiiml)L>rs, uliiili pertains to a study of the amounts
579
and types of drugs that are being used by members of the general population of
New York State. We believe this survey to be the first of its kind, and it was
partially supported by a grant provided by the New York State Office of Crime
Control Planning. The data was secured through interviews with 7,500 scien-
tifically selected representative persons. The report is the first of a series and con-
stitutes an assessment of use for the total State. Subsequent reports will
subdivide the State into geographical regions.
It should be noted that the numbers represent a projection of the more "stable"
drug users, those with a fixed address, and consequently constitute minimums.
Any one who has become personally and socially dysfunctional as a result of
drug use, for example heroin street addicts, "speed freaks," et criteria, generally
were not available for interview. Thus, only those drug users with a place of
residence or routine "at home" hours were located. In some cases these minimal
figures should be multiplied by three or four in order to project maximum
involvement, for example heroin.
In this connection, attention is invited especially to the "Epilogue" on page
156 of the refKJrt beginning : "This study was not designed to determine the
incidence of drug abuse in New York State. Methodologists and epidemiologists
responsible for the survey design were in agreement that such a determination
would require a more sophisticated interview schedule and more experienced
interviewers than budget and time limitations permitted * * *" making clear
that this is fundamentally a survey of drug use and that the figures relating to
drug abuse or the use of hard drugs undoubtedly understate the situation.
I can summarize the data secured through the study as indicating, among
other things, that of the statewide population age 14 and above :
1. Some 361,000 people use barbiturates on a regular basis (at least six times
■per month ) and some 10 percent of these obtain none of these drugs with a legal
prescription ;
2. Some 187,000 people regularly use the nonbarbiturate sedative-hypnotics ;
for example Doriden, Noludar, and some 15 percent of these obtain none of these-
drugs with a legal prescription ;
3. Some 525,000 people regularly use the minor tranquilizers ; for example,
Librium, Miltown, and some 5 percent of these obtain none of these drugs with a
legal prescription ;
4. Some 71,000 people regularly use the major tranquilizers ; for example, Thora-
zine, Mellaril, and some 5 percent of these obtain none of these drugs with a legal
prescription ;
5. Some 39,000 people regularly use the antidepressants ; for example, Tofranil,
Elavil, and some 18 percent of these obtain none of these drugs with a legal
prescription ;
6. Some 110,000 people regularly use pep pills ; for example, Dexedrine. and
some 33 percent of these obtain none of these drugs with a legal prescription ;
7. Some 222,000 people regularly use diet pills, usually containing amphet-
amines, and some 19 percent of these obtain none of these drugs with a legal
prescription ;
8. Some 17,000 people regularly use controlled narcotics other than heroin ;
for example, Demerol, morphine ; and some 12 percent of these obtain none of
these drugs with a legal prescription ;
9. Some 1,043,000 people have smoked marihuana during the past 6 months,
and 487,000 of them do so on a regular basis (at least six times per month) :
10. Some 203,000 people have used LSD during the past 6 months, and 45,000
of them do so on a regular basis ;
11. Some 111,000 persons have used methedrine (speed) during the past 6
months, and 35,000 of them do so on a regular basis ;
12. Some 64,000 persons have used heroin during the past 6 months, and 32,000
of them do so on a regular basis : and
13. Some 101,000 persons have used cocaine during the past 6 months, and
6,000 of them do so on a regular basis.
In addition to the data summarized above, the report contains an assessment
of the population's attitudes about drug use and drug users. General consensus
was elicited on the following items :
Everyone should try drugs at least once to find out what they are like,
90.3 percent disagreed.
Addicts will do anything to get more drugs, 87.7 percent agreed.
Drug addicts should be treated as sick people and not as criminals, 86.7'
percent agreed.
580
Education is the best way of preventing drug abuse, 77.1 percent agreed.
People can use drugs to find out more about themselves, 75.9 percent dis-
agreed.
The study indicates the need for further research into specific drug issues, and
NACC scientists are currently making plans to assess the social costs and
jpersonal difiiculties attendant to these various types of drug use.
Sincerely,
Howard A. Jones,
Chairman-Designate.
The Chairman. Gentlemen, you see the intense interest there is on
the part of the conunittee in this expert knowledge that you have, and
we are sorry that we cannot hear more from you, but we will have
the benefit of your fuller statements in the record. We want to thank
jou very much for coming and giving us your valuable testimony
today, Dr. Chambers and ]\Ir. Hesse, with Mr. Jones.
Thank you very much, gentlemen.
Mr. Jones. Thank you very much, Mr. Chairman.
(Mr. Jones' prepared statement, with addendum, follows :)
[Exhibit No. 21(b)]
Pbepabed Statement by Howard A. Jones, Chairman-Designate, New York
State Narcotic Addiction Control Commission
introductory remarks
It is a privilege, Mr. Chairman, to have this opportunity, in behalf of Governor
Eoekefeller, the State of New York, and the Narcotic Addiction Control Commis-
sion, to present our views on the urgent and growing problems of narcotic de-
pendence and drug abuse. ;'
Our commission congratulates you. Congressman Pepper,'' = ori*"fhe leadership,
imagination, and dedication you have given to this complex cause, especially
your efforts to control the various psychotropic substances — for these are the
principal drugs of abuse in this Nation — and also for your efforts to bring about
more effective controls over the production of narcotic substances.
Our commission is also proud that a New Y'orker, Congressman Rangel, is
serving on this all-important committee. As you know he represents perhaps
the most impacted area of crime-related drug abuse in the country ; and has,
throughout his legislative career, both here and in Albany, proved to be a most
eloquent spokesman in this and other matters relating to the interest of his
district.
I will depart from traditional presentation practice by omitting lengthy
references to the history of our commission and details of our programs. These
matters have been amply documented by other commissioners in previous testi-
mony before this and other congressional committees.
We are especially pleased that your committee is attempting to focus upon
the broad issue of drug dependence, in all its manifestations and ramifications,
and is not confining its interest solely to the crime-related aspect.s of drug abuse.
We are confronted by a nationwide drug abuse pandemic, and the issue must be
weighed in the perspective of all its component parts.
general observations
In our opinion, President Nixon has supplied an excellent frame of reference
for our discussion today.
In his news conference of June 1, the President stated that the administration
considers this Nation's drug probliMu a matter of "the highest priority."
Mr. Nixon promised that the administration will '"give it the highest priority
attention at all levels, not just in regard to veterans where it is a special prob-
lem, but nationally, where it is one that concerns us all."
Accordingly, there was an announcement last week of a new admintstration
progi-am.
At the time wo prepared this presentation, we did not have the specific details
of the new program.
581
It is absolutely essential that the Federal Government provide for the treat-
ment of returning veterans because State programs currently do not have the
capacity to absorb this new group of addicts.
We are encouraged by the intention to expand the force of Federal narcotics
agents, as we are by other existing and reportedly contemplated efforts to control
the trafficking in narcotics.
We were pleased to learn of the recent appointment of Dr. Jerome Jaffee as
Director of the Special OtBice of Drug Abuse Prevention, and look forward to a
close collaberative relationship.
Gentlemen, it is our fondest hope that the promise of policy will be transformed
by the administration and this Congress into the performance of program.
We have no doubt that the concern of the present administration, as well a&
this Congress and the various Federal agencies, is genuine and sincere. The
programs espoused by both the President and the Congress, like the work of the
departments directly involved, have been meritorious.
However, the question before this committee, indeed before the Nation today,,
is whether those efforts have in fact been proportionate to the problems that
confront us. The legislation approved by this Congress in its last session,.
together with the demands of the Members of Congress at this session and the
statements of the President last week, amount to a declaration that to date the
total Federal effort has not been sufficient, and must be expanded.
Thus, it would seem, we will profit most today by discussing what level of
Federal commitment will be commensurate with the problem ; what programs
and resources should be applied to achieve that level ; and what directions such
programs should take.
Speaking for a State commission that has been demonstrably concerned with
social progress, and very much concerned about government's response to the
most critical social problem of this century, it seems a fair ob.servation to say
that a,s a whole our society has not made up its mind about drugs ; apparently
we have not reached a firm determination as to what precisely we want to dO'
about drugs and drug abuse.
Gentlemen, this Nation needs leadership. The people need assistance. Our
conmiission is thankful that we have served under a leader like Governor Rocke-
feller and that we have enjoyed the support of a progressive legislature whose
combined efforts have produced the largest narcotic treatment program in the
w^orld.
But that is also a major part of our problem. This is a pandemic, requiring not
only national attention but international action as well. It is the foremost medical,
social, criminal, and educational problem in this Nation, and we must have the
continued cooperation and support of the administration and the Congress,
taking coordinated, concerted action through increasingly comprehensive, long-
range, high-impact programs.
Our commission has some very positive ideas about the direction such pro-
grams should take, beginning with an assessment of the actual drug scene in
this country, and especially in New York which has the most severe problem.
SCOPE OF THE PROBLEM
There are an estimated 200.000 narcotic addicts in the United States today..
Perhaps more than 110,000 of these addicts are in New York State. Their principal
drug of abuse is heroin, and, because of their numbers, their involvement with
crime and general antisocial behavior, heroin addiction and heroin trafficking
have so far drawn the major share of attention and program dollars at all levels
of government.
However, you should know that there has been an evolution on the drug
scene. Changes have occurred in drugs of preference, patterns of abuse, and the
identity and character of drug abusers — changes which require corresponding
shifts in our thinking and in our programs.
We approach the problem more accurately when we si)eak of drug abuse and
drug dependence, narcotic and nonnarcotic. We demonstrate that we have learned
some lessons from the expenditure of millions of dollars when we make program
differentiations for four distinct clas.ses of drug abusers : The experimenters, the
recreational or social users, the involved abusers, and the dysfunctional abusers,
the latter group including but not limited to narcotic addicts.
58-2
Certain essential facts must remain in tlie forefront of our thinking and
-planning. First, today's drug abuser is younger, more inclined to take risks,
.-and, importantly, he is a multiple drug user.
We have determined that various physiological, phychological, and sociological
factors are involved; but we must also recognize, as the addict himself recog-
nizes, that there is also a recreational aspect to drug abuse. We must concede the
existence of the user who seeks and derives pleasure from these drugs and then
concentrate on the larger question why so many individuals in our society choose
mind-altering substances for pleasure.
We must recognize that there are adaptive as well as escapist abusers, persons
who use drugs to cope with life and to adjust to the problems of society.
There are estimates that one out of every four Americans regularly uses a
psychotropic substance. There are other estimates that 30 to 50 percent of our
students have experimented with drugs.
The National Institute of Mental Health predicts that 65 percent of the ex-
perimenters with marihuana will use the drug only once or twice, and the ma-
jority of the remainder not more than 10 times in their lifetime.
Recent research by our Commission suggests that of 100 students in a given
high school, ."»0 will exi>eriment with drugs. Of these 30 percent will continue to
use drugs for social or recreational purposes. Of these, five will become involved
users while 25 will discontinue drugs. Of the involved users, three will become
dysfunctional multiple drug abusers or addicts.
I think, gentlemen, we can all agree we have an epidemic of drug abuse in this
nation. I think we can also agree that, unfortunately, our knowledge of these drug
abusers is sadly limited.
Authorities in many fields speak incessantly about the drug abuser's involve-
ment in crime. Much of this data is actually speculation, much of it is actually
inaccurate, partly because we use a variety of reporting systems, with differing
bases.
In addition to the vast number of criminal acts that remain hidden, many of
these that are detected are not reported to the police. Moreover, reiwrted crime
does not always become recorded crime. One study by our research unit showed
that every addict in the study had engaged in criminal acts, hut only 79 percent
had arrest records. We found that drug use began at age 13. on average, and
that for the majority the first illicit drug used was marihuana.
Direct, acquisitive property crime dominated their criminal activity in terms
of total offenses. 93 percent as against only 7 percent for voilent crimes against the
person. Burglary was the crime most often committed, accoimting for 37 percent
of the property offences and 35 percent of all offences. Furthermore, three-
fourths of the sample had engaged in crimes of burglary, a participation rate al-
most double that of any other crime.
Our statistical computations suggest that, collectively. 26 of the addicts in
the sample were re.sponsible on a daily basis for 22 major crimes including two
robberies, seven burglaries, four thefts involving motor vehicles, four instances
of shoplifting, and four miscellaneous thefts.
A most significant finding in terms of your interest, gentlemen, is that our
study suggests the possibility that no more than 4 percent of the property crimes
and 5 percent of the crimes against the person are reflected in our national crime
reporting statistics. Moreover, the study suggests that the addict on average may
commit up to 120 crimes for each crime for which he is arrested and charged.
Other interesting statistics uncovered in our survey indicated that there were
.52.479 narcotics arrests in New York City last year, including 38,790 arrests in-
volving morphine and heroin. There were 11,702 narcotics arrests in Harlem
alone.
T mentioned that today's drug abuser is more of a risk taker than the former
heroin street addict who used to be regarded as a passive, dependent per.son.
Just 4 years ago. when our commission began operations, the average age of
the heroin arVlict in Now York wns 29. Today, the median age is estimated at 21.
Todnv. 35 percent of the approximately 12.000 reliabilitants under our direct
juTisdiftion are under age 20. Similarly, whereas only 15 percent of the addicts
admitted to the Federal hospital at Lexington in 1936 were 20 or younger, today,
53 percent o^ them, as you known, are under age 19.
As you know, worthwhile studies involving the behavioral sciences are in
woefully short supply. Our division of research, which we consider the finest
in the Nation, has conducted what is probably the only indepth statewide sun^ey of
drug abuse ever attempted in the United States.
583
Some of the results of this study tell us rather significant things about drug
abuse today.
For one thing, the primary drugs of abuse are psychotropic substances. The
users include top corporate executives, middle mangament, clerks, salesmen,
white- and blue-collar workers, housewives, as well as young people.
We have defined a major problem of drug abuse in industry, at all levels of
work, including a significant percentage of employees who abuse drugs while
actually on the job.
In one study of the students in a suburban ninth grade class, boys and girls
approximately age 15, we found that 27 percent had used either drugs or drugs
combined with alcohol, and another 24 percent reported using alcohol only.
Approximately 10 percent of the student body had experimented with glue
snifiing. 7 percent with stimulants, 5 percent with methamphetamines, 5 percent
with barbiturates, 8 percent with codeine, 4 percent with opium or its derivatives,
3 percent with tranquilizers, 15 percent with marihuana, 8 percent with hashish,
5 percent with mescaline, 5 percent with LSD, and 4 percent with cocaine.
If you note that these percentages exceed 27 percent you will find corrobora-
tion for our earlier statement concerning multiple drug abuse.
An examination of the case records of your hospital at Lexington, Ky., pro-
vides further corroboration. In 1944 only 8 percent of the admitted heroin
addicts concurrently abused barbiturates, while only 1 percent were concurrently
addicted to barbiturates. In 1948, the comparable percentages were 17 and 5
percent ; in 1957 they were 39 and 18 percent. A followup study in 1966 showed
that 54 percent were concurrently abusing barbiturates while 35 percent were
simultaneously addicted.
Another recent study by our research division shows that it is not uncommon
for today's user to consume as many as 15 to 25 different substances. Obviously,
one reason for this is availability. But there is another significant factor. Of the
many lessons to be learned from this research, we must recognize that the multiple
drug abuser, who has been evolving for perhaps a decade, becomes involved in the
concurrent use and abuse of this variety of chemical substances because he wants
to receive a specific effect and reaction from each. For too long we have focused
our research, our concentration, our publications and our treatment programs
on what drugs do to an individual. If we are to relate to today's drug abuser,
from experimenter to addict, and especially the multiple drug abuser, we must
speak in terms of what drugs do for him.
Our studies show that only 7 percent of the t6tal offenses committed by one
study group in a year's time involved crimes against the person. But 60 percent
of the addicts interviewed had committed such crimes, a remarkable and disturb-
ing increase, by anyone's calculations.
New Jersey officials say that only 18.6 percent of the total number of persons
arrested iia one study period were drug users. But, 12 percent of the persons
suspected of violent crimes were drug users.
The apparent conclusion is that today's multidrug abuser commits crimes of
opportunity, with an increased willingness to commit violent crime.
Director John Ingersoll, of the Bureau of Narcotics and Dangerous Drugs,
estimated earlier this month that the total drain on the national economy caused
by heroin is as high as $3.5 billion, including the cost of crime committed and
the law enforcement costs.
The Urban Center of Columbia University said in an April 1971 report that
the cost of narcotics-related crime in Harlem alone runs as high as $1.8 billion,
exclusive of the costs of law enforcement and crime prevention.
I do not suggest that these figures are contradictory. I do suggest that they
constitute a virtual mandate upon the Federal Government reexamine its
priorities, particularly since traditional cost of crime estimates fail to include
the other incalculable losses suffered by the victims of violent crime. We must
add a new dimension to our calculations of the cost of crime, recognizing that
the victim of an assault quite often loses not only his property but sometimes also
his life, his capacity to earn, and suffers the costs of hospital and medical care.
In New York State, aside from treating the addict, we also recognize our re-
sponsibility to the innocent victims, not only of the addict but of other criminals
as well. In the current fiscal year. New York has appropriated $2.2 million to
compensate such victims of crime.
Comparison of Federal effort with Neiv York State
I think it may be useful to compare existing Federal and State programs, not
to belittle your efforts, gentlemen, but hopefully to demonstrate what can be-
584
done through determined action, and to illustrate why all the States, not just
New York, need your assistance.
Since April 1, 1967, the day our commission began operations, Governor
Rockefeller and the legislature have authorized more than $475.3 million for
the programs of the commission. That sum of almost a half million dollars does
not include separate appropriations for the departments of education, health,,
mental hygiene. State police and others to combat drug abuse.
Our operating budget for the current fiscal year is $91.7 million, compared with
our original budget in 1967 of $20.7 million. At its current level, our operating
budget is larger than the entire budget of the World Health Organization for
all health programs and exceeds the total national commitment for treatment and
prevention programs.
In addition. New York State has appropriated $71 million for our special youth-
ful drug abuse programs in the current fiscal year.
During these past 4 years, some 38,933 addicts have been admitted to our
public and private programs, exclusive of the youth program which will reach
an estimated 25,000 persons.
As of December 31, 1970, there were 10,764 certified narcotic addicts in the
various commission facilities and 10,419 addicts under care in private, voluntary
agencies accredited and/or funded by the commission.
The Commission this past fiscal year contracted for over $51 million in local
assistance funds to create and support new community-based programs to combat
youthful drug abuse. These programs, which require matching funds or con-
tributed services by localities, have a gross value in excess of $130 million.
In less than 12 months, we extended one or more program services to each of
the 62 counties in New York State.
Our emphasis upon community action is not limited to the youthftil drug abuse
program. In just 2 years, we created and began funding 338 narcotic guidance
councils, citizen units created at the village, town, city, and county level to focus
attention on the drug problem and to provide information, education, and assist-
ance to the victims and casualties of drug abuse and their families.
We are currently spending $20 million on 20 methadone maintenance programs,
operated by outside agencies, as well as our own internal program, with a ca-
pacity to serve a total of 17,000 addicts. This is the most extensive methadone-
maintenance program of its kind in the country.
The proof of our commitment has many manifestations. The Commission can
point to its workshop training courses in which more than 11,000 of our citizens
received instruction and training to enable them to render assistance in their
communities. We i>rinted and distributed more than 6 million publications on
drugs.
There are those in Washington who have noted that our program was recently
reduced by the Governor and the legislature. It's important that we speak to
that issue.
In the first place, our operating budget was actually increased from $84.4
million to $91.7 million. For the record, that increase is larger than the total
amount of money provided the National Institute of ISIental Health to implement
Public Law 91-513 and is three times larger than the latest reported total that
the world community will grant to the United Nations for its new program.
Although we could not, in a time of fiscal austerity, command a budget increase
that would permit all of the program expansion we desired, we have achieved
certain significant changes in program direction by altering various of our in-
stitutional approaches, including a major decision to make virtually all of our
facilities multi-modality treatment and rehabilitation centers, thus actually
spreading our potential reach further into the addict community.
Ironically, there are those who suggest that because New York State did no*-
vote another major increase in funds we have somehow reduced our commitment
and lessened our concern.
Nothing could 1)<> further from the truth.
New York State is confronted by a fiscal crisis. I think Governor Rockefeller,
who has led the Nation on this issue, hns amiily docmiieuted the economic plight
of the stntes as he has simultaneously argued for a reordei'ing of national priori-
ties and for a system of federal revenue sharing with the States.
Federal oflficials from many agencies speak proudly of the $135 million
Federal drug abuse progi-am. However, it is important to note, in contrasting
this figure to our Commission's total budget of $150 million last year, that the
Federal outlays included $40 million for law enforcement, $53.4 million for
585
treatment and rehabilitation, $12 million for education and training, and $23
million for research and other support programs.
Those were tJie budget projections for your current Federal fiscal year — and
this Congress declared, and the President concurred, in passing and signing the
Comprehensive Drug Abuse Prevention and Control Act and the Drug Educa-
tion Act, that these Federal efforts were not sufiicient.
Public Law 91-513, authorized $428 million over 3 years, including $189
million to the Department of Health, Education and Welfare for community
mental health centers, drug abuse education, and special projects. This act
authorized expenditures of $23 million in the current fiscal year. Instead of $23
million, HEW allocated only $6.5 million, and these were from supplemental
funds.
There can no longer be any question of the need for these funds, from all
sections of the country.
Against its $6.5 million allocation, the National Institute of Mental Health
received a reported 79 program grant applications totalling $26.5 million,
slightly in excess of but in keeping with the amount the Congress also thought
was needed — but didn't provide.
I sincerely hope that the recommended appropriation for the next fiscal year
will be substantially more than the rumored 5 or 6 million.
Similai'ly, Congress and the President joined forces to produce Public Law
:91-527, an education act whose well-stated public purposes coincide with the
purposes enunciated by the President last week.
Yet again, instead of $10 million as authorized, HEW had to use supplemental
funds of $6 million. And, of the $3 million available imder the institutional grant
section of this act, some $2.2 million was reportedly immediately consumed by
the refunding of existing programs.
I will quote from a letter sent by an official of the Office of Education :
We regret to inform you that it will not be possible to support your proposed
project which was submitted for consideration under the Drug Abuse Educa-
tion Act of 1970, Public Law 91-527.
Our office received 850 proposals. We appreciate the time and effort which went
into the preparation of each one, and the interest and commitment each
displayed.
We regret that with available funds, only one of every 18 proposals, a total
of 46, could be recommended for support.
The 850 proposals requested $70 million in support, but our appropriation for
"1971-72 is only $6 million.
I wish I could px'ovide you with a new deadline for a funding cycle. It is how-
ever uncertain at this writing what money, if any, will be available for new
projects in 1971-72, However, if you write us in early 1972, we will be happy
to provide whatever information we have about 1972-73.
The Office of Economic Opportunity received approximately $13 million for
community drug abuse programs, but officials there tell us that more than $10
million was immediately consumed by funding their tremendious backlog of ap-
proved but unfunded programs.
FURTHER RESEARCH NEEDS
The record shows, gentlemen, that the national response to your principal
legislation of 1970 was overwhelming. The people are in need, because they are
afraid, because they want help, because they see the future consequences of
current inaction, and because the patients in need are their children.
And so they came to the Federal Government for help, the help promised in
laws enacted by this Congress and supported by this Administration. In just
two Federal offices, nearly $100 million in programs were authorized — but only
$12.5 million appropriated to fund them.
Gentlemen, we are engaged in government, the art and science of politics.
W^e are seasoned professionals who understand the necessities of attaining
maximum visibility, even from low profile programs.
I ha-ve no quarrel with those in legislative bodies who adhere to the dictums
of holding public office, so long as they also insure that the available resources
are applied in the most optimal manner, commensurate with the dimensions of
the problem.
There is apparently no dispute that New York State, with some 110,000
beroin addicts, not to mention the hundreds of thousands of abusers of other
586
druffs, has the Nation's largest addict population and probably the Nation's
largest drug abuser population.
Yet, the National Institute of Mental Health, in setting up its recent 25
target cities program, did not include a single city in New York State.
Our division of research has made the projection that, out of every 1.000 non-
white ghetto males. 500 will experiment with drugs, 470 will smoke marihuana,
300 will try amphetamines, 280 will try barbiturates, 190 will try narcotics, 60
will try all four, and 100 will become addicts. We similarly project that 70
percent of these narcotic addicts will become known to the police, 60 percent will
receive some form of formal treatment, and 40 percent will remain addicts for
at least 10 years.
Despite this knowledge, and despite the obvious dimensions of the problem
in New I'^ork City and New York State, previous Federal regulations have per-
mitted Federal officials to exclude aid if there is a finding of "appropriate and
adequate local facilities."
And, naturally, in New York State, since such findings were always affirma-
tive, the Federal Government has largely directed its efforts elsewhere. One
cynical observer recently expressed the view that New York State is being
penalized for its initiative and effort. Cynical or not, the record is that the
Federal Government provides only minimal supi>ort to the New York State
program and insufficient support to the individual programs in our cities.
At present, we have two NIMH research contracts totaling $107,000. We re-
ceived $114,807 in Federal funds for our state-wide survey but we obtained
these funds from the New York State Office for Crime Control Planning out
of its State block grant funds. Finally, we received $60,000 in funds from the
U.S. Department of Labor for an on-the-job training program for our addicts.
All of the $1.06 million in proposals we made to the Office of Education were
rejected, although two non-commission programs were approved.
We do not at this time know the fate of our applications to the National
Institute of Mental Health, which total $6.8 million.
Obviously, our total program proposals exceed available funds. Originally,
when it was still hoped the Congress would appropriate the full amount of the
actual authorization, we submitted preliminary applications to NIMH totaling
$27.0 million.
We were not demanding the whole of the national appropriation. We were
going on the record not only with a statement of our program needs but also
with a declaration of those areas of program endeavor in which we and the
Federal Government could cooperate to our mutual benefit.
We still seek cooperation on these and other programs. Again, we beseech the
Congress to make the authorized funds available.
It is worth noting here that, despite our budget problems at the state level,
we did not ask the Federal Government to assume any part of the cost of
financing our existing programs. We approached the Federal Government with
new programs, programs which we believe would not only improve services
for drug abusers but add significantly to our knowledge and expertise with re-
spect to treatment and prevention programs.
For example, we proposed to create : a day care center for youthful drug
abusers : a community house program ; a therapeutic community center ; a mul-
timodality methadone program ; a therapeutic center for nonopiate abusers : a
therapeutic center for adolescent heroin users ; a paraprofessional workers pro-
gram ; a program to combat discrimination in employment against addicts ; and
a variety of education and prevention projects.
When we speak of priorities, let's establish a very high priority on evaluating
the effectiveness of existing drug education programs — before we spend large
sums of money on new education programs.
New York State had hoped that such evaluative research would be possible
under the Drug Education Act but HEW officials advised us that there were
no funds in Public Law 91-527 to support such a project.
Gentlemen, for all of our money spent, both you and I, we know so precious
little about drug abuse that it is shocking. We suspect that a factor in the spread
of drug abuse has been the failure of drug education programs. Indeed, many
authorities are suggesting that we are experiencing an abuse of drug abuse
education.
Nor is our need confined to program evaluation. Our division of research
has developed an impressive list of research needs, projects which we would
like to conduct cooperatively with the Federal Government.
587
For instance, we need to study acute drug reactions among youth, withi
important concentration on post treatment activities. We need an intensive-
investigation of narcotic deaths among youths, vpith emphasis upon life styles,
drug habits, etc., and the incidents preceding death.
We must very soon analyze the relationship of marijuana use and subse-
quent drug abuse looking not only at transitional factors but also at the phe-^
nomenon of association, especially among multiple drug users.
Our current knowledge of onset factors is quite limited, and must be im-
proved quickly by expert etiological research. We must probe the onset of drug
use among young people, with special emphasis upon attitudinal studies.
We need to study the economics of narcotic addiction, and the patterns of
drug abuse in the new underground. We should survey official attitudes on
drugs and rehabilitation.
We need to do foUowup studies on arrested addicts, and, even to do studies-
on the children of addicts.
The list is virtually endless, but, it is not impossible.
In this important instance, we want to do more because we have done so
much and we know we have the capability to produce the data and findings that
will help resolve this national dilemma.
Our list of completed research projects, in addition to the mammoth state-
wide survey and the on-going special attitudinal and incidence studies in schools
throughout our state, is worthy of your consideration. It is attached as an
exhibit to this statement.
We do not include this list to boast of our accomplishments but to demon-
strate to you the vital role quality research plays in any effective drug pro-
gram and to underscore again our desperate need for knowledge — and for as-
sistance.
We should, as Governor Rockefeller has suggested, conduct exhaustive re-
search into other chemical means of controlling addiction to narcotics and also
to control dependence on other substances. Our interim success in the very long^
fight against drug abuse could well depend upon our finding such a chemical.
However, to those who see such chemicals as methadone as a final solution,
or to the others who now jump to proclaim acetyl methydol, let me remind
you that chemical maintenance for narcotic addiction does not apply to the
vast majority of drug abusers in our society, because the majority are not
narcotic addicts.
Some Members of Congress, like drug professionals and lay persons around
the country, reach out to methadone and methadone maintenance as a panacea
to our problems of narcotic addiction.
There have been significant accomplishments with methadone ; it has worked
for many addicts. But, it is very much still an experimental program.
There are many unanswered questions about methadone ; so many questions
in fact persist about methadone maintenance that we cannot at this time call
it an answer.
There is strong evidence that a successful maintenance program requires highly
effective supportive services. There is evidence suggesting that methadone has
limited value in treating today's multidrug abuser. In addition to certain medical
problems, there are problems of dose manipulation and the abuse of other drugs.
A series of studies conducted with one group of long-term, stabilizetl methadone
patients disclosed that, during an 8 week period, members of the study group
were dnig free only 41 i)ercent of the time.
On the other hand, the group abused heroin 35 percent of the time, with lesser
use of other drugs. It was disclosed that 14 jiereent of the group resorted to
daily supplementation of their methadone dosage during this period, and that
32 percent of the total study group used cocaine at least once during the 8 week
period.
A separate study of a stabilized group in another State revealed that 82.5
percent of the patients had abused at least one of the detectable drugs during
a 1 month period. Specifically, 77.5 percent had abused heroin, 30 percent had
abused the barbiturates and 25 percent had abused amphetamines. Sixty percent
had abused at least two different classes of drugs and 22.5 percent had abused all
three.
Moreover, a followup study of this same group 8 months later disclosed that
the incidence of drug abuse increased from 82.5 percent to 97.4 percent. Multiple
drug abuse was also found to have increased, from 60 percent of the patients to
76.9 percent.
588
To repeat, methadone maintenance has provided some new answers but it also
has posed many new questions and presented new sets of problems. These studies
may not be indicative of the whole of methadone maintenance ; they do indicate
we need much more research into this program and much more knowledge about
its administration.
For all these reasons, New York State has adopted stricter control systems
to help regulate its expanded methadone maintenance programs.
We are encouraged, as I am sure you are, Congressman Pepper, by the recent
announcement of curbs being implemented on the production om amphetamines.
I might add my i>ersonal opinion that your strong demands for such curbs were
instrumental in bringing about this most fundamental and necessary regulation.
At the same time, we are pleased by the recent meeting between President
"Nixon and Governor Rockefeller which produced an agreement to expand the
capacity of our criminal justice system.
Along the same lines, the Federal district attorney in New York has announced
that his office will conduct an active program of obtaining treatment rather than
incarceration for Federal offenders who are narcotic addicts.
Further program, needs
There are those who question the need for supportive services and long-term
rehabilitation services, the so-called high cost items in drug treatment. But,
gentlemen, our research also indicates that only 24.9 i>ercent of those who receive
detoxification without other services remain drug free for any length of time.
Eventually, we must accept the fact that we are going to have to learn to live
with and control drug usage before we can even hope to eliminate it. A drug cure
is a long-term and very complex process, requiring a variety of professional and
nonprofessional inputs on a sustained basis. We miist face the prospect of requir-
ing such multipurpose programs for many years to come.
The need, not only for a well-funded program, but one which gives priority to
those States liaving the major drug abuse problems was recognized by the last
session of Congress in Public Law 91-513.
That law states :
"The Secretary shall make grants under this section for projects within the
States in accordance with criteria determined by him, designed to provide prior-
ity for grant applications in States, and in areas within the States, having the
higher percentage of population who are narcotic addicts or drug dependent
persons."
We recognize that this is a project grant rather than a formula grant program
but the priority was established in law. To this date, despite our frequent in-
quiries, officials at HEW and NIMH have not defined what their criteria will be
for adhering to the congressional mandate.
By regulation, by necessity, and in keeping with sound practice in the treat-
ment of all handicapped persons, especially youth, we provide in our facilities
an excellent and complete educational program, not only for school-age youths,
but also for older addicts who lack learning and educational skills.
HEW has ruled, however, that we are not eligible for title I education funds.
If existing Federal regulations are susceptible of only such narrow construc-
tion, then obviously the regulations should be changed.
There is a lesson here, gentlemen. We must not become so hidebound to tradi-
.tional practice, so wedded to narrow concepts, that we create unworkable admin-
istrative nightmares.
When we planned the implementation of our $05 million youthful drug abuse
program, we concerned ourselves .solely with seeking tho.'^e grouixs and organiza-
tions having a demonstrated capacity and desire to provide .>^ervices.
Accordingly, we accredited and funded community mental health boards,
boards of education, county 'and local health departments, local narcotic guidance
councils, hospitals and clinics, citizen volunteer organizations, youth groups, anti-
poverty and community action agencies, social service agencies, civic groups, and
the like.
It seems to me that we can pursue no other course if our goal is to be true
community involvement in programs, and if our purpose is to seek action by
the people — for this is truly a people's fight, not just a concern of Government.
To the best of our knowledge, there is no single manpower program or com-
bination of programs which address themselves directly to tJae problems of drug
dependent persons.
To the contrary, the current combination of programs and regulations to imple-
ment programs seems to serve only to frustrate agencies like our commission
and thus to frustrate our clients.
For example, at present, we have to negotiate separately with an endless
vaiiety of city and other State and local agencies in order to participate in
neighborhood youth corps and other similar programs.
We have been told of task forces which have examined this problem ; we
have been toid of proposals submitted to this or that official for special man-
power programs. We have yet to see any positive programing.
Any such program developed by the Department of Labor must recognize that
there is severe discrimination in employment against narcotic addicts and drug
abusers in general. We understand the attitudes of fear born of ignorance and,
ye.i of experience, but we believe these can be replaced by policies of reason.
First. Federal and State programs must assist industries with their onboard
employees who use drugs. If we cannot treat or rehabilitate or render assistance
to- those persons who have sufficient motivation to hold jobs and attempt to lead
productive lives, we surely cannot succeed with society's casualties, the unmoti-
vated who have no skills, no work exi)erience and low educational attainment.
Indeed. I believe our ultimate success in persuading employers to hire re-
habilitated drug abusers and ex-addicts depends entirely on our success in help-
ing them with their onboard employees wlio are also in difficulty.
Far too many employers are adopting policies of firing any known drug user.
Businessmen have told us that in large part their reaction is predicated upon the
reported failures and limited resources of so many treatment programs.
In other words, gentlemen, we have not given our businessmen reason to believe
in our ability. At the same time, we have not created enough treatment and re-
habilitation opportunities, especially for nonnarcotic drug abusers.
We are working with the U.S. Department of Labor to assess the problem of
drug aluise in industry which, by all accounts, is substantial.
Vs'hile it is not true that all heroin addicts are unemployed or that all heroin
addicts steal, it is axiomatic that we cannot have long-term success with any
individual until we have enabled him to become a u.seful, self-productive mem-
ber of our society.
Today, only half of our rehabilitants can find work. Only 15 percent obtain
on the job training or institutional program acceptance. The other 35 percent go
on welfare ; they are critically vulnerable to a resumption of drug usage because
society offers them no meaningful alterntaive.
During 1970, our after care officers referred 568 rehabilitants to the New York
State Employment Service. The State could place only 173 on jobs and 16 others
in training programs. There were 164 addicts who were referred and not hired,
while 71 others were told there were no suitable jobs for them.
A major point is that the great majority of these rehabilitants made a sincere
effort to get jobs. Only 91 failed to report for their State Employment Service
interviews and only 5 of those who were offered jobs failed to report.
The rehabilitants who are the most difficult to place on jobs are precisely those
same individuals who are the focus of many of your manpower programs. But,
gentlemen, we have seen regulations for some of your manpower programs which
specifically permit prospective employers to exclude drug addicts.
Another of our studies has revealed precise correlates between the problems
of poverty, unemployment, lack of education, poor health standards, and drug
abuse. In fact, in those areas of New York City where these problems are the
most severe, you also have your most severe drug problems. (A copy of our
report is attached.)
We do not assert that these are the only causal factors in drug abuse today ;
certainly they are not the factors causing nonnarcotic drug bause in our suburbs.
They are, however, influential in the cities,
RECOMMENDATIONS
Gentlemen, in testimony today I have tried to give you some parameters of
the drug abuse problem as we see it. Through comparisons of past program ef-
forts. I hope I have shown you some of the mistakes of the past but also some
of the opportunities for the future.
The Federal Government must enable local governments and State govern-
ments to do more in the areas of treatment, rehabilitation, education, and preven-
tion : you must give u.g new initiatives in manpower programs. You must help
us conduct the research so vital to the success of all our efforts.
60-296— 71— pt. 2 17
590
I believe the Federal Government would assist itself, and certainly the pro-
fessionals in the field, if it would coordinate its various drug activities.
We would not attempt to tell you what kind of agency or commission should
be established.
We are therefore most encouraged by the announcement that the White
House will have a special unit acting as coordinator of the various Federal
programs.
Your need, under any administrative mechanism is for a national plan to
combat drug abuse — ^in all its forms. Just as the last session incorporated a
priority system into Public Law 91-513, we think the Federal Government should
assess the national drug scene, determine the priority areas, their program
needs, and concentrate on well-defined objectives within those areas.
From our experience, you will need a powerful, well-funded, and highly flex-
ible administrative mechanism to achieve such a plan and such objectives.
In New York, Governor Rockefeller made the decision to vest funding authority
and control over the youthful drug abuser program in our Commission. We
proved that we could involve the Departments of Education, Mental Hygiene,
and others in this total plan and apply our collective resources to a single
program.
Finally, we support and encourage the various U.S. efforts on the interna-
tional front to control the production and traflSc in narcotic raw materials and
to assist other nations, through international agencies, with their drug prob-
lems. Our State and our Commission have more than a passing interest in such
activities because we are truly held captive by forces beyond our control.
It has been argued that we in the treatment, rehabilitation, education, and
prevention fields are fighting a holding action. We cannot, in a real sen.se. this
argument goes, win the larger war until you win the battle to control narcotics.
The supply is simply too great.
This is not totally true, however. Supply and demand in the narcotics field
reinforce each other. Thus, the Federal Government must amend its posture of
late which has been to put its primary emphasis on external controls and law
enforcement. The legal and medical initiatives must be in balance.
Recall the 1970 report of the World Health Organization's expert Committee
on Drug Dependence :
"Until the demand for dependence-producing drugs is markedly reduced, it
cannot be reasonably expected that measures to control their availability will
have the desired result. A reduction in demand can be achieved only by preven-
tive measures designed to limit interest in drugs on the part of potential users
and through effective treatment and rehabilitation of drug dependent persons."
Perhaps the best evidence of this is the case of Sweden which has banned
amphetamine production. Yet. according to Dr. Rexed. their national authority,
the intravaneous injections of amphetamines continues to be their primary
drug problem.
The more commonly used example, of course, is the United States which for-
bids the production of opium and heroin, yet. is the largest consumer in the
Western World.
Recently, an international expert on narcotics confided to us his opinion that
the international cartels in narcotics have concluded that the U.S. efforts to con-
trol the flow of Turkish opium will succeed, if not this year, in the not too distant
future. In this exi>ert's opinion, however, the traflSckers have already begun to
develop their trade channels to bring opium and heroin from Southeast Asia
into the United States. In fact, we are told that opiiun from this area began
reaching these shores in 1969.
It is doubtful that any of these nations or even the trafl3ckers are concerned
about "hurting" the United States or inflicting a social dilemma upon us. It is
simply a matter of economics. We have the world's key marketplace.
We encourage the U.S. efforts in programs such as crop substitution and crop
elimination in overseas countries. There are, however, risks which Mr. Ingersoll
is aware of, such as the risk that opium producers will simply take our money
to retire one growth area and produce their opium in another.
There are also the problems, as recent reports and news stories suggest, of
oflicial involvement by governments or government oflScials in other nations. Mr.
Ingersoll recently charged ofBcial connivance on the part of some governments.
We wish the Government the best of success, gentlemen, knowing the many
problems. Our success and the lives of our children depend upon your efforts.
591
We appreciate your frustration that some of the foreign governments really do
not have effective control in the producing areas. I think you can appreciate our
even deeper frustration because we have no controls at all but must depend on
others who have little or no control either.
Mr. IngersoU's successful effort to create a United Nations fund for drug
abuse control is praiseworthy as are the preliminary plans of the United Nations
Division for Narcotics and other international agencies to implement the drug
program.
We also congratulate the U.S. delegation to the recent World Health Assembly
for sponsoring the successful resolution on drug dependence. I should add that
our Commission is very proud that Rayburn Hesse, our special assistant for
Federal-State relations, was the adviser on drugs to that delegation.
The concern and hopeful involvement of other nations in this problem hold
promise for us. For too long this has been thought of as primarily an American
problem. As more nations become affected, unfortunately, we have our best
chance to attain true international cooperation.
Thanks to the United States, the World Health Organization and its member
states became committed to a resultion which declares that narcotic dependence
and nonnarcotic drug abuse are major world health problems, requiring the co-
ordinated efforts of the member states and international organizations and
agencies.
Similarly, the United States led in the effort to adopt a convention on psycho-
tropic substances and is proposing amendments to the 1961 Single Convention on
Narcotics, including mandatory embargoes and inspections.
These two are promising initiatives.
CONCLUSION
There has been a tendency on the part of altogether too many people in this
country, including Government officials, to see our drug abusers as something
other tlian social casualties. The black heroin addict suffers from very unfortunate
characterizations which stigmatize him even after rehabilitation.
But our adolescent drug abusers also suffer denigration. It's as though only our
American youth were drug users, and that the only American youth involved are
hippies, hippies, and yippies.
On point one, the European Public Health Committee reported last year that
drug dependence and drug abuse are today, in most European countries, a serious
social, economic, and medical problem.
That committee reported six discernible trends ; a growing incidence among
young iieople ; new patterns in drug dependence ; a rapid increase of the abuse
of well-known drugs among other age groups ; a rising frequency of multiple de-
pendencies, occurring in 50 per cent or more of ail cases ; an increasing number
of women dependents ; and, a rapidly increasing problem of alcoholism.
As I said at the outset, this is truly a pandemic, and we will watch with interest
the response of the European nations, assessing not only the breadth of their
commitment, but also their ability to perform without the hypocrisy, indifference,
and regressiveness that has stunted too many of our efforts.
Whatever else these young drug abusers may be — acid heads, pot heads, speed
freaks, junkies — there is one overriding consideration, one common denominator
that must permeate our thinking and our actions — they are our children.
My final question : what will you do to help them?
Addendum
(Commissioner Jones' testimony was drafted prior to President Nixon's pro-
gram announcement and prior to the release of New York's confidential survey.
The addendum contains comments on both. The survey has been approved for
release on June 24.) .iTOi
PRESIDENT NIXON'S PROGRAM
New York State is naturally most encouraged by the President's response to
this national emergency, by his declaration of purpose, by his commitment of
resources, and especially by his recognition of the need for a proportionate and
balanced program.
There are those who would take satisfaction in observing that President
Nixon has agreed with them that the existing Federal effort is insufficient. We
take no such satisfaction. We have made that point; the record proves that
point.
Aijain, tlie only productive dialogue in which we can engage this morning is
a discussion of the future of cooperative programing.
As my original remarks note, we would not presume to recommend a par-
ticular administrative structure to the administration and to the Congress.
President Nixon has taken a hold step, an effort obviously designed to give maxi-
mum control and coordination.
The final de.sign of that administrative structure will be weighed closely and
scrutinized intensely by this Congress, as it should be.
But, let me say this. The President has properly defined a major problem with
Federal programing. He has proposed what the Administration believes is a
workable solution. The Congress may differ on the mechanics, but whatever
your differences, we urge you to reconcile them in the interests of national need,
a need that can be met only by coordinated programing.
President Nixon has proposed significant increases in all the major program
categories, specifically $105 million for treatment and rehabilitation, .$10 million
for education and training, $12 million for re.search, $2 million for special com-
munity programs, and $37 million for law enforcement. These increases, if ap-
proved, will bring the level of Federal programing for drug abu.^e up to $371
million.
Importantly, President Nixon, in asking the Congress to give this program
its highest priority, ."^aid he will take every step necessary to deal with the
emergency, including the use of additional funds.
We have details on some of the administration's goals; \ve do not yet have
the !<pecifics on implementation.
Among the goals :
President Nixon makes a critical distinction between law enforcement and
treatment and prevention, recognizing that we mu.«t destroy the market for
drugs by reducing demand — a point we also have emphasized.
At the same time, Mr. Nixon declares we must eliminate, in total, the pro-
duction of opium.
He underscores the need for research to find suitable and effective medical
substitutes.
He proposes to bring the resources of the Government to bear on the problem
of addicted military personnel.
Again, we congratulate the President on the balance reflected in this compre-
hensive approach. We reserve final judgment because his program is still just
a plan and we do not know what the important second step will be.
We recommend that the Federal Government consult the major State pro-
gram administrations to discuss implementation, resources, joint efforts and the
like. We recommend that such meetings be held at the earliest opportunity.
For instance, because of budget cuts and program changes, our Commission
can make available on short notice up to 800 residental beds and up to 1.300
trained personnel. We could accommodate several thousand addicts on an out-
patient basis. Inpatient care is dependent upon the variable of programed
length of stay.
Thus, we hope that the administration and the Veterans' Administration will
consider contracting for services. Our Commission for one has the capability and
resources to enable the Federal Government to implement its veterans program
on virtually an overnight basis.
For the record, we are already treating some 1,200 Vietnam veterans in our
addiction programs.
This experience causes us some concern about the reported plan of treatment
to be used for Vietnam veterans.
As we understand the proposal, addicted veterans would undergo a 7-day de-
toxification treatment in Vietnam and then be compelled to undergo 3 weeks of
mandatory treatment at rehabilitation centers in the United i^tates.
Inasmuch as Congress will reportedly be asked to api>rove bills authorizing
the Government to keep a veteran in service beyond his discharge date, if neces-
sary, to accomplish this treatment, we ask the Congress to consider the pros
and cons of utilizing existing and proposed Federal legislation that would certify
the.se veterans as addicts.
A rehabilitation period of 21 days is questionable at be.st. But, as we read this
plan, the Federal G<)veniment's responsibility would end there, even though these
593
veterans could avail themselves on a voluntary basis of Veterans' Administra-
tion and other facilities. A.:,! • :■
You and I do not linow the rehabilitation period that will be required for any
individual soldier, nor even the majority of soldiers.
But, I do know that, unless the Federal Government extends its responsibility
for these addicts, New York State and New York City will bear the bulk of the
social and fiscal responsibility.
Certification and mandatory treatment are not .-entences to confinement. They
are a protection for both the addict and society. We have many addicts who
respond afl3rmatively and quickly to treatment; many addicts who are not as-
signed to residential treatment programs because they have suflScient motiva-
tion and stability to live in the community while they receive continuing treat-
ment and assistance.
We would like to help you discharge your responsibility rather than have to
bear it for you.
In the education area, we strongly recommend that an early and very high
priority be given to an analysis of drug education programs before major sums
are spent.
Despite certain cost and social advantages, we recommend the administration
and the Congress weigh very carefully any propo.^als that would give dispro-
portionate weight to methadone maintenance, as opposed to all other forms of
treatment. Our prepared testimony more fully explains this note of caution.
Above all, we recommend that the Federal Government make every effort to
capitalize upon the experience and knowledge of other professionals in the field
and that the Ftnleral Government insure that its resources are committed to the
areas of greatest need.
It's more than just the money, gentlemen. We have the capacity and the desire
to help you and help ourselves to solve this problem.
THE CONFIDENTIAL SURVEY
I said in my major remarks that our Commission has the finest behavorial
science research group in the Nation. The director of that division, Dr. Carl D.
Chambers, is with us this morning. And, we are submitting to the Government
today copies of our statewide asses.sment of drug abuse in New York, an extremely
sophisticated, highly useful, and most expert document. A summary of the study
is included.
Dr. Chambers is to be congratulated on this notable contribution to our state
of knowledge, as are the staff personnel of the Commission who assisted in its
development and production.
Along with the study, which will be released tomorrow, we are submitting to
the committee the following research papers : ^'t; i:
1. A Research Overview of the Extent and Types of Drug Abuse in the United
States.
2. Considerations in the Treatment of Non-Narcotic Drug Abusers.
3. Self-Reported Criminal Behavior of Narcotic Addicts.
4. The Detoxification of Narcotic Addicts in Outpatient Clinics.
o. The Incidence and Patterns of Drug Abuse Among Methadone Maintenance
Patients.
0. Predictors of Attrition During the Outpatient Detoxification of Opiate
Addicts.
7. The Rationale and Design for a Multi-Modality Approach to ^Methadone
Maintenance.
8. Characteristics Predicting Long-Term Retention in a Methadone Mainte-
nance Program.
n. The Correlates of Drug Abuse.
10. A Bibliography of Commission Rt-search Reports.
We tru.st the findings in each of these submissions will lie of assistance to the
committee in its deliberations.
Chairman Pepper. Xow. if I iiuiy. I will caU on Gavernor Shapj) of
Pennsylvania. (Tovernor Holton of Virginia. G(>^(l•ll()^ Carter of
GeorLna. and Tjieutenant Governor I'rickley of ^Michia-.tn.
We are very pleased this morning; to have so many young peoj^le
here, many of them school pupils. We hope you will learn something
594
of value in the testimony you have heard and the testimony you will
hear from these distinguished Governors who now honor us with their
presence.
The committee is pleased and honored to have with us at this time
four distinguished Americans who have achieved the leadership of
their respective States: The Honorable Milton Shapp, Governor of
Pennsylvania : the Honorable Linwood Holton, Governor of Viro;inia ;
the Honorable Jimmy Carter, Governor of Georgia ; and the Honorable
James H. Brickley, Lieutenant Governor of Michigan. We have asked
these dedicated and distinguished public servants to testify today be-
fore the committee because we want to benefit from their experience in
dealing with heroin addiction in their States. While we have called
for a larger Federal role in combating addiction and in the rehabilita-
tion of addicts, we do not want to give the impression that this is a
Federal problem alone. The States have long battled this problem and
their help, guidance, and leadership is vital to the success of any at-
tempt to combat addiction. We want to hear from these distinguished
leaders of America who are fighting the battle in the front lines, as it
were. We want to hear from them as to what their States are doing,
what they think the magnitude of the problem is, and what, if any-
thing, in their opinion the Federal Goverinnent should do to help them
to meet this problem in their respective States and through tJiem. to
gain an impression of what the problem is in the count rj' and the need
for Federal assistance.
So we are very much honored. Governors, to have you here today.
I am advised that Governor Holton is pressed for time, so with the in-
dulgence of the other Governors, we will first call on Governor Holton
of Virginia.
STATEMENT OF HON. LINWOOD HOLTON, GOVERNOR,
COMMONWEALTH OF VIRGINIA
Governor Holton. Thank you, Mr. Chairman. I appreciate your
courtesy in arranging for me to go first. I have had a further complica-
tion this morning in that we had some radio trouble coming up, so I
really do not have a great deal of time, and I am sorry.
We do have a rising drug problem in Virginia, however. It parallels
the national experience in statistics from 1960 to 1969. In that period,
there was a 556-percent increase in narcotic addiction in Virginia. That
is made a little grimmer and more frightening by comparison of deaths
in just a 4-year period. We had only one narcotic death in Virginia in
1966. Last year, we had 20. We have one hospital alone reporting a o50-
percent increase in drug abuse patients in just 1 year. Distressingly,
more and more young people are becoming addicts. We had, for exam-
ple, our youngest addict just last week, a child just a week into her 12tli
year, a confirmed heroin addict, picked up in the Tidewater area of
Virginia.
We have tried to develop a sound solution. Though we know there is
no miraculous cure, we believe that the correct ap])roach requires co-
ordination of the educational, rehabilitatiA-e, law enforcement resources
available to tackle the problem. For that reason, just after I took
office — as a matter of fact, it was in March of 1970 — I created a Gov-
o95
ernor's Council on Narcotics and Drug Abuse Control by an execu-
tive order. The mission of this council was to coordinate the efforts,
assets, technology and experience of all of our State agencies in any
way concerned with drug abuse and to direct them to a solution of the
drug problem. Coordination was their first priority and a summary of
the plan of coordination is being submitted to your committee with my
testimony, sir.
Cli;nrnian Pf.fper. It will be received.
Governor PIolton. We also created regional drug councils. Our State
is one of the few that has been divided into 22 planning districts for
coordination of all of our services, and we are seeking through the
regional drug councils to tie the localities into State effort. It was
amazing how many various agencies or volunteer groups there were
in some areas of our State working on this. I think we reduced as many
as 90 in the A/'irginia area to eight groups through these regional coun-
cils. We asked the regional councils to develop a plan that would bring
direction, planning, objectives, and goals against drug abuse to the
grassroots level. The assembly, the Legislature of Virginia, also passed
a new drug code in 1970 which is very close to the model code. We
have this year, in a special session of the assembly, created a new drug
strike force within the State police department. This strike force will
try across the entire State to move against those criminals who profit
bv dealing in drugs.
In the education phase, I think we have had very good success. Last
sunmier, in 1970, we gave 200 teachers a 2-week intensive course in drug
;ibuse and use and then required them to go back to their communities
to give 10 hours of awareness training to fellow teachers. Now, by
awareness training, we meant knowing what the drugs are, the symp-
toms that the children will exhibit when taking drugs, and some of
the syndromes behind the taking of drugs. Those teachers are really
in the frontline, Mr. Chairman, and today, through this program,
47,000 of our teachers have been given this 10-hour awareness train-
ing and by the end of July, we hope that we will have gotten 55,000
teachers.
That is not enough. We are revising the health curriculum from
kindergarten through the 10th grade to include drug education, not
just drug information — real drug education. That means that we are
going to have to certify teachers to teach the program. It means that
we are going to have to retain 1,500 teachers and 2,000 counselors be-
tween 1072 and 1974, and we expected to do it. This gives a 2-year
period for universities and colleges to gear up to begin to produce cer-
tified teachei's.
Besides this training, the State is also carefully looking at a program
to utilize the PTA's throughout the Commonwealth as a vehicle to
give the people of our State the same 10 hours of awareness training,
and we hope to reach 214 million by 1975. That is the outline of what
we are doing in education.
In treatment and rehabilitation, we are really in the beginning of a
program and we very strongly feel the inadequacy which is so general
in this area of treatment and rehabilitation. We' doubt, I think with
most everyone, that there is any single type of treatment or rehabilita-
tion which will be successful in all the cases, and we are not confident
about even some of the more popular programs. However, we have
596
gone ahead with several. We have tried different therapeutic tech-
niques and we are searching with everybody else to find the best.
The Medical College of Virginia, which is one of our two outstand-
ing medical schools, has a methadone program and it has functioned
for 14 months without a single case of death or overdose. It is not just
a maintenance program. We have tried to work it in with the other
facilities like vocational rehabilitation, job training, and counseling,
while the methadone is being used. We are trying to reorient the pa-
tient back into productivity ; and over a long period of time, we are
trying to see if the methadone can be cut back. With this counseling
and other rehabilitation effort, we will try to put them back into
society.
We have, too. an outstanding example of Federal, vState, and local
cooperation in a therapeutic community that we recently opened in the
Richmond metropolitan area. This was supported by the Richmond
community action program with the permission of the city. Our State
department of health furnished medical funds and services and some
Iniildings, and we have given them approximately 70 acres of land near
Richmond on a State hospital site on loan from the department of
mental hygiene and hospitals while operating costs are paid by GEO.
This ]:)roject is going to have a capacity of about 100 inpatients and
about 200 outpatients and we will be watching it to see if we can use
this as a method of rehabilitation.
The results to date are A^ery exciting. People have come to it volun-
tarily, are participating enthusiastically in it, and I feel that maybe
it may give us some real hope for the future.
Very shortly, our State also will be instituting models within the
prison systems to begin work with people who are addicted and abusers
of other drugs. In Tidewater, Va.. we have underway a plan to use
part of our State military reservation which has heretofore been ex-
clusively for National Guard use and very underutilized. We are put-
ting there personnel from the health department, the department of
welfare and institutions, the vocational i-ehabilitation department and
thQ department of education, perhaps with others — I think specifically
mental hygiene hospitals. This group of people will go to Camp Pen-
dleton, actually in the bachelor officers quarters, and will live there.
They will have a director and they will answer to that director, though
they will, as T sav, come from these other agencies of State government.
The patients will come there for counseling and treatment. We hope
that the opportunity for several agencies to interact OA^er each patient's
problems will give the pi-ogram the ability to grow without won-ying
about the autonomy of anv one agency as such. This is a program that
will deal mostly with youth.
Now, those are some of the activities that we are doing larjrelv on
our own, although as I indicated with the GEO fundss, some Federal
funds are iuA^olved. But let's discuss the cost of the treatment and re-
habilitatiou. Di'ogT'ams. because I think that is where you are just going
to have to help us.
As ])art of our overall State plan, we have developed maior esti-
mated cost requirements for drug abuse ti'eatment and rehabilitation
pi-ograms to treat 2,000 addicts. That is somewhere between a third and
a fourth of the addicts that we estimate we have in Virginia. I have
an exhibit that shows how these costs add u]> to a total of $7,065,000.
597
That would, as I lia\'e pointed out, meet only about a quarter of the
addicts. But it would give the minimum to try to get treatment to that
quarter and perhaps to experiment and, of course, if we could get the
additional funds, we would try to serve all of them.
In fiscal year 1969, we spent approximately $100,000 on drug abuse
outside of our alcoholic program. In fiscal 1970, the State spent almost
$.'^ million, and today, we are faced with four times that $7 million
figure if we treat them all, or $28 million. It comes at a time when, just
like all States, and I am sure Governor Shapp is going to tell you about
this, we are very hard-pressed financially. You are hearing that from
all your cities and from all your States. We have a $321 million gap in
projected revenue and just exiDenses of carrying on, not even beefing up
this drug program that we think is critical.
So the additional costs of the drug program are just going to be
extremely difficult for us if we have to do it on our own. If we do it
alone, the funds more than likely will have to come out of some other
program. It has come on us, the narcotics problem, suddenly, just as
it does for everybody else. We have to have all the resources. Federal,
State, and local. We emphasize to you that we must have Federal
assistance to combat this problem.
(Governor Holton's prepared statement follows:)
[Exhibit No. 22]
Prepared Statement of Hon. Lin wood Holton, Governor, Commonwealth
OF Virginia
It is a privilege to report to you on the drug problem in Virginia, the steps
we are taking to meet this problem, and the need which we have for Federal
assistance.
The rising drug problem in Virginia has paralleled the national experience.
From 1060-69, there was a 556 percent increase in narcotic addiction in Virginia,
according to statistics of the Bureau of Narcotics and Dangerous Drugs. A grim-
mer measure of the rate of increase is revealed by these statistics : in 1966 there
was only one narcotic death reported in Virginia ; in 1970 there were 20. One
hospital alone reports a 350-percent increase in drug abuse inatients in the past
year. A very conservative estimate of the minimum number of narcotic addicts
in Virginia ranges from 6,000 to 9.000 individuals.
The most tragic fact is that 90 percent of these addicts are under 30 years
old. Just last week, we received a report of the youngest addict thus far dis-
covered in our State, a 12-year-old girl.
Faced with the sudden growth of the problem of narcotic addiction to alarm-
ing proportions, Virginia has attempted to develop quickly a sound solution. We
realize that there is no one miraculous cure. We believe that the solution must
come through coordination of the educational, rehabilitative, and law enforce-
ment resources available to tackle this problem.
Therefore, in March of 1970, I issued an executive order creating the Gov-
ernor's Council on Narcotics and Drug Abuse Control. The mission of this Gov-
ernor's coimcil was to coordinate the efforts, assets, technology, and experience
of all State agencies concerned with drug abuse and direct them to a solution of
the druET problem. The first priority of this Governor's council was to develop a
State plan to coordinate our efforts. A .summary of that plan is being submitted
to your committee with my testimony.
We created regional drug councils to tie the localities into the State effort.
Each of these regional councils was also charged with the responsibility of de-
veloping a plan which was comprehensive and coordinated with the State plan.
Thus, we brought direction, planning, objectives, and goals to the grassroots
level in our efforts to solve this most complicated pro^blem.
In 1970, we took steps to improve the law enforcement phase of our program.
The General Assembly passed a new drug code which closely parallels the Model
Code. In 1971, a special session of the General Assembly created a new drug strike
598
force within our State Police Department. This will have the ability and
mobility to move across the face of our State after the criminals who profit by
dealing in drugs.
In the education phase of our program, in the summer of 1970, 200 teachers
were given an intensive 2-week course in drug use and abuse. These teachers
then returned to their communities with the mandate to give 10 hours of aware-
ness training to their fellow teachers. By awareness training is meant knowing
what the drugs are, the symptoms the children will exhibit when taking them
and some of the syndromes behind the taking of drugs.
Virginia recognizes our t.eachers are the front line of defense in our schools
and that education is the long range weapon to thwart the spread of the drug
abuse. To date 47,000 of our teachers have been given this 10-hour awareness
training. By the end of July we hope to have some 55,000 teachers trained.
We do not feel this is enough in education. The State is now completely re-
visiting the health curriculum from kindergarten through the 10th grade to in-
clude drug education — not drug information but drug education. This then means
the State will have to certify its teachers to teach this program. This also means
the State has to retraiji, between 1972 and 1974, its 1,500 health teachers and
2,000 counselors.
This gives a 2-year period for the universities and colleges of the Common-
wealth to gear up to begin to produce certified teachers in this area. Besides this
training, the State is also carefully looking at a program to utilize the Parent-
Teacher Associations throughout our Commonwealth as a vehicle to give to the
people of our State 10 hours of awareness training. Our hope would be for at
least 21/4 million people to be trained by 1975..
This brings me to the efforts we are making in the area in which you are most
concerned — treatment and rehabilitation. In 1969, Virginia had no rehabilitation
program to speak of. Today we have the beginnings of such a program, but we
share the feeling of inadequacy which is so general in this area.
We doubt that there is any single type of treatment and rehabilitation pro-
gram which will be successful in all cases. We are not even confident about the
relative merits of the more popular programs used today. Therefore, we have
begun with several different models of different therapeutic techniques so that we
may determine which will be the best method or methods for Virginia to use in
the future. V.^!,,;i,. ,,,,, i,.,, .; -ir.., • ,;,,..!.,.
One of the most respectell medical schools'in the country, the ^ledieal College
of Virginia, has a methadone program. This program has been functioning for
14 months without one incident of death or overdose. It is not simply a main-
tenance program. The program u.ses other facilities like vocational rehabilitation,
job training and counseling while the drug methadone is being used as a buffer
tool to give us time to reorient our patient back into a productive life. Over a long
I>eriod of time the patient's methadone is cut back as he receives counseling and
becomes strong enough t.o reenter society.
An example of local. State, and Federal cooperation is a therapeutic commu-
nity recently opened in the Richmond metropolitan area. The Richmond com-
munity action program supported this program with permission of the City <'>f
Richmond. Medical funds and services were provided by the Department of
Health on the State level and seven buildings and approximately 70 acres of
land on a state hospital site were loaned to the project by the Department of
Mental Hygiene and Hospitals while the operating costs are being paid by the
OflSce of Economic Opportunity. This project will have a capacity of 100 inixi-
tients and approximately 200 outpatients. Ag'ain, we will be watching this pro-
gram as a model to .see if Virginia can use this method of rehabilitation.
Several programs of the reliabilitation community type are in different so^*io-
ecoDomic areas, including a methadone clinic in the more rural western part of
the State.
Tlie State will very shortly be instituting models within the jn-ison system
to bpgin to work with its )>eople who are addicted and who are abusers of other
drugs. In the Tidewater area, plans are on the way to take a good section of one
of our military bases. Camp Pendleton — in fact we will use the bachelor officer's
quarters — and take personnel from each of the service agencies such as the
health department, vocational rehabilitation department, and department of
education who will live on the Pendleton project. They will be answerable to
only one director and have that director answerable to the board of agencies
vi^hich submitted the personnel. In this way we give the personnel the freedom
to interact over each patient's problem, and give the program the ability to grow
599
without worrying al>out the autonomy of each agency. This project will deal pri-
ii'.arily with youth.
Evaluation of these programs is the key for our State to find the best method
or methods to treat and rehabilitate narcotic addicts.
Now, let me discuss the costs of these treatment and rehabilitative programs.
As a part of our overall State plan, we have developed major estimated co.st re-
quirements for drug abuse treatment and re^habilitation programs to treat 2,000
addicts. I am submitting with my testimony an exhibit outlining the.se programs
and estimates of their major costs. The total estimate is $7,065,000.
Yet, we have an estimated 6,000 to 9,000 narcotic addicts in Virginia at the
present time. Therefore, these facilities would serve only approximately one-
fourth of the minimum estimated number of addicts. The cost would be approxi-
mately four times this $7 million figure to serve the entire minimum estimated
number of addicts, or $28 million.
In fiscal 1969, the State of Virginia spent approximately $100,000 in funds on
drug abuse outside of alcoholic programs. In fiscal 1970, the State spent almost
$3 million on drug abuse programs. Today we are faced with this estimate of
approximately $28 million to meet the need just for treatment and rehabilitative
facilities.
This comes at a time when Virginia, like all States, is being severely hard-
[»ressed financially. We see a gap of $.321.3 million between our estimated revenues
and expenses for the upcoming biennium. Thus, additional costs such as these,
no matter how important, are very difficult to meet. It may be that they can
only be met by taking them out of the hide of another program. The narcotics
problem which has come on us so suddenly calls for a marshaling of all of our
resources at the Federal. State and local level to check it. We must have Federal
assistance, particularly for treatment and rehabilitative programs.
Appendix
Drug AsrsE Tkeatmext and Rehabilitation Programs Projected Major
Program Costs
The di'veloirment of comprehensive drug abuse treatment and rehabilitation
programs in Virginia will require significant funding. The Federal Comprehen-
.•-ive Drug Abuse Control Act of 1970 authorized $75 million to be spent over
the next 3 years. If Virginia acts quickly in planning mo<lel programs. Fedei'al
grants should represent one source of funding for locally base<l programs.
However, Fetleral funds alone will not be sufficient to have a major impact
on Virginia's drug abuse problem. Significant funding by both the localities and
the State is required to develop statewide comprehensive programs. I^ocal fund-
ing will encourage community support and a community program orientation.
State funding, in addition to providing necessary fund.s, will provide State agen-
cie.M Che authority to insure program quality control and continuity throughout
Virginia.
''■ The tot^l amount of funds required to develop comprehensive drug abuse treat-
ment and rehabilitation programs throughout Virginia is difficult to estimate.
Both the demand (number of drug dependent individuals) and cost per patient
are not accurately known. However, a key principle discussed previously in the
recommended overall program approach section should be reiterated :
•j(f; (1 Large programs for any given community should be built on the basis of
objective data from a smaller program.
Every present-day program for the treatment and rehabilitation of the
drug dependent person has its limitations and remains in the research state.
Any program component not achieving substantial progress toward the de-
fined goals should be abandoned or altered.
The number of drug addicted individuals in Virginia was estimated in the
nature of the problem section at a minimum of 6,000 to 9.000 individuals. Of these
individuals an estimated (by program professionals) may be drawn into a volun-
tary rehabilitation program.
Virginia should establish an objective of implementing model programs to re-
habilitate a si>ecified number of drug dependent individuals. A goal of 2.000
individuals under treatment and rehabilitation by December 1972 is proposed
as an ambitious but feasible goal.
60P
Rased on the proposed goal of 2.000 persons, major incremental funding re-
(inirement-; c-an he estimated. The following section outlines the estimated costs
of communit.v-based programs and State agency requirements.
The fost of Mny rehabilitation program will vary by the number and types of
modalities utilized. Based on an analysis of average treatment costs for various
I)r<gram modalities across the country, the potential costs of various modalities
in Virginia have been estimated. These are presented in exhibit II-7 on the
following page.
Exhibit II-7
Estimated annual costs for various treatment and rehabilitation program
modalities and sen-ices
Eatimnted nvernge
MODALITY annual cost
per patient
Methadone support (including supportive .services) $1,800
Narcotic addicts only.
National estimates ranges from $1,200 to $1,800.
Cost varies by number of supportive .services provided but will be
relatively high per patient during development stage.
Therapeutic community (including supportive services) 4,500
Addicts and nonnarcotic abusers.
Estimates range from $3,000 to SC.OOO.
Costs will be relatively high per patient during developmental
stage.
Medical-Psychiatric approach (including inpatient, outpatient and sup-
portive services) 4. 300
Addicts and nonnarcotic abusers.
Based on experience of N.A.R.A. program.
Medical-Psychiatric approach (all inpatient) 10.400
Based on Federal program in Lexington.
Civil commitment (including high security residential care plus thera-
peutic and supportive services) 7.000
Based on average cost per correctional inmate in Virginia plus
estimate of therapeutic costs.
STATE PROGRAM SERVICES
Vocational rehabilitation .services 65.000
Includes cost of purchasing medical and other vocational rehabili-
tation services.
Based on vocational rehabilitation Department estimates.
Probation and parole services 10.000
Based on probation and parole board esl:imates.
Note. — .\ttention Is dlrerted to the fact that, althoiich this projection has heen prp-
pared from the best available esMmates, it Is based upon numerous assumptions as to
future events and therefore cannot, of course, be conipletel.v accurate. It should be viewed
as a presentation of tlie results to be expected if tiie several assumptions are fulfilled.
In order to estimate the costs of treating 2.000 individuals in a multimodality
program, the number of individuals treated in various modalities must be esti-
mated. Since no accurate statistics are available, estimates were ba.sed on the
experiences of other programs and estimates of knowledgeable professionls in the
field. Based on these estimates, approximately 50 percent of the 2.(X10 patients
would be in methadone support jtrograms. Twent.v percent woidd be in the
therapeutic or residential communities. Thirty percent would lie under medical-
psychiatric treatment, both ini)atient and outpatient, and other modalities and
supportive services.
Exhibit IT-H illustrates a cost "workup" of e.stimated treatment and r<>habilita-
tion costs. In addition, costs for State programs in vocational rehabilitation an<l
probation and parole and estimated initial organizational staffing requirements
are also presented.
The funding requirements for community-based treatment and rehabilitati<iii
programs approximate $6.2 million. State vocaticmal rehabilitation and proba-
tion and parole programs total $750,000. Initial organiz;iti<in staffing nM]uiretnents
for State agencies total $115,000. The.se costs do not include costs for the proi>ose(l
civil commitment program since it was reconmiended that this project not be
implemented until local programs have been develojted. .\fter development ()f
601
local programs, costs for a civil commitment program may reasonably be esti-
mated. An average patient cost for civil commitment is included in exhibit II-7.
Federal funds can represent a significant portion of treatment and rehabilita-
tion program costs. The amount of Federal funds received by Virginia will de-
pend on the actual dollars appropriated by Congress for drug abuse and on
Virginia's ability to act swiftly in applying for Federal grants.
Exhibit 1 1-8
Estimated major cost requirements for drug abuse treatment and rehabilitation
programs {Proposed goal, 2,000 individuals in comprehensive treatment and
rehabilitation programs)
Estimated
Community-based program costs : annual costs
Methadone su]>port : Narcotic addicts only : 50 percent of pro-
posed goal at $1,800 per year, per patient $1, 800, 000
Therapeucic communities : Drug abusers or deiiendent indi-
viduals (nonnarcotic) aud narcotic addicts; 20 percent of pro-
posed goal at $4,500 per year, per patient 1, 800, 000
Medical-psychiatric programs: Drug abusers or dependent indi-
viduals (nonnarcotic) and narcotic addicts; 30 percent of pro-
posed goal at $4,300 per year, jter patient ._ 2. 600, 000
Total costs for community-based programs 6,200.000
State organization and program costs :
Vocational rehabilitation: 10 counselors at $65,000 650. 000
' Probation and parole : 10 officers at $10,000 100, 000
Total program costs 750, 000
Governor's Council on Narcotics and Drug Abuse Control : One
treatment and rehabilitation program analyst 15,000
Department of Mental Hygiene and Hospitals : Bureau of Com-
munity Drug Abuse programs^mf^fa? staffing costs 70,000
Bureau director.
Two local program coordinators.
Administrative support.
Welfare and institutions 30, 000
One program coordinator — division of youth services.
One program coordinator — divisicm of corrections.
Total State organization costs . 115,000
Summary of program costs :
Community-Based Programs (both Stare and locally funded )__ 6, 200, 000
State organization and program costs 865, 000
Total 7, 065, 000
Note. — Attention is directed to tlie fact that, althougli thi.s projection ha.s been pre-
pared from the best available estimates, it is based upon numerous assumptions as to
future events and therefore cannot, of course, be completely accurate. It should he viewed
as a presentation of the results to be expected if the several assumptions are fulfilled.
Chairman Pepper. Governor, we thank you very much. If you will
j ust stay as long as you can with us.
Next, I want to call on Governor Shapp of Pennsylvania and par-
ticularly and publicly to thank the Governor for his great kindness
in adjusting his schedule twice to this committee to give us the benefit
of his appearance.
We are glad to have you, Governor.
602
STATEMENT OF HON. MILTON SIIAPP, GOVERNOR,
COMMONWEALTH OE PENNSYLVANIA
Governor Shapp. Mr. Chairman, members of tlie committee, I appre-
ciate this opportunity of appearing before you to talk about the drug
problem. I must confess that after listening to the experts from New
York and listening to Governor Holton from Virginia, I realize how
much of a novice I am in this whole field and how far we have to go
in Pennsylvania to really have the effective programs to deal with
our drug problems.
I would just like to add one note to this and that deals with what
is really causing so many of our people today to turn to drugs. I
think we have many disillusioned people in this Nation who see no
way out of their present dilemmas of living and as so many in history
have done, they have turned to drugs.
I think that Vietnam is just an example of what we are facing
nationally. Our men in Vietnam see no way out and they turn to drugs.
A lot of our young people are scheduled to go to Vietnam and see
their lives more or less as they have planned them being dashed. They
turn to drugs.
And I think we find that there are many people in our society who
find it very difficult to adjust to the hypocrisies they see all around
them and turn to drugSj and in general, people who just feel that they
have no future to serve m society and turn to di'ugs.
If we are effectively to deal with the drug problem, it seems to me
we also have to deal with these inconsistencies in our lives, because
T think this is just as much a part of any regular treatment that we
will have for handling drug addicts. It is part of the educational
process that we must deal with, and certainly, it is as important as
the controls we will place in our Nation and in our communities to
stop tlie flow of drug traffic. I think the prol)lem of drug abuse in this
Nation and certainly in Pennsylvania is the No. 1 social issue of
■our time. It is an issue that could destroy us.
I might add in reference to something that Governor Holton just
said about deaths attributed t/O drugs, we have had more deaths attrib-
uted to drugs in the city of Philadelphia this year than we have to
traffic.
I think that this is an indication of how serious the situation is,
I feel that drugs and the drug problem must be contained and con-
trolled. If it is not, then tliis Nation is going to be in much greater
trouble than it is today. It is unfortunate that to date, there has Ix^en
no conceited nationwide effort to deal with the drug problem, mobiliz-
ing the coordinated resources of our National, State, and local govern-
iments. I am encouraged by recent announcements from the administra-
tion here in Washington that they are going to be moving in this
•direction. But I think it is important to recognize that this Nation
lias never fought a battle like this before and we do not have the
knowledge that we need. We do not have all tlie tools, we do not by
any means have the funds.
I just cite, for example, this $155 million souglit by the Nixon
administration. In my opinion, it is woefully inadequate to meet the
needs and just listening to the ex]ierts from New York talk about
$188 million that they are spending there annually in their one State,
603
I think that indicates that the problem is much greater than is
lealized here by the administration.
In Pennsylvania, we have estimated our statewide needs at a mini-
nunn of $45 million. However, facing realistic budget requirements
this year, we have appropriated only $20 million in the next fiscal year
and I add that this amount will only permit us to inaugurate a reason-
able program. The $15 million that I just mentioned really is not the
amount we find we would need once we got the program started in
Pennsylvania.
I might add in that connection that when I assumed the governor-
ship just 5 months ago, I was a little astounded to find out that despite
the fact that we have an esimated number of heroin addicts of some-
where between 30,000 and 50,000 people in Pennsylvania, and about
15,000 to 20,000 of these are in Philadelphia alone, and of course, there
are many others using all kinds of other drugs, yet we only had 30
people employed by the Commonwealth to deal with the drug prob-
lem in the Commonwealth. These 30 people were employed just to
try to contain the illicit flow of drugs in the State. There was no pro-
gram in Pennsylvania. It was fragmented all over the place, and I
will come back to that in a moment.
The economic impact of the drug problem is as startling as the
human toll it takes on its victims. In order to make the $50 or $70
or $80 a day it takes to keep the heroin addict alive, the heroin addict
usually steals goods v/ith a market value of $100 or $150 or more per
day, which he then sells to a fence at a lower price.
Philadelphia alone suffers property loss of over $500 million a
year. That is just an estimate. Nobody really knows what it is. State-
wide, it would not be unreasonable to claim that the loss approaches
at least a billion dollai'S annually. This is in addition to the fact that
two-thirds of the muggings and street crimes in our cities are drug
connected.
These are the harsh economic facts and I am sure you are familiar
with theui. But the question you want answered is this : How can the
National Government help us at the State and local level to deal
effectively with the problem? Assuming a Federal financial conunit-
ment, where would the money go ?
When I took office on January 19, I called upon the State legisla-
ture in my opening address to inaugurate the first comprehensive
statewide drug control and rehabilitation program in the history
of the Commonwealth, and I might add to be included in that a co-
ordinated program to deal with alcoholism as well as clnigs. We esti-
mated that to get the program started would cost us about $15 million
to fund the program. Finally, we settled on a first-year figure of $20
million, spread through a number of departments, with the central
coordinating point being a council on drug abuse within the Office
of the Governor. This bill is now before the legislature and I hope
that within the next couple of weeks, it will be passed.
As I indicated, we fomid that on a payroll of more than 100,000
on the State payroll, only 30 special narcotics agents were charged
with the responsibility of controlling the illicit drug traffic. So first,
we intend to upgrade the positions of the narcotics agents, add more
men and give them better training.
We intend also to greatly intensify the active role of the State
police by giving them more tools, tools that they need to fight traffic
(51)4
and apprehend the wholesalers and retailers. In this connection, al-
though for security reasons I cannot detail the present work of the
State police, we are starting with some excellent progress and there
will be some news coming out of Penns3dvania very shortly. But we
have called for the creation of 240 additional positions for State troop-
ers for assignments to the drug-control force. This is a measure of the
tremendous importance which we attach to this problem, in 1 year
going from 30 to 270.
In'the department of health and public welfare, we intend to expand
our programs for rehabilitation and basic and applied research for
the cure for addiction.
The status of the rehabilitation of addicts not only in Pennsylvania
but throughout the Nation is somewhat in the Dark xlges. I might
add that education concerning the danger of drugs in my opinion
reaches the level of the stone age. We are far sliort of the need in terms
of rehabilitation. Rehabilitation does not stop at the door of a treat-
ment center. It must follow the former addict back into the world to
the ])oint where he becomes once again a productive member of society.
We have very little inf onnation at our disposal and I hope there would
be some from this committee and from the Federal Government and
from other States as to how to set up programs to really accom-
plish this very important aim. Because unless we can get an addict
rehabilitated and back into work so that he becomes a member of
society in fact, then we are not really doing much because we are just
starting the cycle all over again. We are just starting to develoj) pro-
grams In Pennsylvania that recognize this program and we are co-
ordinating programs that are part of community affairs so that part
of their funds for ongoing job training goes to former addicts.
We have increased this jol) training appropriation. Seventy percent
of the men presently serving time in our State pi'isons have drug-
connected records. Recognition of the drug problem witliin our prisons
and a program to cope Avith it will become part of our o\'erall program
of prison reform and I am waiting for such a report now from our De-
partment of Justice.
We are also improving our State board of probation and parole to
continue seeking Federal grants under LEAA and to pro\-ide pro-
grams whereby those on probation and parole with drug-connected
records will receive the appropriate followup in this vital arm of our
corrections system. This is something that has not been done in the
State at all and we are just starting it.
Today we are holding a meeting of the appropriate agencies of
State government to start chartering a statewide program of return-
ing vets, with special emphasis on drugs. Again, I will be lia[)py to
report our proposals to this committee as they are formulated.
As to treatment, presently in Pennsylvania, this is being accom-
plished by several kinds of facilities. These facilities range from
emergency beds in some hospitals for immediate ])roblems to private
hospitals for long-range treatment. We have tlierapentic communities
like Gaudenzia House, Eagle\ille Sanitorium, and Ten Challenge
Farms. We have some halfway houses, some nonprofit treatment
centers and counseling organizations. But I must admit to you that
this dominant im])i'ession received from those many eil'oits is one
G05
of complete fragmentation and I suspect that fragmentation is one
of the key descriptions for onr nationwide effort tlu^s far.
Another dominant word for that effort is inadequate. In Pennsyl-
vania, we only have six methadone maintenance clinics serving a])out
l,r>00 addicts.In the Commonwealth of Pennsylvania, there is no State
facility devoted solely to the drug problem.
Let me add that my remarks are not meant to downgrade the fine
work of our ]:)eople at lioth tlie private and public levels. They have
done an excellent job, particularly in law enforcement and through
the Law Enforcement Assistance Agency here in Washington, we have
had some Federal help.
Rut it would be wrong for me to tell vou that the fight against
drug addiction is not fragmented and inadequate. At best, there are
a minimum number of beds devoted mainly to detox at State hospitals.
Programs of rehabilitation, and aftercare to the extent that they are
available, are privately administered with a negligible degree of State
and local involvement.
These activities must become coordinated and recognizing the need
for coordination, I have already discussed one area, for exam]:)le.
with Governor Cahill of New Jersey, a different kind of coordinating
plan, a joint effort between our States to stop the illicit traffic of drugs
over State lines.
But we desperately need much more than our State can provide. We
need more and better facilities, professional people in greater numbers,
better enforcement, a better education program, starting in the earliest
grammar school grades. All of these call for a massive infusion of
help from the Federal Government.
I might add in this connection that some of the studies I have been
looking at indicate that perhaps we should be starting our educational
program via television, educational television networks, and so on, at
kindergarten and prekindergarten years so we can get the minds set
at the ''no-no'' level very simply so that these youngsters recognize that
drugs are just not something that are to be plaVed with.
Gentlemen, I just ask that you help us with professional assistance
and financial resources and I'think this job can be done. But I think
we would be wrong to say that it can be done with the ])rovisions of
the present administration bill. I think that vre are thinking just in
terms of $45 million for our State and the Federal Government is
recommending a program that is less than one State is already spend-
ing and they think that is inadequate. I think that if we are really go-
ing to challenge this thing and come to grips with the drug problem,
we are going to have to look to a massive program. Then T think w^e
can make strides but only if we apply our collective resources and
imagination to solving this issue.
I appreciate this opportunity of bringing yon up to date about what
is happening in Pennsylvania. I am sorry I cannot come and report
to you that we are doing great things in our State because most of
the things that we want to do are still in the embryonic planning
stage.
Chairman Pepper. Governor, we thank you very much for your
very able statement.
( Governor Shapp's prepared statement follows : )
60-2,96 — 71 — pt. 2 IS
606
[Exhibit No. 23 J
Prepared Statement of Hon. Milton J. Shapp, Governor, Commonwealth
OF Pennsylvania
The drug traflSc in this nation is the number one social issue of our time.
It could destroy us.
But it could also be contained, controlled and, finally, defeated by enlightened
Government action.
It is unfortunate that there has been no concerted, nationwide effort to
deal with the drug problem, mobilizing the coordinated resources of national,
State and local government.
Recent announcements by the administration here in Washington, and other
national sources, are encouraging.
But we have never fought a battle like this before.
We do not have the knowledge we need.
We don't have all the tools and we don't by any means, have the money.
For example, the $15.'5 million sought by the Nixon Administration is woefully
inadequate to meet the need.
New York state alone spends $188 million annually. '
In Pennsylvania we have estimated our statewide needs at a minimum of
$4."> million. Facing realistic budget requirements, we have appropriated $20
million for the next fiscal year. This amount will but permit us to inaugurate
a reasonable program.
But if such amounts are needed in New York and Pennsylvania, it is obvious
that much more than the $155 million allocated by President Nixon will be
needed nationwide if we are to really come to grips with this problem.
Gentlemen, you must make up your minds to wage total war on the drug
traffic in America.
That war will call for an enormous commitment of our knowledge and our
resources.
The alternative to such a commitment will surely be more wrecked lives, fur-
ther social deterioration, an ever increasing crime rate and ultimately the po-
tential destruction of our society.
In Pennsylvania today, our best estimate of the number of heroin addicts
is between 30,000 and 50,000 persons.
In Philadelphia alone there are between 15,000 and 20,000 heroin addicts and
between 25,000 and 30,000 persons addicted to other narcotics or dependent
upon other dangerous drugs.
The economic impact of the drug problem is as startling as the human toll it
takes of its victims.
In order to make the $50 or $70 a day it takes to keep the habit alive, the
heroin addict usually steals goods with a market value of $100 to $150 or more
which he then sells at a lower price.
Based on these figures, Philadelphia alone suffers a property loss of over
$500 million a year. Statewide, it would not be unreasonable to claim that the
loss approaches a billion dollars annually. This is in addition to the fact that
two-thirds of the muggings and street crimes are drug connected.
Those are the harsh economic facts, facts with which you are probably all
too familiar.
But the question you want answered today is this : How can the national
Government help us, at the State and local level, to deal effectively with the
problem? Assuming a Federal financial commitment, where would the money
go?
When I took ofiice last January, I called upon the State legislature to in-
augurate the first comprehensive statewide drug control and rehabilitation pro-
gram in our history, to include the problem of alcoholism.
As I snid before, estimates as high as $45 million were made to fund the
program. Finally, we settled on a first year figure of $20 million, spread through
a number of departments, with the central coordinating point being a council
on drug abuse within the Office of the Governor.
I was astounded to find that the State of Pennsylvania had. on a payroll
of more than 100,000 people, only 30 special narcotics agents charged with the
responsibility of controlling the illicit drug traffic.
So, first, we intend to upgrade thi' i)oai(ioiis of the narcotics agents, add more
men, and give tliem better training.
607
Second, we intend to greatly intensify the active role of the Pennsylvania
State Police bv giving them the tools they need to fight the traffic and appre-
hend the wholesalers and retailers. For security reasons, I cannot here detail
the present work of the State Police in this regard, but I can assure you that
their work will have an impact. In my budget for next fiscal year, I have called
for the creation of 240 additional positions for State troopers for assignment
to the drug control force.
In both the departments of health and public welfare, we intend to expand
our programs for rehabilitation and for basic and applied research into the
proper cures for addiction.
The status of the rehabilitation of addicts, not only in Pennsylvania, but
throughout the Nation, is in the Dark Ages. I might add though that educa-
tion concerning the danger of drugs reaches the level of the stone age.
We are far short of the need in terms of rehabilitation. Rehabilitation doesn't
stop at the door of a treatment center. It must follow the former addict back
into the world, to the point where he becomes, once again, a productive member
of society.
We are starting to develop realistic programs that recognize that process in
Pennsylvania.
For that reason, I have wholeheartedly endorsed the proposal by my de-
partment of community affairs that they use part of their ongoing job training
program to train former addicts for employment. I have increased their job
training appropriation for next year, but we are short of suflicient funds to do
the job to the fullest extent since we are only able to produce $4 million for the
entire program.
Seventy percent of the men presently serving time in State prisons have
drug connected records. Recognition of the drug problem within our prisons and
a program to cope with it will become part of our overall program of prison
reform.
But, at the same time, I am encouraging our State board of probation and
parole to continue seeking Federal grants under LEAA and to device programs
whereby those on probation and parole, with drug connected records, can receive
the appropriate followup in this vital arm of our correction system.
At this point, I want to mention that I am fully aware of the tremendous
problem of drugs among our returning Vietnam veterans. Today we are holding
a meeting of the appropriate agencies of State government to chart a statewide
program for returning veterans, with special emphasis on the drug situation. I
shall be happy to report our proposals to this committee.
Presently, in Pennsylvania, treatment is being accomplished by several kinds
of facilities. These facilities range from emergency beds in some hospitals for
immediate problems to private hospitals for long range treatment.
We have therapeutic communities like Gaudenzia House, Eagleville Sani-
torium and Teen Challenge Farms. We have halfway houses, nonprofit treatment
centers, and counseling organizations.
The dominant impression received from those worthy efforts is one of frag-
mentation. I suspect that "fragmentation" is one of the key descriptions for
our nationwide efforts thus far.
Another dominant word for the effort thus far is "inadequate."
There are only six methadone maintenance clinics in Pennsylvania, serving
approximately 1,300 addicts.
And the Commonwealth of Pennsylvania has no State facility devoted solely
to the drug problem.
Let me add that my remarks are not meant to downgrade the fine work done
by our people at both the private and public levels.
They have done an excellent job.
Particularly through the Law Enforcement Assistance Agency here in Wash-
ington, they have had Federal help.
But, if they were with me today, they would tell you the same thing I am
telling you, that the fight again.«t drug addiction is fragmented and inadequate.
At best, there are a minimum number of beds devoted merely to detox at some
State hospitals. Programs for rehabilitation and for after care, to the extent they
are available, are privately administered with a negligible degree of State or
local involvement.
These activities must be coordinated. Recognizing the need for coordination.
I have already discus.sed with Governor Cahill of New Jersey a joint effort
between our States to stop the illicit traffic in drugs over interstate lines.
608
Under our 1071-72 budget proposal, the State will do more to cooperate witli
the local communities.
But we desparately need much more than even the State can provide.
More and better facilities, professional people in greater numbers, better en-
forcement, a full education program starting in the earliest grammar school
grades, and all of these initiatives call for a massive infusion of help from the
Federal Government.
Gentlemen, provide the professional assistance and financial resources of the
Federal Government to our States and the job can be done.
When analysing the national need, remember that .$45 million is what we
really need to' cope with the drug problem in the nation's third largest State for
the first year of operation. Remember that our State appropriation is also .$20
million. Extend those figures nationwide and you will get a good idea of the
minimum needed from Washington.
The important thing now is to act.
I am convinced that we can make great strides if we but apply our collective
resources, and imagination to solving the No. 1 social issue of our time.
Thank you.
Chairman Pepper. We will now hear from Governor Carter of
Georgia.
STATEMENT OF HON. JAMES CARTER, GOVERNOR, STATE
OF GEORGIA
Governor Carter. Thank you, Mr. Chairman. I am particularly
thankful to be here this morning to hear the testimony, particularly
from New York, and also to hear the otlier two very fine Governors
tell about the program in their own States.
Tlie State of Georgia is experiencing just the initial throes of a
heroin epidemic. In Atlanta, doctors who are working daily with
heroin users, including Dr. Peter Bourne, just behind me here, now
estimate that in the metropolitan area alone we have 5,000 heroin
addicts, a figure that has been determined from tlie number of deaths
from overdose of heroin. I understand that the multiplication factor
involved State and nationwide is perhaps one to 200. Kecently in the
last few months, we have had this .5,000 figur(> increase because we now
liave an average of one death per week from an overdose of heroin in
Atlanta, compared to an estimate of a total number of heroin addicts
in Atlanta 12 months ago of less than 2,000. So we have seen our heroin
addiction increase from 21/2 to five times in Atlanta itself over the
last 12 months.
If the experience of other cities holds true, we can anticipate that
this will be increasing at least double or triple in the next 12 months.
Hundreds of addicts have also been reported in tho other major cities
of Georgia like Savannah, Columbus, Macon, Augusta, and so forth.
We have had in the past up until this point a dependence upon
Atlanta and Fulton County, which is the county in which Atlanta is
located, for tlieiu to conduct their own heroin control program, financed
in part by State funds. Withiii the last few weeks, they have simply
thrown up their hands and said, we cannot contend Avith this program
and we hereby turn it over completely to the State of Georgia. Tlie
skyrocketing rise of heroin addiction across Georgia has produced an
emergency which exceeds by far the abilities of tlie local administrators
and local treatment facilities and the judicial system and the jails and
the laws enforcement agencies to handle this vei-y great need. And as
Governor of Georgia, I liave now accepted full responsibility for devel-
oping and coordinating our res])()nse to this emergency.
609
I do not intend this morning to outline in detail plans which have
been promulgated for combating heroin addiction. I would like to
say that I will expect our program to result in a radical improvement
in'the services available to addicts, that we will look for opportunities
for regional cooperation within all the Southern States, and that above
all, we will attempt to develop flexible and varied services so that each
addict can be treated as an individual, with unique needs.
I think it is more appropriate for me today to give my thoughts to
you about the problems of heroin addiction in the armed services and
iiow this problem affects Georgia. Georgians have always held the
military professions in high regard and we have probably tended to
join the armed services in highly disproportionate numbers. Today,
some 71,500 Georgians are serving in the armed services. We know that
many of these Georgians have been exposed to heroin use in Vietnam
and Europe and we can expect them to bring their habits home when
they return.
Further, Georgia is the location of several of our country's largest
military bases. Eighty -one thousand servicemen and women are sta-
tioned at Georgia's 11 military bases. Fort Benning in Columbus,
which is near the Alabama line, and Fort Gordon in Augusta, near
the South Carolina line, together have more than 50,000 personnel,
or about two-thirds of the total in Georgia.
Military operations are an important part of Georgia's economy —
and military personnel are a large part of our heroin addiction prob-
lem. Although precise information dealing with heroin use in the
Armed Forces is simply not available, it is probably safe to estimate
that the return of Vietnam veterans, either to Georgia military bases
to serve in the Armed Forces, or to civilian life in Georgia after dis-
charge, will double again the heroin addiction problem in my State in
the coming year.
To Georgians, therefore, it is crucial that the Armed Forces carry
out thorough and conscientious rehabilitation programs for service-
men who are addicted to heroin. Let us make no mistake — the heroin
addiction that is growing so rapidly among our troops in Vietnam is
in large part the result of a problem in morale, discipline, and leader-
ship. The blame for this breakdown rests with the Military Establish-
ment; the responsibility for caring for veterans who are disabled by
heroin addiction must also rest there.
Chairman Pepper. I met this morning, immediately before coming
here, at the Pentagon with the two men responsible for the armed serv-
ices program on heroin addiction, Mr. Hobson and General Tabor. I
came to ask them their plans for helping the States, particularly Geor-
gia, in future care for heroin addicts who are being discharged. I was
extremely disappointed because their complete commitment to me
was, in effect :
We are responsible for heroin addicts who contract this addiction in the armed
services only up to the date when they are discharged. We anticipate keeping
them within the armed services for an additional 30 days and perhaps 60 days ;
at that point, our responsibility ends.
They hopefully expressed some opinioji that the Veterans' Adminis-
tration might help with this problem, but tliey very quickly pointed
out that the Veterans' Administration now only has five regional
GIO
centers for the treatment of heroin addiction, that this ultimateh' over
a period of 3'ears might be expanded to 30,
Our experience in Georgia has been that heroin addicts are not going
to leave tJieir own habitat, their own commmiities, to travel to any dis-
tant point for concerted treatment for heroin addiction, even across
a city where it requires a bus ride or the hiring of a taxicab to go for
tiio daily treatment required.
We also asked them if they would be willing to give us records to
inform us when a heroin addict was being discharged to take his place
within one of the Georgia communities. General Tabor said that he
wished this could be the case, but he did not have any reason to assume
that the military forces would give me as Governor or the head of our
drug treatment pi'ogram any information about a discharged service-
man w^ho did have this affliction, I pointed out to him that this should
be parallel to a man who has tuberculosis or a more serious disease and
that Ave ought to be able to know the identity of a returned serviceman
who still had the heroin addiction so we could care for him, offer him
service, and observe his operations.
Dr. Bourne, behind me, just recently had one of the armed services
veterans tell him that he was personally responsible for 50 additional
addicts having acquired the heroin addiction in order to finance his
own addiction within the city of Atlanta.
I am concerned that the Military Establishment will shirk this
responsibility and that no Federal agency vrill assume it for them. We
understand that the typical heroin addict in the military is not A'ery
different from his counterpart in civilian life. He did not finish h'"h
school, he comes from, a broken home, and there is a good chance he
is a member of a minority group. In all likelihood, he is a draftee, and
no one would argue that treating his habit is essential to the military
mission. When he returns to civilian life, he will find himself on the
street with little chance of landing a good job. In short, he is powerless,
and it is not hard to suspect that the Armed Forces would be happy to
quietly svreep him under the rug. or into the hands of civilian agencies.
The Armed Forces and the Federal Government should not be
allowed to discharge their responsibility for heroin addiction by simply
retaining an addict on active duty for an additional 21 davs of treat-
ment. There is no 21-day cure for heroin addiction, and it is dishonest
to lead the Ajnerican public to believe this. To the Vietnam vetei-an
who is retained, and to the civilian agencies that must eventually pro-
vide him services. 4 short weeks of extra treatment by the military is
a cynical joke.
If the iVrmed Forces take seriously their responsibility for treat-
ment of their heroin addicts, then I am <'onAinced that Geor<zia can
bring its heroin emergency under control. In Georgia, I will make
every effort to assure that State and military efforts are coordinated. I
intend to propose that a joint druir al)use coordinating committee be
established, with inembership I'onsisting of tlie Governor and the com-
manding officers of the major military bases in Georgia or our repre-
sentatives after the coordinating agency is formed. This connnittee
would meet regularly to discuss progress, the impact on servicemen,
both those discharged and those still on active duty.
I am not conviiiced that the Veterans' Administration alone should
be expected to be capable of mounting the many types of progi-ams
611
required to treat heroin addiction among returning servicemen. I
hope that we will be able in Georgia to arrange for contracts between
the Veterans' Administration and those civilian programs which will
complement VA programs. The Veterans' Administration might, for
example, contract with Georgia's statewide program to operate store-
front treatment centers in cities where military bases are located. Or
the Veterans' Administration might seek epidemiological advice from
the U.S. Public Health Service's National Center for Disease Control,
located in Atlanta.
We also asked General Tabor if it would be possible to have young
draftee doctors work part time, after hours, even with pay, with the
State agency to help us control drug addiction in communities near
military bases. He was very discouraging in his answer and thought
that the Surgeon General would not be willing for these young men,
who often work 8 hours or less per day in military service, to help us
in these communities. We would hope that this could be arranged.
A simple solution ma^^ be joint financing of our overall drug addic-
tion program for Georgia, which will cost from $4 million to $7
million annually — a cost which; we cannot afford and which has not
been budgeted. " '
At the Democratic Governors' Conference in Omaha last weekend,
I discussed heroin addiction with other Governors and particularly
southern Governors. They and I believe that the heroin addiction
pi-oblem offers important opportunities for regional cooperation, such
as centralizing laboratory facilities and record systems. At the present
time in Georgia, private laboratories cost $5 to $6 per urine sample to
have tests made for controlling heroin use. I understand this can be
done for about $1 and we would be happy to see a laboratory estab-
lished in Atlanta or perhaps a recordkeeping system established in
Atlanta to serve Georgia, South Carolina, Tennessee, and other sur-
rounding States. I expect to set a date in the near future for a meeting
of southern Governors in Atlanta to which representatives of the
White House, the Pentagon, and successful drug treatment programs
would be invited. We passed a resolution out there in Omaha express-
ing our concern about the inadequacy of the administration's
program :
Because of inaction of the present administration, drag abuse now menaces the
health and life of an alarming number of American private citizens and service-
men, and is a major cause of violent crime. The National Government must
utilize the instruments of foreign policy to cut off the supply lines of illicit drug
traffic, support research which will yield a better understanding of the con-
sequences of drug use, stimulate an intensive educational program that will reach
all of the Nation's communities, provide more significant funding for the treat-
ment of those who are drug dependent, and enforce effectively Federal laws
against domestic criminal elements engaged in the drug traffic. The recent pro-
posals of the Nixon administration, which come tragically late, fall far short of
achieving any of the above objectives.
' We absolutely must have an adequate Federal program to help us
now to meet this critical problem. We Georgians are ready to move on
a well-coordinated State and regional plan as soon as Federal financial
assistance and cooperation of the Department of Defense and other
Federal agencies is available. We now have available some OEO fmids.
We would hope that they \YOuld be coordinated with an overall State
plan.
612
. Dr. Bourne informs me that we have used successfully methadone.
It was first used in Georgia in August 1970. We have 530 patients
who were treated over an 8-month period on a methadone witlidrawal
program, of whom within 60 days, 70 percent reverted to their pre-
vious addiction. We now have 60 patients on methadone maintenance.
We feel methadone is an excellent tool for the treatment of addiction
of heroin, based on our own experience and knowledge from Wash-
ington, D.C., and New York. We have never had an adequate program
to utilize it effectively. We recognize the dangers involved. We have
nevei' had a serious incident or death from overuse of methadone in
Georgia.
I notice that Dr. Chambers, or I think Mr. Jones, said tliat metlia-
done was only effective in 20 or 30 percent of the cases. I think this is
certainly' true in a permanent withdrawal or treatment or corrective
situation. But if you put into the picture the effect of heroin addiction
on the crime rate, we believe that it will seriously or greatly alleviate
tlie problem in at least 80 percent of the cases.
A recent interrogation by me of the Athmta police authorities re-
sulted in the information that 75 percent of the robberies recently com-
mitted in Atlanta were caused by heroin addicts.
Well, I would like to express my own personal appreciation on be-
half of the State of Georgia to this committee for bringing to light an
extremely serious problem which has now progressed far beyond what
it should have. I can assure you that if the Federal Government would
gi\e us the means and the advice and the information, we will strive
with the greatest determination toward correcting what I consider
to l)e the most serious single problem in Georgia today.
Thank you, Mr. Chairman.
Chairman Pepper. Governor Carter, we thank you very much for
3^our able statement. /^' ,".
(Governor Carter's prepared statement follows :)
[Exhibit No. 24]
Prepared Statement of Hon. Jimmy Carter, Governor, State of Georgia
Thanlv you, Mr. Chairman, for this opportunity to testify before your
committee.
The State of Georgia is experiencing the initial throes of a heroin epidemic.
In Atlanta, doctors who are working daily with heroin users agree in their
estimates that the metropolitan area now has some 5,000 heroin addicts, a
ligure which is substantiated by the number of deaths from h(>roin overdoses.
Twelve months ago, these same doctors estimated less than 2.000 addicts in
Atlanta. If the experience of other cities holds true, we can con.servatively
expect that there will be more than 10,000 heroin addicts in Atlant<i by June
1972. Hundreds of addicts have also been reported in Savannah, Columbus,
Macon. Augusta, and other metropolitan areas.
The skyrocketing rise of heroin addiction across Georgia has produced an
emergency which exceeds by far the abilities of local treatment facilities and
judicial systems to meet the need. As Governor of Georgia, I have accepted
full responsibility for developing and coordinating our response to this emer-
gency. I intend to place all the resources of my office behind our effort to check
the increase in heroin addicttion.
I do not intend this morning to outline in detail our plans for coml)ating lieroin
addiction. I will simply say that we expect our program to result in a radical
improvement in the services available to addicts; that we will look for oppor-
tunities for regional cooi^eration by the Southern States; and that, above all,
we will attempt to develop flexible and varied services, so that each addict can
be treated as an individual with unique needs.
613
I think it is more appropriate today to present to you my thoughts on the
problems of heroin addiction in the armed services, and how that problem
affects Georgia.
Georgians have always held the military professions in high regard, and we
have probably tended to join the armed services in disproportionate numbers.
Today, some 71.500 Georgians are serving in the Armed Forces. We know that
many of these Georgians have been exposed to heroin use in Vietnam and
Europe, and we can expect them to bring their habits home when they return.
Further, Georgia is the location of several of our country's largest military
bases. There are 81,000 service men and women stationed at Georgia's 11 military
bases. Fort Benning in Columbus and Fort Gordon in Augusta together have
more than 50,000 personnel, or about two-thirds of the total in Georgia.
Military operations are an important part of Georgia's economy — and military
personnel are a large part of our heroin addiction problem. Although precise in-
formation dealing with heroin use in the Armed Forces is simply not available,
it is probably safe to estimate that the return of Vietnam veterans, either to
Georgia military bases or to civilian life in Georgia, will double again the heroin
addiction problem in my State in the coming year.
To Georgians, therefore, it is crucial that the Armed Forces carry out thorough
and conscientious rehabilitation programs for servicemen who are addicted to
heroin. Let us make no mistake : the heroin addiction that is growing so rapidly
among our troops in Vietnam is in large part the result of a problem in morale,
discipline, and leadership. The blame for this breakdown rests with the Military
Establishment ; tlie responsibility for caring for veterans who are disabled by
heroin addiction must also rest there.
I am concerned that the Military Establishment will shirk this responsibility.
We understand that the typical heroin addict in the military is not very different
from his counterpart in civilian life. He did not finish high school, he comes from
a broken home, and there is a good chance he is a member of a minority group. In
all likelihood, he is a draftee, and no one would argue that treating his habit is
essential to the military mission. When he returns to civilian life, he will find
himself on the street with little chance of landing a good job. In short, he is
powerless, and it is not hard to suspect that the Armed Forces would be happy
to quietly sweep him under the rug, or into the hands of civilian agencies.
The Armed Forces should not be allowed to discharge their responsibility for
heroin addiction by simply retaining an addict on active duty for an additional 21
days of treatment. There is no 21-day cure for heroin addiction, and it is dis-
honest to lead the American public to believe this. To the Vietnam veteran who
is retained, and to the civilian agencies that must eventually provide him services,
3 short weeks of extra treatment by the military is a cynical joke.
If the Armed Services take seriously their re.sponsibility for treatment of their
heroin addicts, then I am convinced that Georgia can bring its heroin emergency
under control. In Georgia, I will make every effort to assure that State and mili-
tary efforts are coordinated. I intend to propose that a joint drug abuse coordinat-
ing committee be established, with membership consisting of the Governor and
the commanding ofiicers of the major military bases in Georgia. This committee
would meet regularly to discuss progress on existing programs, and to initiate
new efforts.
I am not convinced that the Veterans' Administration alone should be expected
to be capable of mounting the many types of programs required to treat heroin
addiction among returning servicemen. I hope that we will be able in Georgia
to arrange for contracts between the Veterans' Administration and those civilian
programs which will complement VA programs. The Veterans' Administration
might, for example, contract with Georgia's statewide program to operate store-
front treatment centers in cities where military bases are located. Or the Veterans'
Administration might seek epidemiological advice from the U.S. Public Health
Service's National Center for Disease Control, located in Atlanta.
A simple solution may be joint financing of our overall drug addiction program
for Georgia, which will cost from .S.^ million to $7 million annually— a cost which
we cannot afford and which has not been budgeted.
At the Democratic Governors' Conference in Omaha last weekend, I discussed
heroin addiction with other southern Governors. They and I believe that the
heroin addiction problem offers important opportunities for regional cooperation,
such as centralizing laboratory facilities and record systems. A regional approach
to the problem of heroin addiction among returning Vietnam veterans would also
be important. I expect to set a date in the near future for a meeting of southern
614
Governors in Atlanta to which representatives of the Wliite House, the Pentagon,
and successful drug treatment programs would be invited.
Here is a resolution passed unanimously by the Nation's Governors assembled
in Omaha : "Because of inaction of the present administration, drug abuse now
menaces the health and life of an alarming number of American private citizens
and servicemen, and is a major cause of violent crime. The National Government
must utilize the instruments of foreign policy to cut off the supply lines of illicit
drug traffic, support research w^hich will yield a better understanding of the con-
sequences of drug use, stimulate an intensive educational program that will reach
all of the Nation's communities, provide more significant funding for the treat-
ment of those who are drug dependent, and enforce effectively Federal laws
against domestic criminal elements engaged in the drug traffic. The recent pro-
posals of the Nixon administration which come tragically late fall far .'jhort of
achieving any of the above objectives."
We absolutely must have an adequate Federal program to help us now to meet
this critical problem. We Georgians are r«"ady to move on a well-coordinated State
and regional plan as soon as Federal financial assistance and cooperation of the
Department of Defense and other Federal agencies is available.
In closing. I would like to commend the Select Committee on Crime for its
efforts to shed light on the problem of drug abuse. I can assure you that, in
Georgia, we are unequivocally committed to the task of finding effective solutions.
Chairman Pepper. ]S'ow we are privileged to hear the distinguished
Lieutenant Governor of Michigan, Lieutenant Governor Brickley.
STATEMENT OF HON. JAMES H. BRICKLEY, LIEUTENANT GOV-
ERNOE. STATE OF MICHIGAN (ON BEHALF OF GOV. WILLIAM G.
MILLIKEN)
Lieutenant Governor Brickley. Mr. Chairman, members of t]ie com-
mittee, and Governors. First of all I express Governor Milliken's
regrets at his inability to be here but he has been using me very heavily
in his administration with regard to law enforcement — I have a law-
enfoi'cement background — and in connection with his drug programs.
As a Lieutenant Governor, I have great respect for Governors. I was
impressed with the chairman's statement when I was listening a while
ago and you said you were trying to establish the magnitude of the
prol)lem and the magnitude of the effort. I think that puts it well. I
tliink to do that, my experience tells me that we ought to begin bv
disabusing ourselves, I think, of certain notions that we have had.
I think the late start we are getting nationally, all of us, in combating
this problem has been due in part to some of these false notions we
have liad. We ought to disabuse ourselves that if we could just arrest
a few top organized crime officials, we woidd turn the problem ground.
We ought to disabuse ourselves of the notion that if we could just
get a few foreign countries to control the heroin and the opiates, we
would turn the problem around.
I think we ought to disabuse ourselves of the notion that if we just
had stronger, more punitive laws, that would do it.
I think we ought to disabuse ourselves of the notion that if we could
just come up with a secret drug, the secret antidote, that that would be
the way out.
We ouglit to disabuse ourselves of the notion that if we just relieved
the suffering of those who are suffering from drug addiction, that
vonkl be the answer.
The truth is we have to do all of those things and maybe even doing
all of them is not going to turn it around. Because as Governor Shapp
indicated, and I listened verv carefully to his opening comments
615
because I agree with them, as long as we have significant numbers of
people who in this very affluent society find it necessary to escape from
its realities, that should tell us something about, I think, some very
basic defects in our culture and our society.
Obviously, we are not going to turn those things around overnight.
I think they have been a long time in the making and those of us who
are not addicted to drugs, perhaps we bear our share of the responsi-
bility, our generation, for getting ourselves into this drug culture and
this very unfortunate situation. But meanwhile, back at the ranch, so
to speak, we have to, as I indicated, move on all these fronts.
Let nie just say that the thing I think you are primarily interested
in is tlie relation of drug abuse to general crime. My seat-of-the-pants
opinion on that is that the drug abuse problem is strongly related to
a significant portion of the street crime. As I have heard some of those
from Xew York say, it also accounts for some of the more vicious
type of crime, the more spontaneous type of crime, the type of crime
that is more difficult to detect law enforcementwise because it is not
motivated by people who know one another and so forth. And again,
the most atrocious types of crime. I have heard figures of 30 or 40
percent.
There is a New Jersey study that I just saw for the first time
several days ago that indicates only about 10 percent of those arrested
over a given sample period in New Jersey committed other crimes
because of the drug addiction. I frankly find that very difficult to
believe, I think it has to be higher than that and there have been
some less formal studies made in Detroit, Wayne County, which
indicates that it goes up as high as 40 percent. But it is enough,
anyway, whatever it is.
i think we have to be ready to accept the fact that stricter enforce-
ment, which we are starting to get now — I know in our community
we are — is also going to raise the price of heroin and is going to cause
a more harried crime-committing spree by those who feed the drug
addicts, which would indicate that we should be all the more ready
to treat those who are addicted.
Now, even though I do not suggest tliat methadone obviously is the
answer, that is the kind of approach that o-ot us into the drug culture in
the first place, an easy way out ; nevertheless, we have a fire on our
haiids and we have to use what we have. We have to use methadone be-
cause it does give some immediate relief to the social problem as well
as to the person addicted.
There has been some reference to the drug war in Detroit, Mr.
Chairman, and it has been reported nationally. In my statement I say
things like "running territoi-ial war."' I have to be honest with you and
say the gist of my comments now, after this statement was prepared
and sent up to you, is I have tailored my feelings on that after talking
with some of the police intelligence people in Michigan, that it is not
really a territorial war: so says the best thinking right now. It is
really a question of crimes being committed within the drug com-
munity, the so-called ripoff. where one drug pusher robs another be-
cause they know where each other is and they know they are very
vulnerable, they cannot go to the police. So in that, it is something like
the organizational battles that took place in the 1920's in traditional
organized crime, to establish the disciplines. If that is the case, that is
616
pretty bad news, because it indicates that it is irettin^ more entrenched,
that 3^ou have the strata of authority and so fortli. This is in my jud<i-
ment a new layer and system of organized ci'ime, not tlie same old
Cosa N'ostra that we have talked about, althouirh T do not absolve them
completely.
Obviously, the burden on the criminal justice system of the drug
abuse cases — we had last year something like 9,000 people being arrest-
ed in Detroit for violating the drug laws, and I think if we are only
talking aliout 40,000 or 50,000 arrests totally in the course of the year,
Ave are talking al^out a very significant input into the system that is
already henvily overburdened — the courts, the police, and so on. It is
like courts dealiiig with the alcohol problem, which I think they should
not be. We are plugging up that system., tnking cars out of use, using up
the courtrooms, and so on, for something that is not ]")rimnrily a crime.
It is a sickness.
Obviously, the criminal justice approach is not doing it. That does
not mean Ave shoidd abolish all the laAvs.
Obviously, the treatment of addicts is not doing it either. T think we
have to move forAvard on both fi'onts. I think Ave can rely on funds
from LEAA, the funds coming to improve the administration of jus-
tice. I am VQvy ]:)leased Avith the Avay LEAA is working.
I am chairman of the crime commission in our State. On the side. T
may just say that the most impoi-tant thing is not the money coming in,
but believe me that is very impoi'tant. But it is the cooperation that it
is bringing, that Ave can get the key people in the administration of
iustice, Avhich is as fragmented as Government is itself, sitting around
the same table, talking Avith one anothei- and going in the same direc-
tion.
Our programs, in our State. T find myself saying the same as other
Governors, that I Avish they Avere more ndequate. T Avish T could come
here Avith the ansAver. ObAnously, T do not. "We are spendincr about $3
million noAv. Ave are asking for $7 million — Governor Milliken is — in
next year's budget. Avhich starts next Aveek. Obviously, that is going to
have to be increased rather dramatically.
Now, regarding the Federal hel]^, and that is Avhat Ave are heiv for.
may I say that Avhatever is done ought to be a flexible. bloc-grant-ty])e
of program, by all means, like LEAA is, because that gives the State
the experimentation, the flexibility, Ave can inoA'e moi-e rapidh*.
So many of these programs that are too inflexil>le, that ai'e desigJied
here are fine when they are designed, but by the time they get im-
plemented doAvn in those States, by that time, they are irrelevant. So
I Avould i')lead for the bloc-grant approach.
I Avould plead that they be as flexilile as possible, that the drug in'O-
grams, AvhocA^er administers them in the State, be community based.
We have to invoh'e the comnnniity. T do not necessarily mean the
political community, but the ethnic comnmnities and so foi'th, so they
can be part of it, so Ave can get that kind of responsibility Ave neinl
Avithin the various communities.
And lastly on the Federal help, what Ave are asking for is, T think T
can say that if you gave me a check to tak'e back to Governor Milliken
for $r)0 million, Ave ])robably could not spend that next vtMT- bcn-ause
Ave aT-e not tooled for it, we are not administi-atively i-eadA" for it. unless
Ave thrcAv it out the AvindoAv. But b\- the supm^ token.-- ihi^ happened in
617
LEAA funds — Congress says, you cannot handle it now, so we will
give you all you can handle. But unless it is indicated to use what is
coming, then we cannot gear up for it. And if each year you do that, we
never get to the optimum point we should get to.
So I think whatever Congress does, they should indicate, if it is
going to be substantial amounts of money, what that substantial
amount of money is with sufficient commitment so we at the State
level can begin to gear up for it.
I am not going to go into great detail on what we are doing in Michi-
gan. It is somewhat similar to what the (iovernors have indicated. We
are going more heavily on methadone. We are using our connnunity
mental health agencies and structure which is c^uite progressive, inci-
dentally, in Michigan, to man some of the drug programs. We have
for the first time a drug rehabilitation place which is designed for
sentencing. We were woefully inadequate a couple of years ago in that
the judges had no place to send those who were convicted either for
drug abuse or were drug addicts and were convicted for something
else.
That would conclude my remarks.
Chairman Pepper. Governor, we thank you for your able statement
today.
(Lieutenant Governor Brickley's prepared statement follows:)
[Exhibit No. 25 J
Pbepaked Statement of Hon. James H. Bbickley, Lieutenant Governor,
h>TATE of Michigan
Thank you for the privilege of appearing before this committee. My name is
James H. Brickley. I am Lieutenant Governor of the State of Michigan and am
representing Gov. William G. Milliken.
Throughout my public life I have seen the impact of narcotic addiction on the
(luality of life in Michigan. As a Detroit city councilman, chief assistant prosecut-
ing attorney of Wayne County and as U.S. attorney, I have witnessed first hand
the role heroin addiction plays in the increase in crime in our urban centers.
As this committee is well aware, drug abuse is a massive and complex problem
facing our Nation. Heroin addiction is only one aspect of a larger problem that
encompas.ses youthful drug experimentation, chronic alcoholism, excessive use
of amphetamines and barbiturates, and reliance on over-the-counter drugs. It is
a problem whose solution will surely be as complex and difficult as the problem
itself.
In my testimony today, I intend to limit myself to the problem of heroin and
opiate addiction and the need for the treatment and rehabilitation services for
narcotic addicts.
I Avould like to comment on three aspects of this program : First, the relation-
.ship of n;ircotic addition to crime in Michigan, particularly the impact of narcotic
addition on our criminal justice system : second, the Mchigan approach to treat-
ment and rehabilitation of narcotic addicts ; and third, my suggestions for Federal
assistance in providing rehabilitation treatment for narcotic addicts.
In discussing the relationship between narcotic addiction and crime, I exclude
consideration of the crime of simple possession of narcotics, and essentially
"victimless" crime, and will focus on crimes committed for the sake of financial
gain such as robbery, larceny, burglary, shoplifting, and the illegal sale of
narcotics for profit.
There is no evidence that addition as suCh induces crime, but the need to
supply an expensive habit does. The irony is that the more successful we are in
restricting the supply of heroin the higher the price, and the more expensive
the drug is for those already addicted.
All we will accomplish if we attempt only to reduce the supply of heroin on
the streets is to force tJhe price up of the drugs. Unless such an attempt is coupled
with effective means to lessen the demand for heroin by reducing the number of
addicts crime will surely increase.
618
Scientific statistical ioformation aci'urately indicating the relationship be-
tween crime and heroin addiction is nonexistent. The fact that heroin addiction
is becoming more prevalent at the same time that general incidents of crime are
increasing is not enough by itself to establish this relationship.
We do know that heroin arrests made by the Detroit Police Department be-
tween 1936 and 1970 have jumped 442 ijercent in the age bracket of 17-27. Some
of this increase can be accounted for as a result of more intensified drug abuse
enforcement.
As to the relationship between more drug addition and increased crime, a study
by the Michigan Department of Corrections indicates that 40 percent of the
eiitires into the State prison system were using various drugs during the period
of the offense for which they were imprisoned. But most of the prisoners who
c-omiJose<l the 40 percent were not being incarcerated for drug abuse violations.
Official.^ at the Wayne County Jaih which incarcerates Detroit prisoners Drior
to sentence, report that they have had as high as 40 percent of their jail popula-
tion showing signs of drug addiction.
Tliese figures. I think you will agree, reveal a relationship between addicrion
and an increase in general criminal activity.
It is estimate<l that there are between 10.000 to 20,000 drug addicts in the De-
troit metropolitan area alone. The wide range between these figures indicates the
difficulty in establishing a reliable figure.
The MetroiKilitan Detroit area is the center of heroin use and traffic in Michi-
gan. However, other urban centers including Flint. Grant Rapids, Muskegon,
Saginaw, and Pontiac also have severe and growing heroin problems.
There is one particularly disturbing aspect of the heroin traffic in Michigan
that deserves mention. Evidence points to the existence of a major ''Heroin War"
in Detroit for control of the illegal narcotics market.
On June 14. in the city of Detroit, seven individuals were murdered in an
alleged drug related crime. An eighth victim, believed to be the primary target
of the murderers, died last Sunday before revealing any evidence regarding
the crime. Detroit police officials estimate that these murders bring to about
.50 the number of liomicides in Detroit linked to the illegal traffic in narcotics.
There have been reports in Detroit of "a running territorial war among drug
pushers." This kind of violence — assassination and murder — raises the spectre
of the gangland wars of earlier decades and threatens the safety of every citizen.
We cannot sit by and allow this kind of criminal warfare which is motivated
by the profits of heroin traffic to continue. While we must obviously halt these
murders and curb the deaths resulting from drug use, our ultimate goal must
be to prevent the kind of living death that individuals face as their lives are
destroyed through heroin addiction.
Another aspect of the heroin traffic that should be considered is the tremendous
Iiurden placed on our criminal justice system. For more than 50 years the criminal
justice system — our ijolice. courts and corrections agencies — have been relied on
by our society to deal with narcotics. Increasingly, we are learning that such
reliance is inappropriate, ineffective and damaging to our entire criminal justice
.system.
More than 9.000 arrests for drug offenses in the city of Detroit in 1970 required
thousands of hours of police time, the courts, prosecutors, jailers and correction
and probation authorities. Despite this tremendous effort and allocation of limited
resources we must conclude that the traditional responses of the criminal jus-
tice system (prison, jail, fines, probation) are generally ineffective in desiling
with heroin addiction.
Those responsible for the administration of our criminal justice system have
foitnd they do not have the proper tools they need to realistically deal with
offenders who are narcotic addicts. Sending every addict to prison is not an
adequate solution, this would neither .solve the problem nor help society. In many
cases, it merely delays the return of the addict to the streets, to his habit and to
the commission of crime to support that habit.
It would be an oversimplification, therefore, to .say that law enforcement by it-
self is the answer to drug abuse, just as it would be equally simplistic to say that
drug treatment and rehabilitation programs will alone solve the problem. An
ultimate and effective solution will require greater efforts on both fronts if we are
to reduce drug addiction and criminal activity.
As to our efforts in Michigan, in January of 1970 Governor Milliken established
through a special mes.sage to the legislature, a Ri)ecial administrative unit in his
office to develop and coordinate the State's part in ;i brojul iittjifk on drug jilnise.
619
As a result of this effort, the State of Michigan has launched a comprehensive
statewide drug abuse control program including education, treatment-rehabilita-
tion, and enforcement. More than 3,000 heroin addicts are now in various treat-
ment modalities in Michigan, Approximately 1,000 of these are in State-supported
programs. We plan to expand this number to 2,000 by the end of fiscal 1971-72.
During the current fiscal year the State is spending approximately .$2.5 million
on drug control programs. The request for the next fi.scal year is more than ^'•'1
million.
The treatment-rehabilitation program in Michigan recognizes tliat :
( 1 ) Drug dependence is an outgrowth of conditions which exist in the com-
nuinity and therefore each community must to some extent design and control its
own program ;
(2) No single modality of treatment will be succes.sful for all drug-dependent
I'versons. therefore we must support a variety of treatment approaches (including
methadone maintenance, support of Syanon, droi>in and crisis centers) and over
the coming years determine the proper modality for different types of proi)lems;
(3) Because of tlie experimental nature of treatment for drug dependence the
rate of failure will be high. We must be willing to take risks and iearn from our
failures as well as our successes. To facilitate this learning process, we plan to
develop systems for constantly evaluating drug programs.
I believe the Federal Government can play an essential role in providing treat-
ment and rehabilitation programs for heroin addicts throughout the country. As
with so many other pressing problems facing our cities and our States, the de-
mands for services are increasing while the available resources are growing more
and more limited.
In providing Federal assistance for addict treatment and rehabilitation, I would
like to make the following suggestions based on our experience in Michigan :
(1) A program of Federal funding which relies on traditional agencies and
which includes ponderous Federal controls will not necessarily be productive.
(2) A treatment or rehabilitation program, to succeed, must include com-
munity participation. Community control should be encouraged, including the ad-
ministration of the program by the community to be served. In proposing this, I
recognize the high risk nature of this approach and caution that failures should be
expected if we are to experiment with new and possibly more effective approaches,
(3) Because we presently lack answers, any federally assisted program .•should
provide the maximum ability to innovate, and equally important, to eliminate
programs that prove unworkable and ineffective. It would be a tragedy if fund-
ing and administration were so structured as to prevent the experimentation with
new ideas or which perpetuated ineffective programs,
(4) Drug free alternatives should be encouraged, I believe it is important that
alternative life styles, such as Synauon, be encouraged because they can have a
.significant impact on our culture and our approach to drugs. Ti*eatment programs
that rely on other drugs, e.g. methadone maintenance, can help reduce addition
related crime, but they may, in the long run, reinforce the "chemical culture"
aspect of our society that is itself a partial cause of narcotic addition. In Michi-
gan, we are hoping to establish a working relationship between the strongly inde-
p»endeut Synanon organization and State government whereby the State can assist
Synauon without destroying its essential autonomy while retaining the necessary
accountability for public funds. The success of this effort, I believe, may be a
model for the Federal Government and for other States in assisting this unique
community that has played such an important role in developing truly drug free
alternatives to narcotic addition,
(5) I believe the funding mechanism for narcotic treatment and rehabilita-
tion programs should be based on the revenue sharing or bloc grant approach.
Over the long run, drug abuse treatment and rehabilitation should be incorpo-
rated into other community health and social services available to our citizens.
To create a separate funding mechanism, bureacracy, and constituency for drug
abuse funds could reduce the effectiveness of Federal assistance. In addition, the
particular circumstances of each State differ widely and maximum leeway should
be given to develop specialized approaches. Because of the resources now being
applied by the States to this and other social problems. I believe State govern-
ment should be the vehicle for administering these fund.s. The success in INIichigan
of the allocation of crime control funds is evidence that States can work produc-,
tively with cities, counties, and other units of government in allocating funds for
the greatest impact.
620
((')) Finally, I believe that alterimtive.s witliin the criminal justice system
sfiofiia be provided for narcotic addicts. An addict, like any other individual,
should he responsible for his criminal conduct. But our society, through the agen-
cies of its criminal justice system, must be prepared to provide effective treat-
ment and rehabilitation opportunities. Such opportunities are rarely available
now.
.r appreciate this opportunity to present these views on behalf of Governor 'Mi%
lilven an.d myself. As you contimie your deliberations. I would be happy to supply
you with any additional information on the Michigan program that may he of
assistance to you.
Chairman Pepper. Governor Sliapp, do you have anythinof you
would like to add to your statement before I ask the committee if
they have any questions ?
(jrovernor Shapp. I would like to make one additional point that has
nothing to do with Pennsylvania, but it does have something to do
with my u.rgino; the Federal Government to use all of its world powers
to stop the international traffic in drugs. Granted, Lieutenant Governor
Brickley just mentioned, by itself, this only solves, one part of the.
problem. But for the most part, as I understand it, the nations of the
world that grow the flowers from which the drugs are made are nations
that are greatly dependent upon the financial aid and the support of
the T aiited States. It is my understanding that at the present time in
Turkey, we are following a program of paying them money not to
plant poppies, which is reminiscent of the old days in this country of
passing out money to keep crops from being planted. It seems to me
we could come up with a more sensible program of simply telling that
nation that if they want to continue with the aid they are ircttinn-.
they just have to stop what they are doing and start burning those
fields rather than putting money out to plant new fields. If we are
going to solve the problem, we have to come up with realistic ap-
proaches to eliminating the traffic on an international basis.
What can be done? I think the people in power have greater knowl-
edge than I have, but I do not think that they are using practical
programs at this moment.
Chairman Pepper. Governor Carter, would you like to add any-
thing to your previous statement?
Governor Carter. I would like to back up something that Lieuten-
ant Governor Brickley said. That is, the method of dispensinsf the
fujuls that will Ije forthcoming from the Federal Government. I par-
ticularly like the LEAA approach. This has been very effective in
Georgia. It has let our local governments have complete input into it.
We have 19 planning commissions in Georgia. We have need for the
programs that the 19 planning commissions are requiring. The local
governments cooperate with one another, with the State agency aware
of all those problems. This could well be a pattern for the drug addic-
tion program.
I know this committee is primarily interested in seeking informa-
tion, but it will be very helpful to use as Governors to have some
delineation or listing of Federal agencies which are now equipped fi-
nancially and through authorization to help us finance this program.
The Veterans' Administration may have funds available that could be
channeled into this program. The Armed Services, I am sure, do. The
OEO certainly has funds available. Maybe the Public Health Service.
621
But we need immediate help or some indication of what immediate
lielp can be made available to us so we can accentuate and reemphasize
our own efforts on this problem and make plans in the long run for the
future after legislation is passed.
Chairman Pepper, Thank you very much, Governor.
Mr. Mann, do you have any questions ?
Mr. 1\Iaxx. Governor Carter. I am very much interested in your mili-
tary experience to date and today. Did the authorities at the Pentagon
indicate that thev felt thev were under anv legal disability from being
able to furnish vou names of heroin addicts being discharged from the
service ?
Governor Carter. The response that we received, I think Under
Secretary Kelly was there at the time — he could only stay briefly- — was
that although they would like to do it, it was their opinion that they
would be prevented from doing it because there was an argument about
whether this information ought to be secret or made available. They
did not say where the restriction came from, either from the Secretaiy
of Defense or the Congress ; I do not know. But this is something that
would he A'ery important to use to alleviate.
]Mr. ]Manx. It certainly would. They did not mention medical
priA' ilege ?
Governor Carter. No, because I think they do make available to
State agencies contagious disease information when a serviceman
comes back to his own commuity.
Mr. Mann. I would hate to see us get into a program for the financ-
ing of drug programs on the impact aid theory that we do in education.
But it would appear to be remotely appropriate.
I believe that is all I have, Mr. Chairman.
Chairman Pepper. Mr. Winn ?
Mr, Winn, Thank you, Mr, Chairman,
I want to thank you gentlemen for taking the time from your very
busy schedules to share your view^s with us. I believe it was Governor
Carter who mentioned the problems in the service. I had an interesting
conversation with General Davidson yesterday. He has been in Viet-
nam for quite some time and is now going to take over the European
troops. He is concerned about the problem of drugs in the service, but
made a good point. They are getting their personnel in the United
States, and these are young people who, in most cases, have already
been on drugs. The percentage is high of those who have already
at least smoked pot, and many are addicted to pot, some on hard drugs.
And then when they go into that area, particularly Vietnam, the avail-
ability of heroin and the byproducts of heroin add to the problem. It is
partially a military problem of course, but also they are getting the
problem group from the United States, the recruits. So I think maybe
we are placing too much blame on the military.
But at the same time, they are well aware of the problem, I think
maybe your conversation makes all of us aware that we are going to
have to talk to some of the people in the Pentagon and point out to them
that they are going to have to do more in new programs to take care
of that.
Yes, sir ?
60-296— 71— pt. 2 19
622
Governor Carter. I certainly recognize that part of the problem
originates in civilian life with draftees and otherwise. Of course, I do
want to say that what we would like to have is a workmg relationship
with the military to share their doctors, their facilities. I am strongly
aware, though, that the Department of Defense is not contemplating
at the present time any responsibility for a discharged veteran who
is an addict. The only exception to this would be very intangible
remarks about potential Veteran's Administration services.
I think that this is a mistake. The}^ should give us the names, they
should participate in every aggressive way possible and not seek ex-
cuses for not participating.
I am not sure at what level within the Department of Defense Gen-
eral Tabor and Mr. Hobson are. This meeting with me was arranged
by the Secretary of Defense. I asked the gentlemen assembled in the
room if any of them had ever had any experience in the treatment of
addicts or the supervision of a treatment program for addicts and
they said no, but they understood that some of the people in the Air
Force had had ex]:)erience in this field.
I would hope that the military would take a more ]:)ragmatic and
aggressive approach and incorporate some people within their j^ro-
gram who had experience in tlie treatment of addicts. I was extreme-
ly disappointed in their attitude this morning.
Mr. Winn. I share your concern about their attitude and I think
they are relatively new in this field.
Governor Carter. They are.
Mr. Winn. Their experience level is negligible as far as past his-
tories are concerned. They are, I am sure, looking forward to a work-
ing relationship with the Veterans' Administration and tlie VA hos-
pitals. I am sure all of us will do all we can to share this concern
with you.
Governor Shapp. Mr. Winn, just one comment on this.
It is rather difficult for me to comprehend how the militan' can
say that they are getting a good share of their addicts from r-ivilian
life when, after all, each one of the men and women going into tlie
Armed Forces undergo a complete medical checkup at the time they
come into service. It would seem to me that either the checkup they
are getting is improper and done in a very sloppv way— and having
gone through the process myself, I can understand this mav be one
of the reasons for it. But I just can't conceive that a large percentage,
or any significant percentage of the addicts that thev have in the
Army came through from civilian life without being detected at the
very beginning.
Mv. Winn. Not beinff a medical doctor and not knowing, either,
the total physical examination, I doubt that imtil recently, or if at all,
even today, that they are looking for drug abusers. I doubt if they
are during a urinalysis, looking for tlie results or the possibility of
the hard drugs.
(xovernor Carter, ^fr. Chairman, they did inform us that they :ire
now conducting a urinalvsis (m every veteran who is being dis<"harged
from the Vietnam area. But this is the limit of their urinalysis so far.
Mr. Winn. That is on discharge and Governor Shap]) was talking
about those going into the service.
623
Governor Carter. Tliey are beginning this, that Governor Shapp
referred to.
I think one thing that impressed me, too, was tiieir dependence on
the Veterans' Administration and institutional care for drug addicts.
Our own experience in Georgia, and I think this is shared nation-
wide by those involved in the problem, is that only 2 percent of the
addicts ought to be hospitalized. The other 98 percent are those we
are concerned with. I think the Veterans' Administration has habitual-
ly concerned itself with institutional care.
Mr. Winn. Well, yes ; but they are now under orders, as I under-
stand it, to set up and set aside part, of their facilities for rehabilita-
tion. I think they all have a lot to learn, like all of us who are con-
cerned about drugs. I just do not want to be too critical of any one
phase, because we all ought to look in the mirror a little bit, as one
of the Governors said.
Governor Shapp, you mentioned the "no-no'" philosophy in talking
about television and educational TV and starting with the very young.
You said at the kindergarten age and prekindergarten age, an educa-
tional program showing the effects of drug and drug abuses. I am not
a sociologist and I partially agree with you, but I think this would
have to be very well done and very carefully done. What do we have
now except a high percentage of the youth in America who are rebel-
ling against the so-called establishment and possibly, this would be
a training ground for them to rebel against the so-called establish-
ment if it were not very well done ? Do you see my point ?
Governor Shapp. I agree with you completely, but we start traffic
training about the time a child can walk and instinctively, they grow
up to look both ways except, of course, when maybe a ball is thrown
into the street and they forget. But I think there are habits that can
be handled in this fashion.
Let me throw the reverse at you, though, on television. ^^Hien little
kids, particularly, see these commercials on television where a woman
or a man has terrible pains in the shoulder and just take one })ills and
then everbody is smiling and the pain is gone. Or when they find that
all you have to do is drink this and any discomfort you have has dis-
appeared. I think we are formidating tJhe wrong impressions through
this quick, easy cure of all our pains and ills by taking a pill or a
powder.
I am not a sociologist, either, but I have a feeling that we are in-
graining in the minds of a lot of our young people that there are simple
ways out of our problems and it makes it easier for them to be in-
fluenced by somebody who is peddling the drug cult.
'Sir. WiNX. Mr. Chairman, I only want to make one more statement.
I know that there have been several national conferences on drug
abuse, but it is ray understanding that they have been basically held by
the medical societies, by AMA and people in the medical field. Cer-
tainly we need their advice. At the same time, I think that these gentle-
men are telling us what we already know, that we have to work to-
gether and I think there should be a national conference held on drug
abuse which would get into the problems, the various problems, that
the States have — the military side, some of the other problems that
each State might have — in connection and working with the Federal
624
programs that are now available, and I think if the input, if these
Governors and their staffs and their experts could talk to some of the
experts from the Federal level, we would have a change of direction in
the future that we so badly need. I, for one, would urge this committee
to set up a conference where we would have these gentlemen and their
experts come in, not only from the medical field but even from the
legal field.
Thank you.
Chairman Pepper. Thank you very much.
Mr. Murphy?
Mr. MuRpriY. Mr. Chairman, I have just come in. I do not laiow
what ground has been covered. But there was one point the Governor
of Georgia made in his presentation. I would like to address my ques-
tion to the Governor from Georgia.
That was, sir, with regard to the Army commanders at these vari-
ous posts within your State. Did they ascribe any reasons to this re-
fusal of identification of addicts ?
Governor Carter. That was covered earlier, and they did not. They
told me that they personally would like to see this done — General
Tabor was speaking and Mr. Hobson, and I think Kelly, were present
at the time. They were high officials in the Department of Defense. But
they said they would probably be prevented from it because of the re-
luctance to divulge this type of information, which was considered to
be confidential or secret. I did not pursue the question, mifortuntitely,
to determine whether that prohibition came from a law or from the
attitude of Congress or from the attitude or directives from the Secre-
tary of Defense.
Mr. Murphy. Well, Governor, you might be interested in knowing
that Representative Steele and myself, along with over a hundred co-
s])onsors, have introduced legislation here in the Congress which will
make it mandatory upon the Army, the Secretary of Defense and the
A'arious Secretaries of l^ranches of the service, to identify these addicts
upon their return to the United States and also while they are serving
in the United States, and turn this information over to the White
House on this new taslc force ]:)rogram.
Governor Carter. Would this include information about this addict
when he is discharged ?
Mr. Murphy. That is correct. In other words, presently, the Armed
Services have no test, simpl}' a urinalysis test. They have no require-
ment that the GI leaving the service has to take this. It is one of the
simplest ways of identifying an addict. I think tlie cost ascribed to the
services was $1.80 a test. I think the President has implemented this
now and he is making the test mandatory, and I applaud him for those
efforts.
Chairman Pepper. I know you have to leave. Just two or three things
quickly.
Let me ask each of you gentlemen, if I may, starting with Go^'erno^
Carter, does your State have any law that authorizes you to require one
involuntarily to take treatment for heroin addiction at any stage,
cither after arrest or the like ?
Governor Carter. We passed a law this year that permits a judge as
a part of a probationary sentence to require treatment for addiction.
They have the experience in Georgia, and I think in Washington and
625
New York and other places that the number of vohmtary addicts who
come forward for addiction have more than flooded, exhausted the re-
sou.rces of the treatment centers.
Chairman Pepper. I suppose that sort of legislation would almost
have to be at the State level. It probably would not be in the proper
scope of the Federal Government, except maybe with respect to armed
services.
Governor Carteij. We now have only three methadone centers in
Georgia, all three of which are in i^tlanta. I understand there are more
than twice as many addicts who come forward and say help me as can
be handled under the present system because of lack of funds and lack
of personnel.
Chairman Pepper. Governor Shapp ?
Governor Shapp. We have no such law on the books now. We have a
bill before our legislature to set up this whole program for drug con-
trol and rehabilitation and this is a feature of our new legislation.
However, we have a couple of problems, even if this legislation passes.
First, we have no hospitals in the State and no facilities in the
State where we can start this type of treatment and we will have to
start from scratch in developing this.
Second, there is no Avay at this moment that we know to determine
the attitude of the addicts themselves toward this treatment and if you
set up a program to treat somebody and try to rehabilitate hem and
you do not knovr whether they are going to accept the treatment this
way. yoii may not have an effective program at all. So we are starting
to get our feet wet in this program and I think we have a lot to learn.
We need all the help we can get. We are going to move in the direction
of taking care of these addicts and trying to force rehalnlitation. But
just how far it will go and liow successful this program will be, we
cannot tell at this time.
Lieutenant Governor Brickley. We do have an old statute in INIichi-
gan Avhich provides for involuntary commitment through probate
court of a pei'son addicted. It has been rai-ely used for that purpose.
It requires a confinement at a State hos]:»ital. I suspect it has been
rarely used because we do not have the facilities there. You usually do
uot have a petitioning party and we are so busy with those we can
confine through the ciiminal i)rocess, either through the Federal Nar-
cotic Addict Rehabilitation Act or through an alternative to sentenc-
ing, which is usually sufficient. It has hardly ever been used for that
purpose, but it is there.
Chairman Pepper. While vou are speaking. Lieutenant Govcn-nor
Brickley, would you tell us whether or not the Detroit police depart-
ment has said that they had found by the use of methadone a reduction
in the incidence of crime ?
Lieutenant Governor Brickley. I was just going to volunteer that.
I am sorry I did not say it in my opening statement. The methadone
treatment program really started in the last 6 months in Detroit and
in May, for the fii'st time in my memory, they have had a reduction
in the incidence of crime, particularly those crimes, rape, robbery,
burglary, and larceny fi'om the person. I think there are some con-
clusions you can draw from that.
Governor Carter. One more item that I think might be of interest
to this committee : About 3 months ago, I met at night for supper with
626
all of the top officials in the Federal Government, the FBI, iSTarcotics
Control Agency, my director of State patrol and the Georgia Bureau
of Investigation, the police cliief of Atlanta and DeKalb County and
the district attorney in that area, to talk to them about the criminal
prosecution of those indulging in the distribution of narcotics. At
that time, my orientation was mainly found attacking the problem
through the courts.
They pointed out a very serious problem to them as law enforce-
ment officers. There were 15 drug distributors known to them by name
whom they were observing. They had through a laborious process pre-
pared testimony and evidence against one particular distributor of
narcotics. He had been taken to Federal court and released on bond. In
August of last year, he violated his bond requirements and was caught
again bringing heroin into Georgia from Chicago. Immediately, he
was released on bond again, on $1,500, and he is now distributing diiigs
in Georgia at the present time. This is a Federal court, over which
no Governor, of course, has control or would want control. But this
was an extremely discouraging incident to the people who have de-
voted hundreds of man-hours to bringing this person to justice.
I think if some degree of publicity, through the Attorney General
or otherwise, could be brought to the Federal court judges about the
seriousness of this type of criminal, I want them not to have an overly
severe sentence, of course, but it is very discouraging to local and State
law enforcement officers to bring a person to justice and then have him
immediately released on a very low bond.
Chairman Pepper. Governor, this committee is very much aware of
that problem. It first came to our attention in hearings that we had
in New York, where the representatives of the customs department
and the Bureau of Narcotics and Dangerous Drugs were telling the
same story about how they had spent a lot of money and a lot of time
catching somebody and then a Federal judge would give him a bond.
Even if they posted a $100,000 bond, one of these international gang-
sters would skip the country and quarry had fled.
This committee pointed that out in our recommendations to the
House at the end of last year and we are considering legislation to
rectify this problem.
Mr. Winn?
Mr. Winn. I just Avanted to point out, ^Ir. Chairman, that I believe
Chief Justice Burger has sent out some instructions and made some
comments along this same line and I believe that they are aware of it.
But I believe with Governor Carter that additional publicity should
be sought at this time. And this conuuittee has done everything it can.
Mr. MiiRPfiY. Mr. Chairman, along tliose lines, I suppose we all have
our stories. One of the stories we higldiglit in our report on the world
heroin problem is about an ex-GI who was indifted in New York and is
now presently on a quarter of a million dollar l)ond. He is now liack in
Bangkok, Thailand, where he operat(>s one of tliese lal)oratorios in a
bar where he reduces opium to a heroin base and then distributes it to
our (lis in Vietnam. He has a valid ILS. passport. This is another
story in a long 1 ine of abuses.
Chairman Peppkr. Gentlemen, I would just like to call attention to
this. T have just inquired of the staff and T find that the budget request
for the LEAA for 1972 is $680 million. Now, this committee started a
627
couple of years ago to try to get more money for LEAA, to help the
States Avith their crime problems. It was some $200-ocld million when
we shocked a good many people by going before the appropriate com-
mittee and saying it ought to be $1 billion a year, at least $1 billion a
year, if we are going to do any good to help the States. Well, fortu-
nately, the Congress finally authorized $750 million last year, $1
billion now, and $1.2 billion the third year.
The reason I brouglit this up is that the testimony that we have heard
from our distinguished witnesses today is that anywhere from -iO to 60
percent of the crime in this country is directly related to narcotics.
And here we are, proposing to authorize $105 million for treatment
and rehabilitation and yet dealing with what looks like the more
probable cause of crime, we are proposing to spend $700 million, but
that is not for treatment and rehabilitation particularly. So it looks
like what we have to do is shock the conscience of the Congress and the
country to an awareness that we are dealing with crime. Some people
ask this committee, you all keep talking about drugs; we thought you
were a crime committee. Our opinion is that the quickest and the
cheapest way that we can reduce crime vei-y materially in this country
is through an eifective drug program, programs to help you Governors
and other officials meet the menace of this problem.
The Governor of Georgia spoke about the number of people dying.
I live in Miami, Dade County, prior to 1066, we did not have any re-
ported deaths from heroin. Last year we had 31 and this year, we are
going to have 54, just in my county. In New York, over 1,100 people a
year die, now, at the current rate.
In the New York courts, the chief enforcement officer told us that
48 percent of the cases in Xew York County and Bronx County, two
of the main counties in the New York area, 48 percent of the cases
dealt with narcotics traffic and another 25 percent with crimes incident
to narcotics traffic. These prosecuting officials said tlhat if they did not
accept voluntary j^leas on the best terms they could get, the court
systems would absolutely bog down.
This just emphasizes how drug abuse is directly related to the
problem of crime.
Gentlemen, we welcome anything further you might care to say.
You have been most indulgent.
Did you have anything else to say, Governor ?
Governor Shapp. I just wanted to add one thing to what Lieutenant
Governor Brickley said before. If, in your planning to aid the States
and local governments in this whole process of coming to grips with
this drug problem, you would follow the same procedures you do in
LEAA, it would be very helpful. As I indicated before, we estimate
that about $45 million is about what we can shoot for in the next cou-
ple of years reasonably. We have to build up to it. So we have allo-
cated $20 million in our budgets of various departments. This is for
tooling. Unless we know that we are going to have the funds to expand
the program to cope with the real problem, then we are unable really
to get the statf to implement the programs to build up to do the things
on sufficient scale to make a dent in this pi'oblem.
So I can only urge that you follow the advice that he gave just a
moment ago and as you plan this thing, plan it for the future, because
if New York is at $188 million right now, sure, their problem is
628
perhaps greater than some of the other States. But they do not have
sufficient funds to come to grips with it. I think you can project out
from what they are doing, or project our estimates of $20 million this
year, $45 million next year, to work on this problem. I think if you
give us a program of that sort on a financial basis that is programed
for the future, then we can gear to this and have much more effective
pi'Ograms than we will have on any other basis.
Chairman Pepper. Governor, your statemeiit is obviously a very
reasonable and articulate one. In my own opinion, we should appro-
priate at least $500 million to be available. The President holds up
other money that the Congress appropriates when he does not think
it appropriate to spend it. He does not give it to anybody who could
not use it wisely. But we ought to make at least $500 million available
in fiscal 1972 and ask the States to give us, within 60 days or 45 days,
a good program that you think you could use this money on effectively,
and then we would begin to get somewhere and we would notice a
decrease in the problem.
Governors, we want to thank vou verv much for vour kindness in
coming. You have been most helpful to us.
The committee will recess until 2 o'clock, when we will hear Dr.
John Kramer.
(Whereupon, at 1 :05 p.m., the committee was recessed until 2 p.m.
of the same day.)
(The following letters were subsequently received from the officials
of various cities in response to a request by the committee for their
views:)
[Exhibit No. 26(a)]
City of Bostotn",
Office of the Mayor.
City Hall, Boston, June 9, 1911.
Hon. Claude Pepper,
Chairman, House Select Committee on Crime,
U.S. House of Representatives, Washington, B.C.
Dear Congressman : I wisla to thank you and the members of your committee
for requesting my views on tlie needs of the Nation's major cities in dealing with
the problem of drug addiction.
Drug aliuse and drug addiction have become problems of great concern in the
city of Boston. At the present time there are an estimated 10.000 users of heroin
among Boston's 6-50,000 residents. Although there are no generally accepted
estimates of the number of people who abuse other narcotics and dangerous
drugs, the testimony of educators, community leaders, and youth workers sug-
gests that illicit drug use — particularly by high school and junior high school
age young people — is widespread and constantly increasing. Not only is one
Bostonian out of every 65 a heroin addict, but the number of addicts has risen
at an epidemic rate — a rate possibly as high as 50 percent each year.
To meet this epidemic, in March 1970. Boston established a comprehensive
drug abuse control program. Since that time, we have opened two out-patient
methadone clinics, established an in-patient day-care and detoxification center,
initiated a 24-hour hotline in the accident floor of the city's general hospital
to respond to drug-related crises, and provided funding and other assistance to
sevei-al community-based self-help rehabilitation programs. We have tripled the
size of the police department's drug control unit, and with the generous assist-
ance of the Federal Bureau of Narcotics and Dangerous Drugs, provided all
ofllcers with specialized training. Over 1,2.50 public and parochial school teachers
in Boston have participated in drug abuse education symposia and training
progx-ams. In many neighborhoods, community drug action committees have
harnessed the energy of private citizens in local fund-raising and volunteer
activity in support of community-based treatment and preventive education.
629
Yet, in spite of these efforts, there continues to be a tragic disparity between
services and the rapidly growing need. Between 1966 and 1969, 1,550 drug ad-
dicts voluntarily applied for treatment at a small, State-funded out-patient
clinic located in Boston. Since the beginning of 1970, when we appropriated
city funds for that clinic, quadrupled the size of its staff, improved its method
of operation, and transferred it to the city's general hospital, an additional
1,567 heroin addicts have requested help. The city of Boston's treatment facil-
ities currently have an active caseload of 650 patients, representing capacity
operation. Treatment is available to approximately 350 additional persons
through a multiplicity of small programs — university and community hospital-
based and self-help programs — which are primarily funded by the Massachu-
setts Department of Mental Health. An OEO-funded treatment program de-
signed to serve three housing projects has not yet begun active operation. An
NIMH-funded drug abuse rehabilitation program which was approved in July
1969 did not begin active opex-ation until February 1971. The city of Boston's
treatment facilities receive no Federal support at the present time, although
they treat the majority of the addict patients in the city. One hundred fifty
new patients apply for treatment at those facilities each month. And the com-
bined city-State-Federal resources provide the opportunity for help to only 1,000
of Boston's 10.000 heroin users — 10 percent of the people in need.
At the same time that Boston is seeking to assist its addict population, we
are constantly confronted with the problems of addicts from outside the city
desperaely seeking help. One out of every five persons applying to the city's
treatment facilities is a non-Bostonian. Because of the enormoiis need of our own
residents, in June 1970, we began a residency requirement in the city's treat-
ment facilities. Unhappily, we refuse assistance to non-Bostonians, sending
them back to their own communities most of which have no treatment re-
sources available, to continue their lives of addiction and crime. That is not a
pleasant task, but we have no other choice. With no financial assistance from
the Federal Government, insufficient funding from the State, Boston — which
gets its resources solely from the property tax in a city where over 50 percent
of the property is tax-exempt — is struggling to pay for the vast majority of
IJatients now in treatment, and to provide services for hundreds more who want
to be cured.
My recommendations to Congress are these :
(1) Increase the amount of Federal support available to our Nation's major
cities. I am greatly dismayed that while over S50 cities. States, and private
agencies applied for community drug abuse prevention grants, under the Drug
Abuse Education Act of 1970, only 46 could be awarded since the administration
had appropriated only $6 million of the congressionally approved authorization
of $20 million for fiscal 1971. I am equally dismayed by the administration's
failure to fully fund the Comprehensive Drug Treatment and Rehabilitation Act
of 1970. A 30 percent effort will not solve the crisis of drug abuse which this
Nation faces.
(2) Increase the amount of Federal support for services. Federal support is
now generally tied to research projects rather than on-going programs of treat-
ment, rehabilitation, and education. We agree that such programs should be
carefully evaluated, but the delivery of services should receive high priority for
Federal support. It will do us no good to know 5 years from now how we could
have met this challenge.
(3) Do not treat this problem through an emphasis on any single approach.
Drug abuse and drug addiction are complex pi'oblems which are not susceptible
to simple solutions. The city of Boston's drug abuse control program which I
have outlined above emphasizes a coordinated effort in treatment, law enforce-
ment, education, and community action. I strongly believe that such a compre-
hensive approach is essentia!.
I am proud of the city of Boston's program to combat drug abuse. I am proud
of the many Boston citizens who give freely of their money and time to work
in their own neighborhoods. I am proud of the willingness of many private
agencies to work closely with public agencies. I am proud of this city's health
professionals, educatoi's, law enforcement officers, community leaders, and young
people who are struggling to communicate with each other and work together
to cope with this problem.
It is too soon to measure the effectiveness of Boston's efforts. Although we
cannot state with scientific accuracy the impact of our programs, we do see
encouraging signs. We can point to persons who have overcome their drug addic-
630
tion and many others attempting to do so. We see, with pride, men who led a
life of crime now working and contrihnting to the community. We are fiilly
cognizant, however, of the effort which we must continue to put forth. Boston
has not yet fully experienced the impact of the many drug-addicted young men
who will l)e discharged from military service. We cannot fail them. I liope and
pray that we will have the resources to aid them.
Our Xation has many strengths in its people and in its institutions. We do
have the capacit.v to successfully confront the drug abuse crisis which we face.
The House Select Committee on Crime has held hearings throughout the United
States. You, members of the committee, should be among the most knowledgeable
in the Nation regarding the extent of the problem and the enormous need for
action. I trust that you will provide the necessary means and leadership for
such action.
Sincerely,
Kevin H. White, Mayor.
(A response from Richard L. Krabach, city manager, city of Cincinnati, Ohio,
was retained in the committee files. )
[Exhibit No. 26(b)]
City of Detroit.
June 15, 1971.
Claude Pepper,
Chairman. House Select Committee on- Crime, U.S. House of Representatives,
Wa>shiii(/ton, B.C.
Dear Representative Pepper: The city of Detroit shares with other urban
areas throughout the Nation, the problems created by drug addiction. From the
standpoint of law enforcement, drug related arrests during the first months of
1971 project a total of 9,137 arrests for the year, or an increase of 163 i>ercent
over 1969.
The estimates of drug dependent individuals are many and varied, with esti-
mates well in excess of 20,000 addicts. Further, the total daily amount of heroin
purchases in the city may approximate $700,000, which may necessitate $2 million
of retail valued merchandise.
The numbers of people addicted to drugs and the amount of crime related to
supporting drug addiction has been growing at an alarming rate over the last
few years. The major providers of service have long recognized their inability
to provide treatment if services are predicated on the precious tax dollars large
urban cities are able to allocate.
The financial crises confronting Detroit is the same burdensome problem of
declining revenue sources as expressed by every mayor of other cities. Treatment
and prevention of drug abuse is a very co.stly service which cannot be adequately
provided by current city budgets.
The city of Detroit attempts to provide comprehensive treatment, pi-evention,
infomiation, and educational services to its estimated 20,000 heroin addicts under
a $2,000,000 budget for the fiscal year 1971-72. Federal sources under the Na-
tional Institutes of Mental Health have contributed $r)00.000 for our iModel Cities
drug treatment ])rogram, which serves a populace of 104,000 residents. The Office
of Economic Oppoi'tunity has contributed approximately $500,000 for our pro-
gram of drug ti-eatment, which is conducted by the Mayor's Committee for
Human Resources Development. The Law Enforcement Assistance Act i-ecently
granted $250,000 to the Health Department to establish a treatment program.
An analysis of Federal and State allocations indicates a sum total of $1.3 million,
which is well below the financial commitment by the city.
The absence of Federal Revenue sharing and direct grants to our city to permit
the development and establishment of a comprehensive drug abuse treatment
program will only compound the problem. We cannot delay action on the Nation's
number one health prol)lem any longer.
The basic needs for the implementation of a viable citywide program would
necessitate the following rehabilitation services :
(a) Crisis centers,
(h) Central laboratory.
(c) Court programs.
(d) Research.
631
(e) Therapeutic communities.
(f) Hospital based treatment programs.
(g) Educational centers.
(h) Acute detoxification centers.
( i ) Computer services,
(j) Central registry.
It is my intention to develop a minimum of 26 centers to include a variety
of modalities with special attention to prevention as it pertains to the adolescent.
In the event the Federal Government continues to play a passive role with
respect to our monetary crises, the numbers of heroin addicts in Detroit could
approximate 40,000 in a year.
Gentlemen, our services to the citizens of Detroit have been drastically cur-
tailed. The failure to provide medical/social services for drug dependency will
become unmanageable without adequate Federal Revenue.
Sincerely,
Roman S. Gribbs, Mayor.
[Exhibit No. 26(c)]
Statement of George A. Athanson, Mayor, Hartford, Conn.
Hartford, Conn, is a geographically small city (18.4 square miles) in central
Connecticut, surrounded by relatively affluent suburban towns. The city has a
population of 158,000 including about 44,000 black ijeople and 20.000 Puerto
Ricans. The capital region, 30 town area, of which Hartford is the hub, has a
population of over one-half million.
Conservative estimates of hard drug users in Hartford suggests about 2.000
to 3.000 heroin addicts. About one-half of this number are addicted to substan-
tial amounts of the drug requiring expenditures of $50 to $100 lyer day.
The crime i*ates, especially breaking and entering, shoplifting, burglary, and
mugging are increasing due in large part to drug dependency. Drug-related
arrests by the police department are ranging in the neighborhood of one thousand
annually. In addition to the major heroin problem, there is a large but inde-
terminate amount of usage of a variety of other di-ugs, both hard and soft.
In the city, cocaine, alcohol and glue seem to pi'edominate. In suburban areas,
there is a wide use of marihuana, amphetamines, bai'biturates, and hallucinogens.
Further, and even more alarming, is the recent phenomenon of the "psychedelic
delicatessen". This phrase aptly describes the way drug and alcohol users indis-
criminately mix all varieties of both. Needless to say, the results of this practice
are fatal.
At a recent meeting of the chief executives of the major drug treatment pro-
grams, certain recent trends or changes in drug usage were noted. All agencies
have noted a trend toward younger persons using hard narcotics — children in
the range of 12 years of age are being seen or referred to some progi-ams for
care. The younge.«t seen was age 9. This is also attested to by the increase in
youth drug offenders being sent to the juvenile detention centers in Meriden and
Cheshire. Conn., as well as the younger age group in the State jail in Hartford.
The director of one of Hartford's methadone clinics estimates that nearly 100
drug users between the ages of 12 and 15 have been seen by his facility.
Another trend, noted by all agencies, was toward increasing use of drug com-
binations by young i>eople. Particular attention was called to the use of heroin
and alcohol (Boone's Farm Wine and Malt Duck) by urban young people ex-
perimenting with drugs. The sight of children in the streets "stoned" during
regular school hours was noted. A separate new group of addicts, the Vietnam
war veteran, has recently appeared in Hartford. During the past year, 39 veterans
addicted to heroin approached one agency. Neither of the two Veterans' Ad-
ministration hopsitals (Newington and West Haven) has a drug service program.
A variety of drug treatment programs has sprung up in an attempt to serve
the needs of the community. Some of these programs were originally sponsored
by parents who had lost children to the drug culture.
The most comprehensive programs for drug abuse are provided by the Alcohol
and Drug Dependence Division of the Connecticut State Department of Mental
Health. With the assistance of a major grant from the National Institute of
Mental Health, they currently offer the following programs :
(1) Outpatient clinic care including group therapy, counseling, and vocational
rehabilitation.
(2) Inpatient care in the Blue Hills Hospital including detoxification, a variety
of therapies, and long term followup.
632
(3) Long term residential self-help programs at Valiance House on the grounds
of the Norwich State Hospital and the Dartec House on the grounds of the Under-
clifC Hospital in Meriden.
(4) A methadone maintenance program started with inpatient care and long
term outpatient maintenance. This program includes coimseling and vocational
training and assistance. This program is building toward 150 clients, and is op-
erated jointly with the health department of the city of Hartford.
(5) The division operates a drug line and general information and counseling
program for addicts and their relatives.
The Alcohol Council of Greater Hartford operates an elaborate drug informa-
tion center with a large reference film library and a computer tie-in with the
National Drug Information Center in Washington. This agency is currently mak-
ing some effort to coordinate drug programs within the region.
A criminal and social justice coordinating committee, sponsored by the com-
munity council and the chamber of commerce, is currently oi>erating a second
major methadone program. The program is rapidly building tow^ard 800 clients,
entirely on an out-patient basis. There are centers for the program in both north
and south Hartford, and people in the Hartford State Jail may be enrolled in the
program before being released from jail to continue thereafter.
Each of the city's four general hospitals offers limited service for the addict,
both detoxification and care for urgent medical, surgical or psychiatric compli-
cations of drug abuse. In addition, an increasing number of private therapists
are involved and concerned with the drug problem and approaches to treatment.
It is difficult, even impossible, to quantify the latter types of services. One specific
program is one of the four hospitals is a 30-day residential treatment program
for adolescent drug abusers under the auspices of the Universitj' of Connecticut
Medical School — McCook Hospital Division. This program has had indifferent suc-
cess, but is one of the few devoted to the under-16 drug user. There is a current
attempt to expand this i>rogram to include a long-term residential treatment
center.
A model cities program of the city administration is beginning to devote
itself to the drug abuse problem by establishing two youth centers for education,
guidance, counseling, and referral for teenagers and their parents.
The community renewal team, an OEO Agency, likewise is devoting personnel
time to drug advice, counseling and referral service. A completely nongovern-
mental program, ROOTS, Inc., lias established itself as a center where troubled
youth may find peer-group counseling and assistance.
While the city of Hartford and the State of Connecticut have diligently dealt
with the drug prol)lems confronting them, there are still a great many needs to
be met. Most urgent is the need for greater youth orientation in our rehabilitation
and treatment programs. Specifically :
(1) Because the problems of drug addiction are more than just physical (there
are also grave psychological and environmental factors as well), and because
it is a process rather than a disease, there is great need for youth rehabilitation
treatment centers. The function of these centers would be to allow the young
drug-dependent person, age 16 or under, to receive treatment for a period of 6
months to a year. This amount of time is absolutely essential if we are going to
cure completely a young adu!t's addiction problems. In order to serve the area
suflficiently, an initial residential treatment center with a capacity of at least oO
is necessary. Estimated yearly cost of this facility would be $2.^0,000.
(2) Realizing that the 16-and-under age group is the groiip that most needs
to be communicated with, both in terms of treatment and drug education, it is
essential that we institute massive drug awareness programs for education di-
rected to this grotip. The aim of this program must be twofold: (a) To change
the image of drug usage; and (ft) to make drug addicts realize that there are
agencies ready and willing to help them.
((/) In some areas where drug abuse is most prevalent, the ideas concerning
drugs are often romanticized. As has been true in the past with gamblers and
organized crime, some of the younger (nondrug using) children look up to the
addict because of what (they think) he represents. This often encourages ex-
perimentation. Through massive drug education. thr> point must be driven home
that narcotics use is not desirable and is not to be admired or copied.
(1)) In an effort to make the drug-dependent person more aware of what
help is available to him, the mass media and the public education .system must
bo utilized. Thi-ough these campaigns people who are not on drugs must learn
to avoid them, and those who are addicted must learn where they can be helped.
633
Presently, drug education in tlie public schools is inadequate: It is not at all
unusual for students to be more knovv-ledgeable about drags tlian their school
nurses and instructors. To initiate a more sensitive and meaningful drug educa-
tion program, covering the city's 32 schools, would require an initial staff of
10 counselors and v?ould cost an estimated $150,000.
Another need of the city exemplifies a fundamental problem presently con-
fronting the entire Nation ; that our so-called rehabilitation centers, our jails
and youth homes, increase rather than decrease their inmates' problems. For
example, it is generally agreed that the two State rehabilitation centers, Meri-
deu and Cheshire, which house juvenile court referred youth, only compound
the problems of a young addict sent there. Necessarily, we must have alterna-
tives to present youth facilities. The juvenile courts must not be doing an addict
a disservice when they sentence him to one of these centers. Therefore, the need
for youth drug rehabilitation treatment centers, already discussed, is again under-
scored. Also along the lines of the judicial system and youth drug addiction, a
stronger, more vigilant relationship must be encouraged between probation
officers and those young drug users who receive suspended sentences. In this
way, hopefully, the second-offender problem can be alleviated. This type of rela-
tionship requires a vast increase in the numbers of parole personnel
Another need essential to the city's drug rehabilitation and treatment efforts
is for more places in the methadone treatment program. Presently there are 450
available places for methadone treatment in the city, administered by two sepa-
rate agencies, the Hartford Dispensary and the Blue Hills Hospital. Those who
run them estimate that there are 1,000 who would use the treatment if it were
available. The Hartford Dispensary presently has space for .300 at an operating
cost of $100,000 per year. Of their funds $325,000 is funded from the LEAA and
welfare title 19 (medicade). The other $75,000 is locally funded. In order to
increase the capacity of the methadone program to 1,000, an increase of $800,000
is needed. The other budgets of local and State agencies are : Alcohol and drug
dependency agency of the state department of mental health — $741,000 of which
$472,000 is Federal money and $269,000 is State. The ADD has methadone and
in-out patient programs. Their residential treatment center, Dartec. is geared
to take 45; drug information center— $65,000 ; model cities— $135.000 : roots —
$35.000 ; The Community Renewal Team of Greater Hartford is presently ap-
I'lying for grants to the OEO. Thus the total amount of money now being used
in the city of Hartford for drug rehabilitation and treatment is $1,350,000.
The last great need now facing the city is for an urban residential facility
for adults. This facility must be equipped to serve the Spanish-speaking addicts
of the city. The initial facility should be geared for 50. Because this must be a
residential facility, it must meet the stringent State building codes covering
boarding houses. The estimated cost of this service would be $250,000.
The total estimated additional need for the city of Hartford to finance all
of its needed programs is $1,450,000.
Methadone expan,sion $800. 000
Youth resideniial treatment facility 250J 000
Adult residential treatment facility 250^ 000
Drug awareness program for public schools and mass media 150,' 000
Total 1^ 450, 000
This is without funding of additional parole personnel.
In the area of Federal legislation, we would propose laws for assisting the
narcotics user similar to those concerning aid to the alcoholic under the Hughes
bill. However, no matter vv^hat course of action is decided upon by your com-
mittee, the essential things to bear in mind is that all legislation and"^programs
must be mule more realistic and sensitive to the people's needs.
In summary, there has been a substantial buildup of services for the treat-
ment and rehabilitation of the drug user, perhaps too great a variety of programs
with too little coordination between them. There has been, in addition a sub-
stantial increase in efforts to control the flow of drugs into the region with in-
creasing numbers of arrests, but indifferent success in interrupting the flow of
drugs. The drug trafllc for the city of Hartford has weighed most heavily on
the poor, especially the black and Spanish-speaking poor for whom this has be-
come an additional obstacle to health and happiness.
Many of the programs alluded to are currently in need of funds to even main-
tain present programs, much less to expand them. A substantial infusion of funds
634
for the support of drug service programs for both drug abuse and the hroader
problem of alcohol use is needed in the city and in tlie region. An improvement
of present programs ratlier than the establislmient of many new programs would
do much to improve the lot of the drug user. This will not be possible without
substantial additional funding, probably from Federal sources.
Specifically, the city of Hartford needs additional facilities for methadone
maintenance. The current capability is 4.10 heroin addicts. The agencies pro-
viding service feel there is a potential immediate need for 1,(J00 patients. This
would cost an additional $660,000 per annum. All agencies agree that there is in-
creasing need for service to the juvenile drug user — ^age 16 and under. Currently,
there is only a 30-day hospital program with six beds. Needed is a long-tei-m
residential treatment center for at least 50 children. This w^oukl cost $300,000
per annum.
The Vietnam war veteran is not being served by present programs of the Vet-
eran's Administration hospitals in this area. These hospitals will require addi-
tional funds — proibably at least a million dollars, to develop programs and begin
long-term treatment.
More is needed for drug education, both in the schools, in the community, and
especially through radio and television programing. Some of this needs to be
aimed at the increasing use of drug combinations by young people. Use of hard
narcotics or marihuana and alcohol (Boone's Farm Wine, Malt Duck), as well
as other mixtures, is being recognized commonly. Children in the streets are
"stoned" early in the day.
Present programs are funded at about $1 million in Federal funds, $300,000
in State funds, and $150,000 in local funds. As indicated above, at least another
million dollars for expanded methadone maintenance, residential treatment for
youths, and public education is needed. State and local funds should increase
proportionately.
We need to treat drug abusers as sick children and sick adults. We also need
to attend to the social ills that force people away from reality to the hallucina-
tory, confused world of drugs.
[Exhibit No. 26(d)]
Statement of Bartholomew F. Guida, Mayor, New Haven, Conn.
Chairman Pepper and members of the Committee, I appreciate this opportunity
to submit testimony to your committee about the problems of drug abuse con-
fronting the city of New Haven. I am sure that it is similar to those problems
faced in other cities throughout the country. It is extensively and frightening and
continually increasing. It affects every member of our community and, therefore,
the vital life of our country.
the extent of the problem in new haven
Drug experts in New Haven have given us some idea of the characteristics of
drug usei's and experimenters in our community. In common with most other
cities, all types of drugs are used in New Haven. Among users and experimenters
there is some distinction in the type of drug used by various age groups. For
example, those preteen .voungsters experimenting with drugs concentrate on glue
sniffing, while early adolescents, 12 to 14 years, involved in drugs, smoke mari-
huana and occasionally take LSD or heroin. The middle adolescents, 14 to 17
years, taking drugs, use marihuana, psychedelics, heroin, and amphetamines;
while late adolescents, 17 to 20 years in this category, are into marihuana, psyche-
delics, heroin, amphetamines, and barbiturates. Young adults 20 to 25 years,
who use drugs, are into marihuana and heroin, and less often psychedelics. am-
phetamines, barbiturates, and cocaine. Adults, above 25, who are users, are into
marihuana, heroin, barbiturates, and cocaine.
Surveys by our drug treatment specialists indicate that users and experi-
menters who live in different areas use different types of drugs. Inner-cit.v users
concentrate on marihuana, heroin, and cocaine; outer-city users on marihauna,
amphetamines, heroin, and less often, LSD. ^laribuana, psynhodelics and less
often, heroin and amphetamines are prevalent among suburban users. Black
addicts use marihauna, heroin, and cocaine predominantly ; Puerto Rican addicts,
marihauna and heroin ; and white addicts, marihauna, psychedelics, amphet-
635
amines, heroin, and barbiturates. In terms of causes for drug use, users who suffer
from socioeconomic deprivation mainly use marihuana, heroin, and cocaine.
Psychological disabilities among users lead mainly to marihuana, heroin, barbi-
turates, and amphetamines. Addicts who feel bored or alienated turn most often
to mari'hauna, psychedelies, heroin, and amphetamines.
A thorough survey of drag use and addiction is now being made in the New
Haven area. We estimate that there are now 1,200 to 1,500 heroin addicts and
another 1,.")00 to 2,500 heroin experimenters. There are not even any good guesses
on the use of other drugs in the area, but we do see the following ti-ends :
1. Heroin use is increasing markedly in w^hite suburban and outer-city
areas. The rate of increase in the inner city is slower, but the total numbers
remain higher ;
2. The use of LSD is leveling off to decreasing. There is a rise in the use
of mescaline, but most of what is sold as mescaline is LSD or STP ;
3. The use of amphetamines is leveling off to decreasing ; and
4. The use of marihuana is increasing in all strata of the population.
THE EFFORT IN NEW HAVEN
New Haven has a comparatively extensive drug effort, but one that goes no-
where near meeting our needs ;
1. The drug dependence unit of the Connecticut Mental Health Center, located
in New Haven, is financed through a 5-year grant, which began in July 1968, from
the National Institute of Mental Health. The unit is a demonsrtation project
which provides an almost full range of service to drug-dependent individuals,
plus educational and preventative programs. It services the entire New Haven
region, a 13-town area. The unit sees individuals from 14 on up who have dif-
ficulty with narcotics, amphetamines, phychedelics, and barbiturates. To date
over i.OOO patients have been seen by the program, and on an average day there
are over 350 patients in active treatment.
The drug dependence unit has six major components :
A. Methadone maintenance program
In this program, methadone, a synthetic narcotic which blocks the effects of
other narcotics such as heroin and eliminates drug craving, is dispensed to heroin
addicts over 21 with a history of at least 2 years of addiction and who have pre-
viously failed at attempts to remain abstinent. In addition to receiving the drug,
participants are involved in a variety of therapeutic vocational and educational
endeavors, with the ultimate goal being a productive as w^ell as drug-free life.
B. Dai/top, Inc.
Daytop is a residential treatment community staffed entirely by ex-addicts
who are Daytop graduates. It accepts patients from 16 on up who are drug de-
pendent and has a capacity of over 50. The program utilizes certain aspects of
"reality therapy," with drug-dependent people being helped to understand and
deal with their emotions, evasive behavior, and reasons for using drugs. Partic-
ipants are expected to remain in the program for at least a year.
In addition to work at the facility, Daytop staff and residents are involved
in numerous speaking engagements and four regional activities including a
storefront in Milford, work with the NARA program at the Danbury Federal
prison, work with drug addicts at the Connecticut State prison in Somers, and
work with addicts at Cheshire Reformatory.
C. Outpatient clinic
The outpatient clinic is the initial induction facility for all patients to the
unit, and is involved in direct treatment of adolescent and young adult drug
abusers, and provides consultation to a variety of youth-serving institutions and
agencies. Naloxone, a nonnarcotic medication which when taken daily blocks the
effects of horoin, is available to those who require it as part of the outpatient
program. Participation in a wide variety of activity groups, and graduation to
leadership training toward employment within the program or with other agen-
cies, is based on the individual's readiness to begin helping others.
636
D. NARCO, Inc.
Narcotics Addiction Research and Community Opportunities, Inc., is a store-
front operation concerned witli the rehabilitation of drug dependent persons. It
offers a variety of services, including screening and referral to treatment cen-
ters, legal aid. personal and family counseling, a prerelease program in which
NARCO representatives visit Connecticut's penal institutions to help prepare
inmates to function after their release, and an educational program.
NARCO is about to receive funds from the Connecticut Planning Committee
on Criminal Administration to open a detoxification center. It also is involved
with the drug dependence unit's epidemiology and evaluation unit in an NIMH
grant for the evaluation of drug educational programs and an epidemiologic sur-
vey in various school systems. It has also recently opened a storefront in
Waterbury.
B. Drug Dependence Institute
The Drug Dependence Institute functions on a national basis and offers
training in the prevention and treatment of drug addiction to advance knowledge
and understanding of drug dependence. It also provides orientation and consulta-
tion .services to school systems and agencies throughout the Northeast.
F. Epidemiology and evaluation
This division is responsible for evaluating the drug dependence unit's effective-
ness in dealing with drug addiction, its ability to provide effective treatment for
drug-dependent persons, and its ability to reduce the level of drug dependence in
the area served by the project. To accomplish this, it monitors the activities of the
unit and examines the incidence and prevalence of addiction in the area.
2. Number Nine is a storefront crisis center, a "crash pad" and "hot line",
which works with adolescents iu various difiiculties including those onto drugs.
Its main work has been with users of psychedelics and amphetemines.
3. Youth Crusaders, Inc. is a religious group modeled after Teen Challenge.
It has no local facilities, but sends addicts to programs in New York and Phila-
delphia. It now operates on private contributions and volunteer services and
has been trying unsuccessfully for 2 years to raise funds for a local residential
center.
4. New Haven has several neighborhood-based programs and anticipates the
development of new ones. Similar to most. Project Enough is a storefront opera-
tion which provides information and referral to addicts and potential addicts
in the Fair Haven area. It is hoping to operate a program in a vacant school in the
area, which the city of New Haven is providing to the project free of charge,
which will include group counseling, individual counseling, community educa-
tion, and recreation to local residents. As yet, funds to operate the pi'ograms have
not been available. The other neighborhood-based programs are not firmly
established and have, therefore, not been included.
Besides these efforts, others exist in the city, especially through education
about drug abuse in the schools and enfoi-cement activities in the police depart-
ment. These are not as clearly identifiable and will not be included specifically
here. The funds involved during the current fiscal year in the programs mentioned
above are :
Federal State Local Total
Drug Dependence Unit- $574,000 $146,000 $720,000
Drug Dependence Institute' 317,174 _ 317, 174
NARC02 87,468 87,468
Project Enough (for 4 months) $150 150
Number Nine, 35,000 35,000
Youth Crusaders, Inc 6,000 6,000
Total.. 891,174 283,468 41,150 1,165,792
' Funds for DDI are separate than those received for the Drug Dependence Unit. $139,025 is used for national training and
$178,149 for the New Haven area.
2 These funds are received in addition to those through the Drug Dependence Unit
Thus, a total of $1,165,792 is being spent on these programs alone and it comes
nowhere near meeting our needs. The Methadone Maintenance program which
637
now handles 200 people at a cost of $4.75 per person per day could easily be
doubled. Daytop could use a second facility to handle another 50 people at a
cost of $9.50 per person per day. NARCO has been told it will lose about $33,000
in funding from the State and needs that much plus $50,000 to renovate its
detoxification center. The use of Naloxone at the Out-Patient Clinic is now avail-
able to only 15 people ; funds for 75 additional people at $10 per person per day
could be utilized immediately. The $50,000 now being spent on outpatient services
for acid and speed users could be tripled. Neighborhood centers to provide preven-
tional and educational centers, alternatives and referrals are needed. In other
words, a tremendous amount of money is needed right away for New Haven
barely to begin to meet its needs.
THE ROLE OF THE FEDERAL GOVERNMENT
Legislation for treatment efforts is in place. The item lacking is funding.
Other than possibly consolidating the programs in a single office in HEW,
instead of the current situation in which they are in the Office of Education,
the National Institute of Mental Health and the Office of Economic Opportunity
no new legislation would appear to be necessary, rather increased appropriations.
More funds are also needed for the grants administered through the Law Enforce-
ment Assistance Administration of the Justice Department which provide
money for drug abuse programs.
Enforcement efforts at the local level are not and cannot be sufficient to deal
with the problems of the availability of drugs. We cannot stop the Mow of
drugs into our cities because the flow into this country is not under control.
Greater enforcement efforts are needed along the countx-y's borders. More
customs officers and more stringent procedures for searching incoming goods
and ti'avelers could greatly decrease the amount of available drugs, especially
heroin. In addition, the dispensation of drugs through doctors and pharmacies
should be much more closely regulated. Each should be required to submit
reports to the government on all drugs distributed through them. This could
greatly reduce the abuse of amphetamines and narcotics.
It must be realized that any of these efforts are stop-gap in nature. The need
for drugs or any other outlet stems from pi'Oblems in our society. These are
problems which I would not presume to define but which cannot be dealt with
through anything short of a national effort. What is it in this country or in
human society that makes man turn to drugs or alcohol or any other escape
mechanism?
I appreciate the opportunity to submit this testimony to you and hope that
we can find a way for this country to deal with this serious problem.
[Exhibit No. 26(e)]
Statement Submitted by Joseph F. O'Neill, Commissioner, Police
Department, Philadelphia, Pa.
The narcotics problem in Philadelphia, as in every other area of our Nation,
h,as increased substantially in recent years. This is reflected in the dramatic jump
in the number of offenders arrested for narcotic violations as indicated in the
following table:
Total
lear: arrests
1965 ,928
1966 1446
1967 1871
1968 3047
19G9 3828
1970 7218
Based on current arrest rates, approximately 10,000 persons will be charged
with narcotic violations in Philadelphia during 1971.
iCertainly this tenfold increase in narcotic arrests Is cause for concern. From
a police view, narcotics activity today requires a major portion of police man-
power for the detection and apprehension of persons involved in the sale, posses-
sion and use of narcotics in the community. Also a significant amount of other
crime is generated by narcotics addicts who must frequently commit property
60-296 — 71 — pt. 2 20
638
crimes to obtain the necessary money to support tlieir habits.. Although precise
data is not available, knowledgable estimates inclieate that Ijetween 25 percent
to 40 percent of all property crimes are committed by addicts.
The Philadelphia Police Department realizes that any realistic reduction in
narcotic addiction and narcotic-related crime will only come when treatment
and rehabilitation programs work effectively. Past experience in treatment pro-
grams indicates a very low success rate in keeping the majority of addicts from
returning to the use of narcotics.
The city of Pliiladelphia, like most other communities, has a number of pro-
grams and agencies offering different approaches to the many problems of nai'-
cotic addiction. A variety of approaches is needed to handle the many variations
in the needs of addicts.
However, centralized coordination of these programs must be provided to
achieve the maximum benefit from these various programs. Coordination will
help insure a balanced and more effective approach to treating addicts.
Coordination of programs \\'ill also assist in the evaluation of the efficacy of
the diffei-ent methods of rehabilitating addicts. There has been little done to
measure how successful treatment programs have been in dealing with the
problem of addiction.
In some situations, several treatment agencies must compete and try to obtain
funding from the same source. Funds might be from the Federal, State, or local
governments as well as from private foundations. If treatment programs were
measured and evaluated, maximum results could be achieved from limited fund-
ing programs.
The funding of treatment programs for narcotic addicts must lie greatly
expanded to provide the size of programs needed in most communities today.
While the 7,218 narcotic arrests during 1971 involved about 6,000 individuals,
there are only about 120 beds available for inpatient care and perhaps pro-
grams on an outpaient basis for less than 1.000 people. These figures indicate
that we are only treating a small portion of the addicts who are detected by
arrest.
Expansion of rehabilitation programs for addicts is absolutely necessary if we
are to reduce the scope of narcotics addiction in our society.
Successful treatment programs will strengthen and reinforce police activities
in curtailing narcotics addiction. Without proper rehabilitation efforts, nar-
cotics usage will continue to increase in the years ahead.
Philadelphia Department of Public Health,
Office of Mental Health and Mental Retardation.
Philadelphia, Pa., July 7, 1971.
Hon. Claude Pepper,
Chairman, House Select Committee on Crime. House of Representatives, Wash-
ington, D.C.
My Dear Mr. Pepper : In response to the request from Mayor James H. J.
Tate for information about the drug addictive problems in Philadelphia which
was forwarded to the Office of Mental Health/Mental Retardation, Department
of Public Health, I am pleased to provide you with the following information
concerning the question of drug addiction problems confronting our city.
I deeply appreciate this opportunity to discuss wiith you the needs for drug
addiction treatment and rehabilitation within the Cit.v of Philadelphia. The
social costs of drug addiction and almse are inunense. The activities that illicit
drug users must be involved in to support their haliits represenrs a staggering
cost in terms of lives lost and property destro.ved. There are few reliabh* stati.'^tics
reporting the number of drug addicts or heavy abusers; we must therefore resort
to estimates. A rather conservative estimate of the number of heroin addicts in
the city is put at 20.000 : another 35.000 to .50,000 are heavily abusing barbiturates
and/or ;nniibetamines. The cost to society in terms of jirojierty stnliMi iiee<led
to support these habits I'uns into ninny millions of dollars in Pliiladelohia alone.
Narcotics arrest figures add another measure of the growing epidemic of drug
addiction and abuse sw(>ei)ing our Nation. In tlie city of Philadelphia, arrests
for narcotics have increased dramatically since 1005 when 02S arrests were
made (including 23 juvenile arrests), to 1070 when there were 7,21S arrests
639
(iucludiug 902 juveniles). In 5 years the total arrests for narcotics has increased
almost sevenfold; even more dramatic is Ithe rise in juvenile arrests which
during the same 5-year period increased over 38 times ! This rise in reported
arrests represents a real increase in the numbers of individuals using heroin,
rather than a product of any significant change in law enforcement practices.
Statistics collected by the oflfice of the medical examiner for the period
January 1 to September 30, 1069, reported 79 deaths due to narcotics and nar-
cotics-related causes: for the period January 1 to September 30. 1970. there were
135 such deaths, an increase of 58.5 percent 1 Operating on the generally demon-
strated correlation between the number of narcotics- related deaths and the total
number of heroin users, it can lie reasonably concluded that heroin use in 1970
exceeded that of 1969 by a substantial margin, which predicts an even greater
increase for this year.
It is essential that a coordinated and extensive system for the treatment and
rehabilitation of drug addicts and abusers be developed in the Nation's urban
areas. Because of the nature of the problem of illicit drug abuse, new modes
of treatment must be incorporated. Since the modes of treatment often differ in
individual effectiveness, a broad .spectrmn of programs and services is needed.
The key agency for drug addiction treatment and rehabilitation in the city of
Philadelphia rests with the department of public health, office of mental
health/mental retardation. It is this agency which is charged to coordinate and
plan for an overall city treatment system. In order to mount an effective cam-
p.aign to meet this pressing issue, a multimodal system of drug treatment and
rehabilitation is required. This deliveiy system should include facilities, serv-
ices, and programs such as :
1. Outpatient treatment centers. — These include outreach programs, methadone
maintenance, counseling, group therapy, vocational training, and family
counseling.
2. Inpatient beds and emergency faeilities. — Detoxification is an essential ele-
ment in rehabilitating many drug-dependent persons. In addition, the addict
often requires inpatient facilities for related health problems requiring the serv-
ices of a hospital. Inpatient beds are also required for emergencies from drug
overdoses.
3. Therapeutic communities. — The therapeutic community is a facility coming
into wider use for the treatment of addicts. It is usually a long-term modality,
with re.sidential services as a part of an overall therapeutic program. Tliese
facilities often employ group encounter techniques, individual counseling and
treatment.
4. Halfway houses. — These programs are valuable for helping the drug-free
individual to assume a new role and life style before complete reentry into the
comnumity. Therapy and group encounter are main components of service.
5. Day care centers. — Day care centers allow the addict to live in the com-
munity, yet spend a large portion of his day hours in the facility where treat-
ment and rehabilitation of differing modalities can be offered and prescribed for
the individual.
6. Research, education, and training. — A major effort is requii-ed for ongoing
research into the nature and modes of treatment. Prevention must be organized
on a community scale including the family and schools. Training programs for
addicts, professionals, and paraprofes-sional should also be a part of an overall
approach to develop commiuiity resources to deal with the growing drug problem
To date, the impact of present efforts holds encouragement for the future.
The city's office of mental health/mental retardation presently funds three
methadone treatment units with approximately 900 patients and a waiting list
of 900 additional patients. Two additional facilities .scheduled to open within
the next 2 months will be able to handle another 400 patients. The rolls for these
new programs will undoubtedly fill up in a short time adding further to the
community's disenchantment with the ability of treatment facilities to keep pace
with the drug problem. Other programs operating in the city are not presently
part of any coordinated system, the range of services is limited, and most have
extensive waiting lists.
In order to deal with a situation, the magnitude of the drug problem in the
city of Philadelphia would require a coordinated effort in treatment and re-
habilitation programs and a commitment of large amounts of money. It is esti-
mated that to provide a system of treatment using the modalities outlined for only
25 percent to 50 percent of those affiliated with drug problems would cost $15
640
million to $25 milliou per year. This cost is considerably lower than the estimated
costs of crime and law enforcement related to drugs.
In order to begin to tackle the drug menace, an insurgence of interest and
money is required. The costs of adequate services are such that most loeaiities can
ill afford to make available necessary funds to cope with the needs. The Federal
role must be aimed at the problem center, the large metropolitan areas. Large
amounts of direct funds for ail modes of treatment are required in addition to
continued support for research to develop better treatment modalities. These funds
should be channeled to responsible agencies able to secure a balanced approach
to treatment and rehabilitation.
The drug problem is nationwide. It is not limited to the ghetto or the inner
city, but strikes across all segments of society. Its destructive aspects, if allowed
to continue, could disintegrate the cities and the very fabric of society, the
family. The tragedy of many thousands of young people in Philadelphia forced
into criminal life style to support their habits, the broken homes, the destroyed
families emphasize the need for extensive action now with a high priority.
Sincerely yours,
Leon Soffeb, Ph. D.,
Deputy Health Commissioner.
[Exhibit No. 26(f)]
Statement of Walter E. Washington, Mayor, District of Columbia
I would like to thank this committee and its chairman for giving me the
opportunity to discuss the problem of drug addiction in the city of Washington,
and what the city's additional needs are in coping with this serious problem.
It is estimated that there cui-rently are approximately 17,000 heroin addicts
in the District of Columbia.
Presently, the Department of Human Resources' Narcotics Treatment Admin-
istration, headed by Dr. Robei-t L. DnPont, has 3.500 of the city's addicts in
treatment. This represents a dramatic increase over the 150 addicts who were
in treatment a mere 15 months ago. Our plans are to increase treatment to 5,500
addicts by July of 1972.
The Narcotics Treatment AdminLstratioai, (NTA), is Wa.shington's first com-
prehensive and city-wide narcotics treatment program. In addition, it is the
largest, multi-modality agency aimed at treatment of heroin addicts in the
country. There are several different treatment approaches, each of which is
determined by the individual's needs as shown after examination, counseling, and
pationt-staff consultation. These include: abstinence, methadone detoxification,
methadone maintenance, and urine surveillance. Each is backed up by urine
surveillance and individual or group counseling.
It is my understanding that Dr. DuPont has testified before this committee
and has provided you with more detailed and technical information regarding all
aspects of our heroin treatment program including our planning for the future.
Even though we are extremely pleased with the progress we have made in the
past 15 months, we could further increase the amount of addicts treated if
additional funds were made available.
As .vou know, the District of Columbia has been fortunate to receive Federal
financial assistance. To date, we have received approximately $4.5 million in
assistaiice for our narcotics treatment program. The District government, itself,
has also made substantial contributions of its own towards providing an adequate
treatment program to deal with the city's heroin problem. Allocalions for this
purpose have been $.3.1 million including fimds for fi.scal year 1972.
We realize that the heroin epidemic that exists here in Washington is not a
unique phenom.enon, but a serious problem that is plaguing all our Nation's cities.
We do believe, however, that our treatment program has taken a le;idership role
in the treatment of heroin addiction. And, we would like to continue this role and
go even further.
We know that there are critical areas that need additional and large-scale
attention.
First, is the need for preventive education and information. We nuist not only
treat those who have been drawn into the maelstrom of heroin addiction, but
we must also work to prevent those vi'ho have not yet become involved with drugs.
An effective program of education and prevention would help to achieve this.
641
Second, ia the need for ancillary and rehabilitative services for the addict who
is receiving treatment. Treatment is an important step in breaking the addict's
drug dependency, however additional services are needed to help tliat person to
be able to function without heroin. Such ancillary and rehabilitative services
will help the addict to become a functional member of the community.
Third, is the need for special programing and services for youth. Thirty-one
percent of Washington's heroin addicts are under 20 years old. We must develop
a total range of programs and services aimed at their problems and needs.
These issues and others are liighlighted in a recently released report of the
Professional Advisory Committee on Heroin Addiction in the District of Colum-
bia. This committee was appointed by Philip J. Rutledge, Director of the De-
partment of Human Resources to study and analyze the District's present narco-
tics treatment program and recommend improvements or changes needed to
make the program more effective.
In addition to raising several important issues, the report provides an excel-
lent background and review of the types of problems that the Washington com-
munity is facing in attempting to mount a large scale heroin treatment program.
Many of the people who contributed to the report have expertise in the diiig
problem area, and you might want to elicit their testimony for your commit-
tee's study.
Heroin abuse and addiction are complex problems. The needs of the addict are
varied. The solution to the addict's problem, so far, is only fragmentary.
However, we believe that the effort we have made towards treatment and
rehabilitation, while not wdthout I'isks, has produced humane and constnictive
results. We are anxious to expand our efforts and broaden our spectrum ot
treatment modalities, because we will never really be a true success until the
plague of heroin addiction has been cured in our city.
We in Washington, as well as those in other cities, are trying to commit as
many of our resources as possible to curing this epidemic. But in these times
where funds are short, we will need help. And if the national plague of heroin
addiction is to be stopped, the Federal Government will have to commit itself
to underw^riting the financial help.
Afternoon Session
Chairman Pepper. The committee will come to order, please.
Our last witness today is Dr. John C. Kramer, who serves as assistant
professor in the department of psychiatry and human behavior, and in
the department of medical pharmacology and therapeutics, at the Uni-
versity of California at Irvine.
Dr. Kramer received his medical training at the University of Cali-
fornia at San Francisco and served his internship at Kings County
Hospital in New York. He is certified in psychiatry by the American
Board of Psychiatry and Neurology.
From 1966 to 1960, he was chief of research at the California Re-
habilitation Center, and is presently a staff psj'chiatrist at Orange
County Medical Center.
From 1967 to 1969, he served on the review committee of the NIIMH
Center for Studies of Narcotic and Drug Abuse.
lie is the author of numerous articles on drug abuse.
We heard this morning the chairman of the Narcotics Commission
of New York; we are particularly anxious to have you speak about
your experience in the State of California. As you have noticed, we
have had the Governors from Northern and Southern States this morn-
ing and a middle State, so we are trying to get an overall ^dew of the
magnitude of the problem and the massiveness of the approach that
must be made if we are to solve it.
We are very grateful to you and welcome your statement.
Mr. Perito, would you care to examine ?
642
Mr. Perito. Thank yoii. Mr. Chairman.
Dr. Kramer, you have submitted to the committee a report which
relates to an iipclated version of an article which af)peared in the New
Physician in March of 1969. Is that correct ?
STATEMENT OF BH. JOHN C. KRAMER, ASSISTANT PROFESSOR,
DEPARTMENT OF PSYCHIATRY AND HUMAN BEHAVIOR, DE-
PARTMENT OF MEDICAL PHARMACOLOGY AND THERAPEUTICS,
UNIVERSITY OF CALIFORNIA, IRVINE
Dr. Kramer. That is correct ; j^es.
Mr. Perito. Mr. Chairman, at this point, I wonld ask that that ar-
ticle which has been submitted as a statement to the committee be
incorporated in the record.
The Chairman. Without objection, so ordered.
Mr. Perito. Dr. Kramer, you have been kind enoufrh also to prepare
a summary of your testimony and I would ask at this point that you
proceed, with the permission of the Chair.
Dr. Kramer. Thank you. I would like to read that.
In an introduction to a book on prohibition, the historian, the late
Richard Hofstadter said : "Reformers who be^fin with the determina-
tion to stamp out sin usually end by stamping out sinners.''
Since about 1920, in the United States we liave been stamping out
heroin addicts without stamping out heroin addiction.
In this statement I address myself to the treatment of addicts already
made with full awareness that ideally we should attempt to prevent
the process from ever starting.
P^very treatment ever offered for opiate dependence has had some
individual successes. It is important to keep in mind that when people
with an emotional investment in a particular progi-am make their case
]nil>licly, or before such forums as congressional connnittees, they show
their successes and not their failures.
Regarding civil commitment programs, notably those of California,
Xew York, and the. Federal Government, T note that they liave l>een
structured so that a patient sj^ends a period of time, usually a number
of months in an inpatient facility and is subsequently placed on parole
subject to close scrutiny regarding his general behavior and drug use.
For the most part these programs have opted for complete abstinence
in their patients. Tliese programs are very expensive; the Federal
program, for example, costs in excess of $10,000 per patient-year for
inpatient care, and $2,000 to $3,000 per year for outpatient care. The
Xcw York and California ]')rograms have had veiy little success in
I'ehabilitating their clients. Tlie Federal ])r()grams have ai)])eared so
far to be more successful, but this may be in part accounted for by
massive rejection of difficult candidate^, and because aftercare is con-
tracted out to local agencies Avhich are paid in part on the basis of
the numl>er of ])atients they retain.
Despite its limitations some form of cixil connnitment j^robably
should be retaine<l as a last resort for patients who fail in other
programs.
Sf^lf-help groups such as Syiuinon, Daytop, Gateway, and others
have proven to be ^•ery useful l)ut for a limited number of addicts.
643
Regrettably, few addicts volunteer for these programs, still fewer are
accepted, fewer yet remain, though of those who remain, a moderate
j:>roiiortion succeed. From the point of view of the mass of American
addicts, these groups, it appears, will play a modest role. These pro-
grams too are very expensi\e.
^lethadone maintenance — and potentially narcotic antagonist — pro-
grams are the most widely accepted among opiate depen.dent people
and have proven, beyond a doubt, to be the most elfective teclmique to
control addiction. Methadone maintenance, even on the pharmacologic
level, is not merely a switch from one addiction to another. The long
action of methadone prochices a stable physiology as opposed to
a roller coaster physiology with intravenous heroin. Tens of thousands
of addicts are now waiting to get on such programs and camiot because
of the lack of available facilities. I might point out that I have about
220 patients on my own program in Orange County, Calif., while
450 are waiting to get on. I have been unable to put additional patients
on for the last 3 months because of the lack of facilities which ulti-
mately resolves down to the lack of funds.
For purposes of treatment, heroin addicts can be divided between
those with a relatively short addiction history, that is less than_ 1
or 2 years, and those on the other hand with a long history, that is,
beyond those limits and especially those who have repeatedly relapsed
into addiction. Those witli shoi-t addiction histories, in general, might
best be handled through individual interaction programs, such as
Daytop, Synanon, and j^erhaps by narcotic antagonists; those who
have beeii long-time addicts will probably, for the most part, be best
handled in methadone maintenance programs.
The Federal Government can assist in the treatment of narcotic
addicts by supporting :
(1) Detoxification facilities. In most communities with an extensive
heroin problem there is serious shortage of hospital space even to allow
an addict to get oft' his drug with no further treatment.
(2) Massive facilities to provide methadone maintenance to all ap-
propriate candidates should be provided as promptly as good manage-
ment allows. Federal funds will almost certainly be necessarv for this
purpose.
(3) Nonestablishment rap centers and self-help programs must have
support. One problem of such facilities is their distaste for recltape,
of making formal applications, and of sending in formal reports.
(4) As programs multiply there will be a need for trained staff.
One or several national centers for training a wide variety of profes-
sionals and nonprofessionals should be supported through Federal
funds. In addition the Federal Government might support a faculty
member at each medical school who will devote himself to training and
educating physicians and other medical personnel. A career support
program might facilitate this.
One reason for the range of opinion among specialists in the drug
abuse field has been the inadequacy of data collection, both of program
results and of the ongoing drug scene. Any Federal effort should pro-
vide a system of collection of data particularly from federally funded
programs but also from other programs.
Though new research is alwa^'s necessary, there are two projects of
critical immediate importance; one is the development of a long acting
644
narcotic antagonist, and the other is the final testing of a long acting
form of methadone.
It is also time, I believe, for the Federal Government to bring an end
to a fiction, a useful fiction, but nevertheless a fiction, nainely that
methadone maintenance is an experimental procedure. This fiction is
necessary in order to, in effect, license m.etliadone maintenance pro-
grams. Continued close control over such programs is uncjuestionably
necessary. It should, however, be done through licensing rather than
through its retention as an investigational procedure.
Spending lots of money will not alone assure a good result. Lots of
money may be necessary, but good planning must go with it.
Mr. Perito. Doctor, I take it from your statement that you have
severe reservations about the present concept of the IND number as
presently structured through FDA.
Dr. Kramer. I have reservations about it only in that it is a fiction
and that certain disadvantages in the use of this treatment are caused
by this fiction. I have tried to emphasize that control is necessary,
but it should be done through a legitimate procedure rather than, as
I say, through a subterfuge.
Mr. Perito. In other words, you do not believe that since there are
30,000 addicts being treated under a methadone maintenance approach
that the FDA is seriouslv making a determination as to whether the
drug is in fact, safe and efficacious.
Dr. Kramer. I know that thev are making such statements. I read
one such statement in the press. The American Medical News published
a letter from the public information director of the FDA in which he
insisted that it was, in fact, an experimental procedure. jMost of us
involved in the study of methadone maintenance would disagree, I
believe.
Mr. Pertto. Do you think substantial disadvantages flow to the
physician as a result of the present system of allowing methadone
maintenance only under the investigational new drug permits?
Dr. KRA]vrER. I think that it increases the difficulty in initiating and
expanding legitimate pi-ograms.
Mr. Perito. Doctor, based upon your experience, would you say
that antagonists have a j^lace in civil commitment programs?
Dr. Kraimer. x\ntagonists ?
Mr. Perito. Eight ; do you believe that antagonist drugs, like cyclazo-
cine, naloxone, have a place in the treatment armamentaria of
physicians ?
Dr. Kramer. I believe any useful technique to control addiction has
a place in civil commitment programs; yes, including the use of nar-
cotic antagonists.
Mr. Perito. Do you know, based upon your experience, whether
narcotic antagonists are being used in civil commitment programs in
California?
Dr. KRA:\rER. I am reasonably certain that they are not being so
used. They may be used for detection, the so-called Nalline test is used,
I believe, in Los Angeles County. But in terms of a treatment proce-
dure, to the best of mv knowledge, they are not being used in civil
commitment programs in California.
^Ir. Perito. Doctor, you have a substantial ex]:)erience Avith the civil
ccnnmitment piT)gram in California. Based upon your experiences, do
645
you think that it is possible to structure an involuntary civil commit-
ment program which will produce results, results in the sense that
you will increase the number of people being substantially helped?
Dr. Kramer. Yes, I believe that civil commitment programs can
be structured so that the success rate will be substantially increased.
I think this can be done through reasonable and extensive use of all
the modalities that we currently have available, including methadone
maintenance, potentially including narcotic antagonists, potentially
including Synanon-type programs.
One of the problems in the civil commitment program in California
is that in the so-called group therapy meetings, the man's likelihood of
depaiting from the institution depended on what he said in the group
meeting. This encouraged a certain amount of deception on the part of
the patients.
Mr. Perito. Have the treatment approaches changed with the passage
of time since the inception of civil commitment programs in
California ?
Dr. Kr.\mer. Yes ; there have been some changes. I think a genuine
effort is being made on the part of the people who are running the
program. I have never denied their desire to make their program
successful.
The changes for the most part have been procedural rather than
substantial. The one most promising aspect of this is that the California
Department of Corrections, which has the authority over the civil
commitment program, has on its own initiated a methadone mainte-
nance program, both for civilly committed addicts, and for feloneously
committed addicts, and has in the last year or so allowed their parolees
to be admitted to methadone maintenance programs.
I might point out that about a year ago, we had to go to court to ask
to have a patient of ours admitted to a methadone maintenance pro-
gram and I must say that though we lost in the courts, the pressure of
the publicity probably forced the change on the part of the parole
board.
Mr. Perito. The committee has heard some limited testimony on
the NARA program, Narcotic Addict Rehabilitation Act, which I
know you are familiar with. By and large, I think it is fair to capsulize
it that the implementation of the act has not been particularly success-
ful, has not spanned a broad range of treatment approaches, nor has
it been able to help that may people. Based upon your experiences, why
do you think that NARA has not done so well ?
Dr. Kramer. I pointed out in my statement that from the informa-
tion that I had, which is now about 6 months old — I have not gotten
more recent information — they seemed at least at the beginning to
be doing a little bit better than the California or New York programs.
One reason that they have not done even better, perhaps, is because
those running the program seem, frankly, rather antagonistic to the
methadone maintenance approach. When I spoke with one worker in
the NARA program, he almost apologized for the fact that they had
several patients on outpatient status who were receiving methadone
and he did not in fact include them in his list of successes.
Mr. Perito. Do you think the States on their own can structure
programs in the civil commitment area vrithout substantial help from
the Federal Government ? Based upon your experiences ?
646
. Dr. Kramer. From what I have seen in Califoniia and New York,
it would require an expenditure of a vast amount of money. New York
State, to tlie hest of my recollection spent, I }>elieve, about $70 million
just for capital expenditures to initiate their civil commitment pro-
gram. I think that it would be too expensive at a time when States are
tryino- to conser\^e funds wherever they can.
To o-et behind that question a little bit, I would also say that there
are many other approaches which are more likely to be of greater value
that States should exhaust the variety of other j^ossibilities before ini-
tiating civil commitment programs.
About a year or so ago, in speaking to some people in the State of
Michigan, they asked me the same question. My response to them, put
very simply, was that until they discover how effective a massive
methadone maintenance program would be, they should not start a
civil commitment program. Only when they had taken these other
steps, should they look into the expansion of ci^^l commitment pro-
grams.
Mr. Pertto. Dr. Jaffe, in testifying before the coimiiittee, said that
if he had only a limited amount of money to spend and was charged
with the responsibility of effecting the best possible results — that is
the reduction of crime and the reorientation of the addict into society
and into a productive lifestyle — he would spend such limited funds on
methadone maintenance. Would you agi-ee with that conclusion 'i
Dr. Kramer. Unquestionably.
INIr. Perito. Dr. Jaffe has been doing research on a new drug which
T know you are aware of, acetyl-methadol, a longer lasting metha-
done. Have you done any similar type research in California?
Dr. Kramer. Not with the long-acting form; no. There are very
few people who have. Jaffe is one.
Mr. Perito. Based upon your experiences, do you think that this
drug or a drug similar to it in morphological structure, offers hope?
Dr. Kramer. One of the major problems in the management of
methadone maintenance programs, as this committee is aware, is the
illicit diversion of methadone and any technique that can be developed
which will reduce the methadone or the illicit diversion of the drug
should be sought and certainly a long-acting form of methadone is one
technique to minimize if not to eliminate diversion of the drug.
Mr. Perito. I would just like to direct your attention briefly to an-
other area. The committee has heard a fair amount of testimony about
narcotic antagonists, particularly cyclazocine, nalaxone and M-.505O.
Based ujion your experiences, do you think that money channeled
inio those areas would bo well spent ?
Dr. KRA:\rER. I think that money channeled into these areas wcnild be
indeed well spent and regrettably, from the information that T have,
almost nothing is being done at the present time to develop a long-act-
ing form spocifically of nalaxone, which to mv knowloda-e is the most
promisinjr fori^ of narcotic antau'onist. T was in contact just yesterday
with Dr. Max Fink, who undoubtedly you know, has been working in
this area and almost nothing is being done. There are many things in
the area of drug abuse which, are shameful, but T think that the fact
that so little money is being supplied for this effort is one of the most
shameful, because we have here a tool which has a very high likeli-
hood— it is not certain, Imt it has a very high likelihood — of being ex-
647
ceptionally useful, not only for the long-term addict, but particularly
for the short-term addict, for whom we have no other tool similar to
methadone.
Mr. Murphy (presiding). Let me interrupt you a minute.
Doctor, what type of money are we talking about? What in your
opinion would be a realistic figure to start with as far as pure research
is concerned ?
Dr. KR.\:krER. For the development of a long-acting form, nalaxone ?
Mr. ]\IuRPHT. Right.
Dr. Kr.\mer. I would guess in the terms of half a million dollars for
the development which would take, I believe, about 2i/^ to 3 years.
Mr. INIuRPHY. Dr. Resnick, in testimony before this committee, testi-
fied that he thought that within a year's time, an expenditure of be-
tween $5 million and $10 million on on the part of the Federal
Government would produce positive results in the form of an
immunization drug to prevent future heroin addiction. Do you have
any comments with regard to that ?
Dr. Kramer. Again, the only thing that I know about that specific
piece of research is what I have read in the newspapers.
The idea of immunizing someone against heroin addiction is a very
interesting one. It is a bit more of a "blue sky'' proposal than some of
the others that I have mentioned. But certainly, it is one which is most
interesting and should be pursued.
Mr. ISIiTRPHT. Doctor, in your testimony here, you say that the Fed-
eral Government facilities have massive rejection of difficult candi-
dates. Could you elaborate on that a little bit ?
Dr. Kramer. The figures that I recall — and again, these are about
6 months out of date — were that about 60 percent of those individuals
whom the courts sent to the NARA I and III programs were rejected.
The reasons were for such things as certain physical diseases, psychosis,
and one of the reason, I think perhaps the fifth or the sixth out of
five or six, was a lack of true motivation. This certainly is an um-
brella under which anybody who does not appear to be a good candi-
date can be rejected. What good motivation is, I am not sure, be-
cause particularly in methadone programs, we have seen some very
poorly motivated people do very, very well.
This is the information as best I have it.
Mr. Murphy. In your statement on page 3, No. 2, you say massive
facilities to provide methadone maintenance to all appropriate candi-
dates. Are you not su^gestino- the same thing these Federal institu-
tions are by saying — you call it appropriate candidates. I think then"
terminology is — I forgot what it was — difficult candidates. Are you not
talking about the same thing ?
Dr. Kra3ier. No ; I tliink that some of their good candidates would
be good candidates for methadone maintenance, but some of their
bad candidates would also be good candidates for methadone
maintenance.
I do not want to get into the l)ox of being solely an advocate of
methadone maintenance because I feel that a variety of approaches are
necessary, as I have stated. The issue is that, as Mr. Perito quoted
Dr. Jaft'e, if you have got to bet on one horse, methadone is the horse
to bet on. Certainly, if you have got the capacity to put your money
on a number of horses, there are a number of things that you can put
(348
your money on, but methadone maintenance can't be forgotten, be-
cause it is the most likely procedure to engage an addict. It is the
most likely procedure to lead him into a productive and crime-free
life.
Mr. Murphy. Doctor, I am glad to see that you suggest that a col-
lection bank of data, particularly from federally funded programs,
be instituted. I think my colleagues here and the expert witnesses we
have that have testified before us liave all suggested this. Seemingly,
this is one thing we all agree on, that we are not collecting all our
information.
Have you any ideas how we could do this ?
Dr. Kramer. In order to gather the maximum amount of data, you
have to have a handle on the people who potentially can provide it.
The only handle that is generally available to the Federal Government
is if they give the money, they can insist on the answers. In addition,
nonfederally funded programs might have the opportunity to seek
special grants to provide personnel who will assist in compiling a
variety of information for the use of tlie program as well as for sub-
mission to the data bank. The data banks may be set up on a regional
basis with some sort of a central bank, perhaps, here in Washington.
Some degree of regionalization may be appropriate, because the kinds
of programs, the extent of drug abuse, differs from one part of the
country to another.
Mr. Murphy. Comisel suggests the confidentiality element involved
here, that we are revealing — obviously if you are starting tallc —
about collecting data, you are revealing names, et cetera. The Governor
of Georgia stated today that the Army was reluctant to turn over to
him information about fellows who were about to be discharged who
are addicts because of the confidential nature of that infoniiation.
How would you handle that ?
Dr. Kramer. Absolutely, I believe that any law which is written
which provides for the collection of such infomiation must mclude
an absolute provision for confidentiality — I would underline that- —
must be built into it or else the individuals involved in collecting data
will be reluctant, patients will be reluctant to go into programs that
they fear might reveal them.
The importance of collection of data is not the importance of finding
out specifically who the individuals are, but rather understanding
the problem as a scientific one.
Mr. Murphy. Thank you. Doctor.
Mr. Perito. Just two more questions, Doctor.
We heard from Dr. Frances Gearing and she revealed some very
impressive statistics about the efficacy of the methadone maintenance
approach as far as the reduction of crime is concerned for those addicts
under treatment. Do you know of any similar studies of efficacy of
treatment modality related to reduction in crime rate on diiig-free
therapeutic approaches ?
Dr. Kramer. Yes; the civil commitment program in California
also reported on the reduction in convictions of individuals on out-
patient status in their ]Drogram and it sliowed a fairly marked de-
crease in convictions. The problem in this particular data is that in
practice, when someone committed to the civil addict program in
California is rearrested, even on new charges, often the new charges
649
are not pressed when the civil commitment authorities decide to return
the man to CRC, the civdl commitment inpatient program. Prosecutors
feel that is sufficient; they drop the charges. This is, perhaps, one
reason why there was a reduction in the crime rate.
In addition though, it is possible that the very close parole super-
vision itself, even with the people on parole from the civil commit-
ment program, does have an effect in reducing crime. Credit should
not be taken away from the program, because they may deser^'e it.
Mr. Peijito. Doctor, do you think that lack of proper aftercare
facilities has injured the effectiveness of some of the NARA treatment
programs ^
Dr. Kramer. I am not familiar with any information which would
suggest that the aftercare facilities are inadequate. From what little
I have heard, and again this is hearsay, the aftercare facilities for the
most part are rather good in the NAIiA program. They are well run,
as far as I know, with serious and concerned people running them.
Mr. Perito. One final question. What do you think has been the
biggest roadblock to the problems confronted by the abstinence
programs ?
Dr. Kramer. The roadblocks to the abstinence programs are based
in a well-known but little understood fact; that is, that once an in-
dividual has been seriously addicted for a relatively prolonged period
of time to opiates, the desire to reproduce that opiate effect is so
persistent and powerful that very few people have successfully given
up their drug.
Mr. Murphy. I think the ranking minority member might have
some questions.
Mr. Wiggins. I will yield to Mr. Blommer.
Mr. Blommer. Doctor, I believe that California is pix)bably typical
of the Federal institutions that contain a number of addicts, and I
am talking about prison institutions, a number of heroin addicts that
for various reasons are not receiving any type of treatment. Is that
correct ?
Dr. Kramer. Yes ; of course.
Mr. Blommer. Do you have any suggestions as to programs that
might benefit a man who is in prison for maybe a very long period
of time, looking toward the day when he will get out ?
Dr. Kramer. I do not know of any specific inpatient programs —
incarceration programs, perhaps, would be the better term — which will
better insure a result when the man gets out of prison. One thought
that I did have, which I do not think is apropos at this moment in
our history, but potentially may be apropos sometime in the future —
3 years, 5 years, 10 years — is that when we learn better techniques to
retain addicts on the street so that they do not go back to opiates,
reconsideration of certain individuals who have been imprisoned for
very long mandatory minimums might at that point be made — both
Federal mandatory minimums and State mandatory minimums.
A man, for example, who is sent up for 20 years in 1971 on perhaps
a third sales "beef" may in 5 years still be facing 15 years mandatory
minimum and yet we may have the technolog}^ which will, though
not guarantee, which might, let us say, offer at least a 70- or 80-percent
chance that he will be a useful citizen. I think that it is not the an-
swer to your question, but I take the opportunity to mention it.
650
I know of no techinque in prison right now available to better assure
the I'esiilt when the man gets out.
Mr. Blommer. That is all the questions I have, Mr. Chairman.
Chairman Pepper. Mr. Wiggins.
Mr. WiGGixs. I regret, Doctor, that I was not here at the beginning
of your testimony. I want to say a word of welcome to a fellow Cali-
fornian. In reading your resume, it is clear that you are a Californian
through and through. I take small comfort only in the fact that when
you were required to do clinical research in psychiatry, you had to go
elsewhere, to New York and other States.
Doctor, I have observed in California in recent years a proliferation
of community-based drug efforts, some of which are attempting to use
and perhaps are using methadone as a tool. Are you satisfied that there
are sufficient competent people in the communities in California to
conduct these programs on a medically acceptable level?
Dr. Kramer. Mr. Wiggins, the term "community based programs"
in general refers to abstinence ):>rograms for the most part. Methadone
programs generally are not referred to as community programs.
If you are referring to the methadone programs which are cur-
rently in operation in California — may I ask you which you are
referring to?
Mr. AViGGiNS. All right. To be more specific, in my district, almost
all of the communities are concerned about a recognizable drug prob-
lem within their jurisdiction. Community-based groups — by that I
mean not county-supported nor State-supported, nor federally sup-
ported, so far as I know, although they all seek funds from any of these
agencies — have sprung up, often under the direction of the city council
initially. Sometimes it is a PTA or coordinating council group. But
in many cases, the group is created from local citizens.
In two instances in my district they have rented facilities and are
now undertaking some sort of treatment program for people who de-
scribe themselves as drug abusers. There has been discussion about
methadone. I would hope that they are not to the point of dispensing
it, even for detoxification purposes as yet, but there has been discus-
sion about that. That is the kind of situation I am thinking about.
Dr. Kramer. I see.
Yes; there are a number of community-based progi'ams. There are
a number in your district, several in your district, that I am aware of.
There are many more in northern California than in southern Cali-
fornia. They have talked about the use of methadone.
Earlier, I discussed the problem of, in essence. Federal licensure —
not a licensure, but an FDA permission— to do methadone mainte-
nance. In addition, in the State of California, as you knoAV, we have
a research advisory panel which is con\'ened under Califoi-nia law
which must a])i)rove each methadone maintenance program. There is
a group of seven indiA'iduals who very carefully screen each program.
If anything, it has been, in my observation, that they are careful to
the point of being picky about certain very small issues that seem to
me to be petty. Nev- rtbeless, this has been their practice, as far as I
know.
Mr. Ed O'Brien, who is the chairman of that committer and a
deputy attorney general of the State, continues lo be very careful
about dispensing permission to do methadone maintenance. They
651
have, at least at the present time, with perhaps 18 or 20 programs going
in the State, very close supervision. I, myself, was visit-eel by a neutral
faculty member from another university in the State who examined
the program. Those programs which have been granted permission
to provide methadone have been very carefully scrutinized and as far
as I can tell, this scrutiny will continue.
Whether the program is community centered, whether it is spon-
sored by a private organization, as at least one in the State is, or
under any other auspices, methadone programs are carefully screened.
I can sa}' this because I am also a member of the advisory committee
of the UCLA program, which is a small research program, the Los
Angeles County program, and a private program run at a psychiatric
hospital in the town of Rosemead.
Mr. Wiggins. You spoke a moment ago about the absence of drug
programs in prisons to deal with an addict population which is very
large in the prisons of California. So far as I know, there is no legal
prohibition against using LEAA funds for that. Do you have any
obser\"ation as to why the California Council on Criminal Justice
has not recognized that as a priority in developing its State plan for
the spending of LEAA funds ?
Dr. Krajier. The only reason that I can conceive of is that no
request has been made. I think that the CCCJ — ^the California Coim-
cil on Criminal Justice — makes grants only when requests are made
to it for funds. I am not aware that they have gone out and solicited
such grants.
I think that some of the people in corrections might better be able
to answer that question for you.
^Ir. Wiggins. Thank you very much, Doctor, for appearing and
testifying.
Chairman Pepper. Mr. Sandman ?
Mr. Saxdmax. Doctor, in your State, you have quite an institution
at Corona. Are you familiar with the one there?
Dr. Kramer. I was the chief of research there for 3 years.
Mr. Saxdmax^. Well, I am sorry, I did not hear you testify on
that.
Now, as between whether or not someone who is criminal!}^ com-
mitted enters Corona or San Quentin, for example, what is the differ-
ence that is made there ?
Dr. Kramer. The difference is sometimes difficult to determine, ex-
cept that there are certain individuals who, because of excessive crimi-
nality, because of a history of violence, because of certain other exclu-
sionary reasons, are prohibited from entering CRC. Prior to that, it
will depend in part on the judge and in part on the individual himself.
Either the judge or the district attorney or the man's attorney or the
man himself may make the suggestion that someone who has been con-
victed, either on a misdemeanor or a felon}-, should be considered for
civil commitment.
Mr, Sandman. I am not talking about civil commitment. I am talk-
ing about criminal commitment. Does it make a difference whether or
not it is a felony ?
Dr. Kramer. For someone to go to the addict program ?
Mr. Sax^dmax". Can a felon who is also an addict be sentenced to
Corona as well as San Quentin?
652
Dr. Kramer. Yes, sir. As a matter of fact, at the last count I made,
about 75 percent of the individuals at the institution had an immedi-
ately preceding felony conviction which was held in abeyance on the
basis of their civil commitment to Corona.
Mr. Sandman, Now, if that is the case and if Corona, as far as I
laiow — that is probably the one that has the finest treatment of people
who are inmates in the country. Is that a fair statement ?
Dr. Kramer. I think that ''finest" is a term which can be interpreted
two ways. Tlie}- are ver}' humanely treated. The thrust of some studies
that I did while I was at CRC indicated that in fact, tliey were not
successful. The fineness of the treatment of the people, if it is judged
by the result, was unfortunately not very fine.
Mr. Sandman. That is what I want to get to, the result. Compared
to other States, I know of no other State that has an institution such
as Corona ; do you ?
Dr. Kramer. Yes ; New York Sate has. The New York State civil
commitment program was to some extent modeled after the California
program.
Mr. Sandman. Are you talking about Daytop Village?
Dr. Kramer. No, sir; I am talking about a civil commitment pro-
gram. There are 20 or 30 facilities with perhaps 100 or 200 individuals
each in them. The individuals are civilly committed by the courts of
the State of New York to these facilities. This is a program which is
comparable to the California program.
Mr. Sandman. My only purpose in asking the questions about this
is there have been others testifying that there should be some treat-
ment given in the prisons for the addict, which of course, at the pres-
ent time, in most States, there are none. I agree with that statement.
Plowever, in your State, at least at one institution, Corona, you do
have special treatment that is given to the addict inmate; correct?
Dr. Kr^imer. Correct ; yes, sir.
Mr. Sandman. Now, you have testified that even that treatment,
which 1 understand is very expensive, has not worked.
Dr. Kramer. Yes, sir; that is correct.
Mr. Sandman. Is that a true statement ?
Dr. Kramer. That is a true statement.
Mr. Sandman. Now, if that is a true statement, how do we Iniow it is
going to work any better if we do put it in the prison system ?
Dr. ICramer. My response to Mr. Blommer's statement was — he
asked did I know what we should do for felon addicts, addicts who
are currently residing in prison ; should there be any therapy for them.
Perhaps I did not make it clear enough, but my response was I did
not know of any therapy within the prison that would fa^'orably af-
fect the outcome of the prison stay. I am not saying that there is no
possibility of developing any.
Frankly, I do not know of any therapy available from group thei-apy
through extensive Freudian psychoanalysis, were it to be applied in a
prison program, Avhich would help once the man got out of prison. I
suggest, however, that tlu^re are useful techniques which might be
available once the man hits the street again.
Mr. Sandman. Do you feel that this kind of a program would be
Avorth while?
Dr. KitAMER. A program within the prison ?
G53
Mr. Saxdmax. Within tlie prison.
Dr. KR.VMEH. As far as we know riglit now, it would l)i' a wasteof
money. I am not sayi]ii>- that we mi^-ht not look ijito the possibility
that some experimental programs might not be set up. I think that we
should. But to say that we ought to in some sort of massive \yay provide
money for in-prison treatment, there is no evidence that it will help
anv.
Mr. Saxdmax. If you had sueli treatment in any of the prisons, such
as San Quentin in your own State, it would be somewhat along tlie line
of wliat vou have at Corona, would it not i
Dr. Kkaimer. If T were to do it, I would do it a little bit differently,
l)ut I suppose there would be more similarities than diff'erences.
Mr. Saxdmax. Within the prison itself, you could hardly do it
much difl'erontly : I mean that is the point.
Dr. Kramer. Yes, sir.
Mr. Sandmax"^. Do you believe that the hardened addict should be
se]:>a rated from other prisoners ?
Dr. Kr..i3iER. I have not thought about that very much and I really
do not know. I cannot answer that because I do not know \\hether they
should or should not be.
Mr. Sand^iax'. There has been a great deal of written materia] that
claims that addicts when they are incarcerated, their primary conver-
sation deals with drugs and anyone who has not been exposed to drugs
who is in that kind of environment is moi-e or less excited to a point
where he may try it. Do you not run this danger by mixing the hard-
ened addict with the nonuser ^
Dr. Kramer. I think that is a very real possibility. Certainly it is
the logic of the situation.
Mr. Saxdmax^. Do you think it is a real danger ?
Dr. Kramer. I do not know whether it is a real danger. The logic
is there. Whether in fact it happens to any extent, any great extent,
I do not know.
Mr. Sandmax. I yield to my colleague.
Mr. Wiggins. I was just curious as to the reasons why programs in
prisons would be unsuccessful. I would like to know if it is because
of the prison environment or just because of the ]iature of the beast,
that we do not have anv wav to truly rehabilitate our addicts?
Dr. Kr.\mer. California is a very advanced State in regard to its
prison system, its penal system. I have worked with many of the
people in the State department of corrections. They are far advanced
beyond most other States. Among the problems that they face in
trying to discuss various issues with their clients is that ^^ matter
of the group meetings may influence the man's status in prison. This
reservation may be sufficient that any sort of group therapy loses its
effectiveness.
One of the bases of any sort of psychotherapeutic interaction,
whether individual or in a group process, is the preservation of a
kind of absolute honesty that I think is discouraged in a prison set-
ting. It may be that some teclniique could be developed to encourage
it, for example by eliminating any of the prison personnel that have
anything whatever to say about the man's status in prison; possibly
to bring in individuals who have no administrative powers Avithin the
fiO-296 — 71— pt. 2-
654
prison and who liave no — wlio agree not to commnuicate anything tiiat
ffoes on in the groups to the prison authorities.
I think that some efforts have 1)een made, I belie\e in a Xevada
State prison, possibly in one or two California State prisons, where
Synanon was l)ronght in. This may conceivably have been nsefiil there.
The point that I would like to make here is that T am not saying that
I think it will never be useful, that no technique mi 11 1)0 de\eloped.
What I am trying to say is that to the best of my knowledge, at this
point in time,' the technic[ues that have been tried probably do not
markedly influence the ultimate success.
Perhaps I might add to this some studies by Valliant out of the
Federal system, suggesting that there is value to a ]:)eriod of imprison-
ment folfowed by close parole supervision. In other studies, whether
the individual Avas locked up in pi'ison or in some sort of therapeutic
settina" was unimiwrtant. The variable that made the dilfereuce was
close parole supervision afterward.
Some studies in California by Geis from the De|>artment of Sociol-
ogy, California State at Los Angeles, also suggested that there was
nodiilerence, for example, between the ex-CRC, the civilly committed
addict, and the felon committed addict. Both of them, one that went
through therapy in the institution, one that had no therapy in the
institution, went out, both receiving close parole suj^ervision: that if
anything, the felon i)arolees did slightly better than the CKC parolees.
Tliere Arere certain other differences. The felon parolees were slightly
older. There were some differences that might account for the slightly
better result with the felons, but this suggests that what hap])ened in
the institution had much less to do with it than that they were fol-
lowed by parole.
jMr. Sandman. You talked about a drug called naloxone. I was not
here for your earlier testimony. Could you very brietiy describe that,
comparing it with methadone :'
Dr. KiJAMER. Yes: nalaxone is, of course, a narcotic antagonist. It
Is not (le])endency producing. It negates the effect of any opiate used.
Of itself it has no agonistic effects, no pharmacological effects on the
body alone exce])t to negate the effects of opiates. It is a most ])roinis-
ing drug, especially if it were put up in a long-acting form. A point
that I tried to emphasize earlier before this committee was that an in-
sufficient amount of work is currently going on to develop such a long-
acting antagonist. Work on a long-acting nalaxone is, to the best of
my knowledge, at a standstill, desjiite the fact that occasionally peo
pie state that work is going on. To the best of my knowledge, very
little, if any, work is going on because of a lack of money.
Chairman Pf.i'per. Did you say, doctor, that according to yoni- in-
formation, the research on the development of naloxone is relatively
at a standstill in the country?
Dr. Ki;.\:\rKK. Yes. sir.
Chairman l*F.i'rER. Do yon not regard that as a ])romising drug?
Dr. Kramer. I regard it as a highly ])romising drug and I regard it
as shameful that it is currently at a standstill. ])articularly considei'-
ing the crisis that we are facing.
]\rr. Sand^iax. Have you. or anyone connected with you, done anv-
tliing to promote more of a real job on this pai'ticiilar drug?
655
Dr. Kramer. Dr. Max Fink is a colleague, a friend oi' man}' years
standing-. This coUeaoue and friend has devoted honrs and hours and
days and weeks and time and etl'ort to promote the de^-elojnnent of a
long--acting" form of naloxone and has met Avith a sJiainefnl hick of
support.
Mr. Sandman. At this point, Mr. Chairman, I wanted to bring that
point forward. I lieard him say this before. I think that this is some-
thing that our committee could certainly recommend, that there be
more experimentation done on this particular drug, because as a
member of the profession and certainly somebody avIio knows what
he is talking about, he lias testified tliat this thinn- is at a standstill and
yet it is regarded as one of the nujre promising drugs.
Now, Dr. Casriel mentioned a drug called Perse. Do you know any-
thing about that ?
Dr. Kramer. The only thing I know about it is wluit 1 have learned
from counsel to this committee.
Mr. Sandman. Thank you, that is all.
Chairman Pepper. Mr. Winn ?
^Fr. Winn. To change tlie subject a little bit. Doctor, and I, too, am
sorry I missed your testimony, a fact sheet that we have in front of us
says that you are well qualified to i>resent material o]i the psychology of
an addict and that much of your ex])erience is quite relevant to areas
such as ways to cope with veterans returning frorii Vietnam who are
addicted to narcotics. I am sure that ]\Ir. ^lui'phy, who has done a lot
of work in this field, brought that subject up when he was questioning
you. Would you expound n little bit on that for those of us who missed
your earlier testimony in that general field ^ Because we are very con-
cerned about tliese returning Aeterans.
Dr. Kramer. The returning veterans are a Aery serious problem.
Among the statements that T liaAc made is included a statement that the
methadone treatment is not suitable for individuals Avho have been
using heroin or other opiates for a relatively short time and I think
that most of the returning vetei-ans Avho jii-e addicted fall into this
category.
Mr. Winn. Excu.se me. What do you call a short time ?
Dr. Kramer. Less than 1 or 2 years.
Mr. Winn. Less than ?
Dr. Kramer. And Avithout a history of repeated failure. P)Oth those
pieces are important. And most of the veterans fall into this category,
I would assume, which means that if I were to advise as to AA-hich ap-
in-oach to take, the sort of a))i)roach that I Avould tend to faA'Or Avould
be the self-help group model — that is, Synanon. Daytop„ GateAvay
model Avhere there is indiA'iduid confrontation amor^g individuals
themseh'es who haA-e this problem. In addition, narcotic antagonists,
Avhen fully developed, may aid in their treatment.
Air. Winn. Could they do this, in your o})inioii, after their release
from the service and after they have taken these new tests. Could
they control this or handle this thijjg fi-om 30 or 40 A-etei-ans hospitals,
or in your oi)inion, do you think it Avould be a success or a failure?
Dr. Kra:vikk. That is a ])j-ediction that I really can't make.
Mr. Winn. Well, take a guess, Uc'-siuse your guess A\c)uld be tAvice
as o-ood as ours.
65G
Dr. KT?A:\rEij. 1 suspect tliat tlie snrcess rate would be modest. I
would suspect that certain individuals would not o])t to txo into a ^'A
hospital for any one of a variety of reasons.
I would also take this opportunity to su<i;iiest the possibility that
Federal laws ]ni2,-ht be enacted or amended to ])ei-mit, throuii'h some
sort of mechanism, that a fee be paid on behalf ol" the veteran — )iot to
the vetei\^n himself but on behalf of the "veteran — for treatment at
varvin<2: facilities, which might include comnuuiity-based programs,
mio-ht include methadone programs for those who ure suital)le, that
might be applied to any }>rogram, which is api)ro\ed for treatment
and to wdiich ceitain \'etei'ans would go.
jNIr. AYixx. Whi<'h might be closer to their home than the veterans
hospitals could probaldy lie: right?
Dr. Kkameij. Closer to tlieir home and [)()tentially, more fa\()rable
as far as the man himself is concerned.
]\rr. Wixx. Have you dealt with \ery many veterans ?
Dr. Kr.A?.iER. I have not dealt with verv many. Amon<>- other thinii's.
I operate a methadone maintenance program and we liave several
veterans in that program.
Mr. Wixx. From the psychology studies that you are aware of on
the Vietnam v<^terans, do you thiidv that these v(^terans are going to
want to kick the habit Avhen they return to the States? Do you think
they are going to want rehabilitation? What do you think their opin-
ions v.'ill be?
Again, T am just askiiig you for guesses, because we ha\-e a lot f)f
work to do in this field.
Dr. Kka3iek. I would giiess thnt just as soon as tlie r.ian has spent
his accumulated ])a_v and bonuses on. heroin and has to ]mll his first
I'obbery or cash his first bad clieck, he will be very strongly moti\-ate<l
to seek some sort of hel[) in ending his habit.
Mr. Wixx. All right. Do you tliink that we should lun-e an edu-
cation program wlum they are being phased out or being released
from the service that would ]ioint out what they might expect, or are
th(>y so professional on the subject that you do not have to tell them
that as soon as your money runs out. boys, and you spend your back-
iniy, you Avill be going to (he streets lilcc the rest of the addicts, I'obbing
and so on ?
Dr. IvKA.AiKi;. 1 think that it ccrtaiidy can't hurt, if it is ])r<)duced
in a sensible and not too ju^■enile waj''.
]\rr. Wixx. Tt would have to be very adult. They get these movies
when they go into the servic(> on vai'ious things that they are going
to be faced Avith and the i)robabiliti('s and possibilities. I just wonder,
out of curiosity, if we might woi-kuj) a lilm that would jiist lav it on
thcline, what they might be faced with wlicn tliey come (iiil.tliosc (hat
considei- themselves addicts?
Di-. Kkaaikr. T certainlv do not thii»k it Avould hurt and it might
hel]).
^Ii". Wixx. I have ne\ei- heard it mentioncMl l)efore. ^fr. {Miairn)an.
Tt just sort of came oH' the top of my head.
Dr. l\]i.\.Mi;ij. I think a certain amount of c<lni-a(ion is impoitant,
hopefidly not just aftei- the men be-ome addicted, but e\('n before.
1 (hink (hal tlicre has bi-cn a failure of connnnnicat ion to the ti'oo[)s
657
ill Southeast Asia tliat heroin is as addictive when inhaled as wlien
injected,
^Ir. Wixx. I do not understand.
Dr. KijAMER. TJuit heroin inhaled, sniti'ed, in powder form, is as
addictive as it is wlien injected.
Mr. "Wixx. Is that the waj' they arc taking- it ?
Dr. Ki;.\:\nn;. They are inhaling- it in powder form.
Mr. "Wixx. Is this done because they cannot trace the inhaling
as Avell ^ " -^ !'■■
Dr. Kii.urKii. Xo; inhaling because perhaps they do not have the
injection apparatus, and because the heroin is so i)otent that they can
easily get the desii'ed elfect by iidialing or smoking the heroin.
Mr. Wixx. And they do not lia ve the needle marks i
Dr. Kramer. And they do not have the needle marks. It is just the
way that the drug culture has unfortunately develo]ied in Southeast
Asia; this is the technique of ingestion that the culture has developed.
One of the reasons that it has develo])ed this way is that there is the
assumption that when snitfed or smoked, heroin is not addicting. In
fact, it is highly addicting, almost as highly addicting if not as highly
addicting, througli that route as through being injected.
Mv. "Wix-x". "Well, now, they are getting a more perfect type of heroin
ill that part of the world, and when they get back to the United States
and if they are still addicted and they get some of the junk that is
i)eing sold on the sti-eets, they are not going to realize tii(> high that
they have had over there. Is that true ? ' •
Dr. Kramer. That is correct; unless they do inject it directly
and perha])s not e^'en then.
INIr. Wixx. Because it is ]iot as good a tj' pe.
Dr. Kram]:r. Because of lower potency.
Mr. Wixx. That is what I Avas trying to grapple for but I could
not come np with the words. Well, Dr. Kramer, I appreciate your
coming from California, to api)ear befoi'e this committee and I think
you have given lis some new thoughts and some ditferent ideas that
the committee lias not heard before. I thank yon.
Tliank you, l^lv. C^hairman.
Chairman Peeper. Thank you. ^Ir. Winn. Dr. Kramer, this morn-
ing, representatives from the State of Xew York testified that the State
of Xew York Avas sjjending in fiscal year 1972 for treatment and re-
hiibilitation of addicts of heroin and major drugs $180 milliou. Could
you give us a conrparable figure for the iState of California ^
Dr. Kramer. I cannot oifhand. I do not know what was included
under this umbrella in the statement of the gentleman from New
York.
Chairuiau Peiter. The ligure that I gave you excluded law enforce-
ment.
Dr. IvRAzyiER. Did it include, for example, the Dole-XySAvander pro-
grams. Daytop Villag(\ and so forth ?
Mr. Peuito. Yes, sir.
Dr. Kraaier. I will liaAe to think Avhen I talk because I was not
|)rei)ared for this; I do not have the figures. I will try to get as many
ojf the top of my head as I can think of.
The civil cfjiniiiitment jn-ogram in the State of California costs
iiltout II luillioii ;i year. Tlie State of California may, to some extent,
658
support some of the inethadone proo-rams and some other proirrams
to a ratlier modest degree throncrh a matcliin*;- plan in wliicli tlie State
pays for 90 percent of mental liealth care. I am sorry, I don't know
how much is beino; s]>ent. T would certainly guess that the total sum
is far, far less than that being s]>ent by the State of Xew York.
Chairman Pepper. Do you regard the treatment and rehal)ilita-
tion programs for narcotics in California today as adequate to the
needs ?
Dr. Kramer. Absolutely not. 1 do not know of any place in the
TTnited States, Avhether city or State, with maybe one or tAvo rare
exceptions — possibly the State of Oregon — in which there is any-
where near adequate treatment for narcotics addiction.
Chairman Pepper. You ha\e coveied ]xirt of the question I wanted
to ask in your comment to ISir. Wiggins. But I would like to have
you state again, what kind of treatment and reliabilitation facilities
do you regard as the most desirable? And how widely should they
be spread ?
Dr. Kramer. Tlie most desirable in terms of cost etf'ecti\eness?
Chairman Pepper. Yes; in terms of eifectiveness in dealing with
the problems.
Dr. KiLVMER. In terms of eifectiveness in dealing with the problems.
Mr. WiNX. Excuse me, Mr. Chairman, could we have both, effec-
ti^'eness and cost effectiveness ?
Chairman Pepper. Yes ; give us both.
Dr. Kp^vmer. I think both can be still put under the same rubiic,
which at this time, is methadone maintenance.
Chairman Pepper. Should that be administered by a clinic or some
sort of institution or should the methadone bo prescribed by physicians
or both ?
Dr. Krais[er. At this momeiit in time, I think individual }<hysicians
are not prepared to handle methadone maintenance programs. I think
that the only kind of exception that I would provide is if we ha\e a
single addict who lives somewliere up in Stanislaus (,\)unty and he is
the only addict in town, he should not l)e required to move down to
Stockton to get treatment. I tliink a special exception for an indi-
vidual physician caring for a specific patient might be made in such
circumstances. Ikit 1 think that I)y and large, programs should be run
programmatically rather than by individual physicians.
Chairman Pepper. And should services be rendei'ed to the addict
other than just administration of a drug, vhether it be antagonistic
or detoxifying drug ?
Dr. Kramer, Yes, sir; I think anything less is very minimai (reat-
ment. I think that methadone programs or narcotic antagonist pro-
grams do need additional services, additional aid, wliich should be
tailored to the individual patient. Tliere are certain indi\idual pa-
tients who require very little additiomil treatment. They get theii-
methadone and they lead their V\y{^.> ([uite satisfactorily. The majority
do need other assistance, -whether it is psychological ov job findiug or
legal or othei'wise.
Chairman Pepper. Now, Dr. lloger Smith, wlio headed up one of
the treatment and rehabilitation facilities in the Haight-Ashbury
section, said the same thing you did in sulislauce. tilthough he added
it Jieetl iu)t nt'cessai'ily be a public clinic, it could be a pi-i\ate clinie.
659
if properly operated iiiider ])roper supervision of public iuithorities.
Would you agree ?
Dr. Kramer. Yes, sir; I would indeed. We have one such program
in California. There are several similiar programs in other States
which are privately run, I believe generally on a noni:)rotit basis, though
I believe there may be one or two which are even prolitmaking institu-
tions, supported by outside contributions and the patient's fee ; yes, sir.
Chairman Pepper. Now, Dr. Smith also stated, as I recall it, that
these facilities should be a\ailable in almost every community where
there was a narcotics problem. When one of the Governors testified here
this morning, I believe Governor Carter of Georgia, he said addicts
did not Avant to go across town where they had to get in a bus or a taxi,
you get more im'olved where they are more or less connnunity facili-
ties. Do vou agree ?
Dr. Kramer. I certaijily agree. Some of our patients have to travel
three-quarters of an hour each way to come to our ju-ogram. When
they must come very, very frequently, it is certainly an imposition on
their time, particularly the ones who linally do get a job.
Chairman Pepper. Xow, just two more questions. One is, what can
Ave do to get most of the addicts into the treatment program? Dr.
Jaft'e told me j^ersonally that we would get al)0ut 50 percent, maybe,
of the addicts into a voluntary program. Would you agree? Has that
been your experience? ITow can we get a larger number of addicts into
an effective program ?
Dr. Kramer. At this moment in time, I think that were I to guess
about what proportion of all long-term addicts, again over a year or
two, would come, for example, into methadone or other programs, I do
not care which, the overwhelming majority Avould go into methadone
programs. One thing we do not kno^^•, we do not know A^hat AA'Ould
happen Avhen Ave finally get those 50 percent into treatment.
What I find, for example, is that a man aa'Iio has been uiiAvilling to
come into a treatment program sees seA'eral of his friends in a treatment
])rogram. He has denigrated tlie vnhm of the program. He sees his
friends Avho are noAv not going to jail, aaIio are leading decent liA^es.
He then comes and asks for help. I suspect that Ave might find
that larger and larger numbers of addicts Avill present themselves if
Ave proA^ide effective programs.
One situation may shed some light on this. Because of the support
of the Governor of Oregon, extensiA^e methadone facilities Avere made
available in that State. It Avas estimated that Oregon had l)etAA-een
250 and 300 addicts. They noAv have roughly oOO patients on metha-
done. I am not saying that they have all the addicts in the State, but
I think this might be a testing grouiid, a community in Avhich there
are a relatively limited number of addicts which might lie a microcosm
for all other programs. We iniglit be able to learn something from
people in Oregon as to hoAv completely people are Avilling to come
into a program Avhen the doors are open and anybody avIio needs it
and is appro])riate for this can get treatment.
So far, Ave have not been able to take care of the addicts that Ave
haA^e.
Chairman Pepper. Would you recoimnend any kind of hiAv that
would refjuire anyone involuntarily to be brought into treatment in a
program if he Avere found to be a heroin addict?
660
Dr. IvKAisrKK. 1 believe that I would Diodifv tliat somewhat. It may,
as a last resort, be neeessai'V. However, civil comDiitment for addiction
sliould ncA l)e based merely on the presence of addiction, but should
be based also on a degree of addiction which clearly causes the indi-
vidual to rej)eatedly violate the law or repeatedly seriously endanger
his life and health, a man who has been repeatedly hospitalized with
o\-erdoses, someone who has i-epeatedly been iinprisoued for crimes
related to liis addiction. Commitment should be based on more than
mere addiction, more than mere suspicion of addiction.
Chairma)i PF.rpEU. This mornimr, CIoA-ernor Carter of Georgia told
us that his State has a law which authorizes the judge, when a person
is convicted of a crime, to give that individmil, you might saj', a sen-
tence or an adjudication that he must take a prescribed course in respect
to that addiction as an alternative to being sent to prison. Does Cali-
i'ornia lune such legislation?
Dr. Krameu. Yes. sir. The ci\il commitment jirogram. in essence,
encompasses that; that is, the person convicted of a crime, usually a
felony, occasionally a misdemeanor, will in lieu of execution of sen-
tence, be civilly committed for tivatm.ent to the civil addict program.
This, in essence, is the same as you described for the State of Georgia.
. Chairman Pepim:r. We have learned that the Army, if I understand
correctly, is instituting a [)rogram to test a veteran before he is
discharged, a veteran from Indochina, let us say, befoi'(^ he is dis-
charged and perhaps keep liim oO or GO days after they discover that
he is a heroin addict. Do you consider that a sufficient length of time
to assure anyliody's ichabilitation or a cure for taking heroin i
' Dr. IvRA^iiE];. It certainly does not assure a cure. There was a meet-
ing last weekend in San Francisco, A representative from the Defense
Department Avas thei-e and I quote only from what I heard him state.
This is the extent of my knowledge. The question arose, what if, at
the tei-mination of a man's enlistment, addiction is dis(;overed, what
do you do? Do you kee]) liim foi- some ])rolonged period of time — 6
months, let us say — ^so that a cure is more assured than if you keep
him a shorter ])eriod of time? This would run into the problem of
keeping a man far beyond his enlistment. A good deal of concern
would be felt about that by both the men involved and people con-
cerned with a vai-iety of other issues.
Should the man I)e discharged immediately? In this case, the Federal
Government may be accused of tli rusting addicted men on society. A
period of o, (5, T days is usually sufficient to eliminate the serious
withdrawal sym|)toms. Anothci- -2 or ') weeks wouhl fuither help re-
duce the probability of immediate readdiction.
It does not sihmu. at tlie ju'eseut time, to be an univasonable request
in terms of its being either too long or too short. The i-epresentative.
of the Defense Dt>])ai-tment indicated that should a longer or shorter
period be indicated by future experience, this pei'iod miglit be clninged.
This statement seemed to me to l)e a ivasonable one.
Chairman Feiu'ek. The last question. Doctor. A number of ])eople
liave mentioned to nu- that they thought oui- committee should recom-
mend a ])rogram of heroin maintenance to heroin addicts, making two
principal arguments:
(1) They were not concerned about the addict, thev were con-
cerned pi-imarily about stopj)ing the addict from committing crime.
661
(2) And second, that that would be the way to get tlie addict into a
central place or to some place where he coulcl be identified and where
maybe he could be subjected at least to persuasion to take part in a
treatment program. Would you give us your comment on those sug-
gestions that were made to me ?
Dr. Kra:mek. The experiment which is being proposed in New York
City, is an experiment rather than a treatment, the objective of which
is, as you said, to bring the man into treatment who would not other-
wise come into treatment ; it is heroin maintenance onh^ in the sense
that the man will be initiated on heroin and after some limited period
of time would be transferred to either a methadone program or an
antagonist program, a Phoenix House program, or back out on the
street if he so chooses.
When I first heard of this, my first response was that it was pre-
posterous. On subsequent reflection, it seemed to me to have a few
limited merits. One of the few merits it had was that it might induce a
few people into treatment who might otherwise not come into treat-
ment. As a scientist, I would certainly say that such an experiment de-
served a trial. But it should be very carefully monitored and the serious
disadvantages, very serious disadvantages of heroin maintenance must
also be balanced.
I sat down and I tabulated on a double column bookkeeping basis
the advantages and disadvantages of such an approach. Nine disad-
vantages came to mind and I had to stretch a point to find four advan-
tages. I still would suspect that some investigation might be fruitful,
even if it shows that it is useless.
Chairman Pepper. Thank you very much.
xVny other questions ?
Mr. Winn. Mr. Chairman, I do not want to drag this out and Dr.
Kramer has been very generous with his time. But I am intrigued by
his idea of a fee, because if we are going to get to this problem fast, the
other programs that I have heard mentioned could not take care of the
influx that we are going to get.
Do you have any idea, again as a guess, how much of a fee per addict
would be needed ? Now, I know you have some who have long histories
of addiction, I suppose, and they are harder to get off hard drugs than
those addicted less than a year.
They are not ?
Dr. Kramer. I was shaking my head because I was thinking of some-
thing else.
Mr. Winn. This might be impossible, but I am just vrondering are
we talking about $100 a person, $200 a person ? What kind of fee would
we be talking about ?
Dr. Kramer. Well, I would assume that one would be talking on a
time- fee basis, so and so many dollars per day, week, month, or year.
I think that this would have to be tailored to the nature of the program.
On average, for example, a methadone program would cost about $1,000
a year. An inpatient-facility-type program might cost $3,000 or $5,000
on an annual basis, though the individual might not have to remain
in the facility for a year. There are some programs which are much
more expensive.
If it were an inhouse treatment, at the Langley-Porter clinic in San
Francisco, for example, the cost would be $86 per day, I would not sug-
CO-296 — 71 — pt. 2 22
662
jrest that the Veterans' Administration support that sort of fee. But
there is a range of fees depending on the program.
Mr. Winn. Well, could the Government, going tlie other way, sub-
contract on a fee basis or a contract basis to private clinics and public
clinics so much for an individual addict? Could that be a possibility?
In other words, there would be an agreement between the Government,
the clinic, and the addict ?
Dr. Kramer. Yes ; of course. I tliink some sort of mutual agreenient,
rather than that specifically between the Government and the clinic, or
perhaps with some sort of approval system, the mechanics
Mr. Winn. It lias a lot of possibilities.
Dr. Kra:sier. Absolutely.
Mr. Winn. Thank you, Mr. Chairman.
Chairman Pepper. First, we want to thank you very much. Doctor,
on behalf of the committee, for coming here and sharing your vast
experience and knowledge with us in our effort to grapple with v.hat
I consider one of the most serious problems facing our country today.
I imagiiie you vrould agree with that?
Dr. Kramer. Yes.
(Dr. Kramer's prepared statement follows :)
[Exhibit No. 27]
Pbepabed Statement of De. John C. Kramer, Assistant Professor
University of California (Irvine)
lEdited and updated from an article which appeared in the New Physician, March 1069]
Whatever the intent of the Harrison Narcotic Act and other related Federal
and State laws and their judicial and administrative interpretations, one of
the effects during the last half century has been to obstruct and inhibit the
nianagement of opiate dependency by the medical profession. Though the en-
forcers of the narcotics laws have been subject to most of the criticsm for the
state of affairs, their influence would not have been so great had a substantial
proportion of physicians demanded that doctors retain their legitimate preroga-
tives in the treatment of addicts. Through the years some physicians and social
scientists have persisted in expounding alternate views. All have been castigated,
many have been harrassed and a few have been martyred, mostly for contending
that addicts should be treated by doctors, that maintaining addicts on narcotics
might be an acceptable management technique and that some officials of Uovern-
ment had misrepresented some of the facts.
The contention tJiat strict enforcement of .'^trict laws has been extremely use-
fol is summed up by the claim that since the Harrison Narcotic Act the opi;ite
addiction rate has been reduced to one-tenth what it was I)efore 1ttl4. This con-
tention is erroneous in several resi^ect.s. Fir.st, the reduction in rate is umertain
because of the questionable nature of most such estimates. Still, if we choose to
utilize estimates it is only proper to utilize comparable ones, and if comparable
estimates are used we find the reduction in rate t(^ be closer to one-third than to
one-tenth. Second, if one considers who the addicts ai-e. wliat becomes evident is
that though opiate addiction has diminished among iinddle-class. middle-aged
whites, it has actually increased among people who are yotnig. lower class, black
or brown, and male. 'Third, in the course of the years opiate addiction, once a
moderately serious pergonal problem with moderate socia' signitkance. has 1k--
come a personal catastrophe and a social nightmare. And lastly, we must ob-
serve that we have never tried moderate enforcement of reasonable drug control
hiws. We went from a time just before World War I when anyone could pur-
chase any opiate freely, over the counter, to a time just after World War I when
for example, a physician was arrested, prosecuted, and convicted for prescribing
one tablet of morphine and three tablets of cocaine to an addict who was suffer-
ing from withdrawal symptoms.
There may well be some optinmm combination of legal enforcement and nuxii-
cal control over drug abuse problems. From 1914 to 1020 we went, in one bound,
663
from too little control to too much. And subsequently we erred still more. Ob-
seiTing that drug dependence was not being adequately controlled, and was in
fact getting worse, we increased the penalties, assigned more police to drug
enforcement, and moved .still fnrtiier from an optimum bulance of legal eoutro,l
and medical management.
In the last 10 years though some changi's have taken place, it has not l)een
without opposition. For example, Synanon has been harassed by neighbors and
local officials who felt that their presence would be dangei-ous and corrupting,
and methadone maintenance programs have been opposed by enforcement officials
and some physicians who could not back down from a position held for 40 years,
that maintenance for addicts was unethical, im.moral. unworkable, and illegal.
Other kinds of treatment programs, though less actively opposed, are often
viewed by the hardliners as pitifial attempts on the part of do-gooders to cure
what they "know" to be an incurable vice. Often acceptance of new programs
by the hard-liners is conditional upon the guarantee that they will not be used
iiy addicts to escape any long mandatory minimum sentence which has been
imjjosed.
5s'^evertheless, new programs have been initiated and more are on the way.
Some are under medical auspices, others are run entirely by religious groups or
ex-addicts. They are still inadequate in number to accommodate all the potential
clients. It is impossible to say what proportion of drug users will ultimately use
such programs when they become available; traditionally much ijessimism is
expressed in regard to opiate addicts' utilization of such programs, yet those
programs which have been established in recent years, though differing from
each other in approach and philosophy, have uniformly been encouraged by the
willingness of many opiate users to accept help and the substantial numbers of
them who have benefited from this help. Though different in approach all the
new voluntary programs share at least two common characteri.stics : respect for
the opiate user as a person, and an enthusiastic optimism that he can be helped.
Change will be slow. Though professional workers in the field recognize tlie
need for reform., there is little doubt that most Americans, knowing no other
way, accept and endorse current laws and ixdicies, and there are influential and
concerned i>eople who are resi.stant to nonjudicial approaches to drug-abuse con-
trol. It i.s one thing for the U.S. Supreme Court to declare addiction a disease
but qtiite another for it to be handled as such.
Part of the problem is that it differs from disorders generally accepted as
diseases. Vhe major conceptual obstacle to accepting addiction, or better, drug
dependence, as a disea.se is that it is usually self-initiated and self-sustained.
Other diseases seem to be thriLSt upon the victim from the otit.side. Yet there
may be less willfulness in becoming drtig dependent than it seems. Initially the
motivating force may be curiosity or proving one's boldne-ss or for social accept-
ance or as a protest against the conventions of the larger community ; foolish
l)ei-hap.s, but not criminal. Once initiated, the drug tise may be self-perpetuating.
r)ependency -producing drugs are by definition strong reinforcers and the desire
to renew the drtig effect can be powerful enough to carry the user beyond ques-
tioning the propriety or the legality of his actions.
Whether or not it is more nearly an illness or more nearly a crime, a pragmatic
society which views a particular form of behavior as threatening will take action
to eliminate, or at least minimize the detrimental effects of the behavior. Ini-
tially in a mood of puritanical rectitude and subsequently in a mood of panic,
otir .society chose a course of punitive prohabitionism.
THE SOCIAL PHARIIACOLOGY OF OPIATE DEPENDENCE
Currently, opiate dependence is eqtiated with the regular intravenous use of
heroin ; though this is now the most common form of opiate dependence in the
United States, other patterns of opiate use have been favored in other places and
at other times. Opiates exi.st in several forms ; there are several routes of admin-
istration : the life style and social class of the user may vary : and the social
acceptability of drug use may differ. All of these variables may be combined in
different ways and produce vastly different consequences to the user, to his
immediate social group, and to the larger society.
California law, for example, lists 72 different opiates from crude opium through
semipurified products to purified, semisynthetic and synthetic preparations. The
form of the drug, to some extent, dictates the way it will be used. Crude opium
is usually .smoked though it may be eaten, and is less likely to produce a dis-
abling dependence than are the "white drugs" like morphine or heroin.
664
opiates may be ingested in several ways. Oral use is simplest and widely
used, but it has several disadvantages as far as users are concerned. Onset of
effect is slow and the surge of euphoria (or relief) which characterizes the more
direct routes, is absent. Some opiates lose potency orally, and crude opium is
rather nauseating both becau.se of its central effects and its direct irritant
properties. Because rather large quantities of the drug can be taken orally it is
pos.sible to develop considerable physical dependence by this route.
SnutUng powdered heroin or inhaling the fumes of vaporized heroin has had
periods of popularity. Evidently it is now a primary technique of ingestion
among our men in Southeast Asia who erroneously believe that they cannot
develop a dependence by using this technique.
The technique of "smoking" opium is unlike that of smoking tobacco. The
oiMum itself does not burn, rather it is vaporized. Crude opium is specially
prepared and then is made to adhere to the .small bowl of an opium pipe which
is heated by a flame, thus valorizing the opium which is then inhakxl. Though
.serious dependence may have occurred among opium smokers, this pattern of
use in the social context of Eastern and Southern Asia seems to have been more
benign than has generally been depicted. Since the outlawing of opium in most
of Southeast A.sia follovsiug World War II, the alternate which took its place,
most noticeably in Hong Kong, has been the inhalation of the vapors of a heroin-
barbiturate combination. This pattern of ingestion of almo.st pure heroin can
create a dependence more profound than that caused by opium smoking.
The parenteral use of opiates for .several reasons is the most damaging. Be-
cause it is tlie most eflicient and expeditious technique of delivery, even very
small amounts of drug produce effects. Because of tlie immediacy of the effect the
act of injecting is clearly and unquestionably related to the pleasure (or relief)
which the injection provides. Add to this the hazards of overdose and non-
sterile technique and the picture is complete.
Though the life of regular users is generally depicted as one of rather
complete degradation, this is not necessarily the case. Usei-s can and do, par-
ticularly in other times and places, have legitimate occupations which are
.sufficient to supply their drug needs and they often carry on their lives with
reasonable efficiency. In other instances the drug use may produce such lethargy
that they are not usefully employed though they may not be involved in illegiti-
mate activities other than the simple pos.session and use of drugs. In most in-
stances in the U.S. opiate users must engage, at least in part, in some illegitimate
activity in order to .secure sufficient funds to support the habit
As has been mentioned above, the "tyi^ical" addict in the United States cur-
rently is a heroin u.ser who is young, lower-class, male, and black or brown.
thougJi as this committee is aware, even this pattern is changing to include more
white, middle class youth. Prior to 1914 tlie typical addict was middle-aged,
middle-class, female, and white. There is a good chance that she was quite re-
spectable and that her "vice" was known only to her pharmacist, her doctor, and
her husband. Elsewhere the characteristics of the typical addict vary even more.
In Hong Kong today addicts are mostly middle-aged male laborers, while in some
societies, the use of opiates was the prerogative of the wealthy and powerful.
Obviously, societies differ in their acceptance of drug use. Still, even where no
laws exist there is usually some social condemnation, particularly in instances
where drug use comes to dominate the individual's life. Legislation controlling
drug use is a relatively recent historical phenomenon, though there have been
occasional examples in the past of judicial control of drugs. Though most nations
have enacted control laws, enforcement is often intermittent and selective. In
many Western nations, most notably the United States, both the legal and social
sanctions against certain forms of drug use are enforced vigorously. Obviously,
the psychological meaning and the social consequences as well as the kind of drug
use, the pattern of use. and even the route of ingestion may be determined by
these social events independent of the psycliological pattern of the user and
the pharmacology of his drug.
For a variety of historical and social reasons we have today in the United
States about 150.000 to 200,000 people who are currently or who have recently
l>een dependent on opiates. Many are incarcerated in in-isons, jail.s. or other in-
stitutions. Some wlio are free are not curi-ently engaging in the illegal use of
opiates for any one of a variety of rea.sons. including personal detei'mination,
religious conversion, pharmacological blockade, close parole .sui)ervision. member-
ship in an anti-drug organization, or the substitution of other drugs. Different
665
communities laave different programs, though many have none at all. The only
"treatment" modality available everywhere is prison or jail.
Let us examine several of these approaches to the treatment of opiate
dependence.
NARCOTIC MAINTENANCE
It has long been observed that people can function for prolonged periods with-
out disability or serious toxic effect while receiving regular daily doses of
oidates. When such a regime is carried out with the acquiescence of the patient
and under careful supervision of a knowledgeable and ethical physician, the
patient feels normal, acts normal, and seldom seeks out supplemental sources
of drugs.
There are instances in which maintenance programs have not worked well.
The fault here lay in one or several errors in management. Among the errors
have l;een treatment of a patient whom the doctor does not know adequately;
allowing the patient to determine his own dose of the drug; or supplying the drug
in such form and quantity that it can easily be resold or misused.
Opiates have pharmacologic characteristics which permit a maintenance ap-
proach. Though overdose can cause death, sublethal doses have uegigible toxicity.
INIaintenance even on substantial doses of opiates produces sufficient tolerance
so that neither motor nor intellectual functions are disrupted, unlike barbitu-
rates and alcohol which will induce persistent ataxia and lethargy when used
in high regular doses or stimulants which will ultimately induce toxic psychosis
if so used.
In a number of countries (Britain is not the only one) physicians have been
permitted, tacitly if not officially, to prescribe opiates on a maintenrtuce schedule
for patients wlio have a siibstantiated history of intractable addied<m. In Great
Britain this permission has been official, but there, during the mid-19G0's a prob-
lem arose. One physician in particular, and perhaps an additional half-dozen to
a lesser degree, were prescribing heroin to addicts in phenomenal quantities, far
beyond the doses required for maintenance. The result was that some addicts
sold their excess drugs for profit to previously non-usei's of opiates. It is yet to
be determined if these physicians were motivated by stupidity, perversity, or
wickedness.
In response to the abuse of their privileges by these very few physicians, the
British Government removed from physicians as a whole the prerogative for
prescribing heroin and cocaine to drug dependent people and invested it in a
few doctors specially designated to handle these cases. Curiously, moiphine and
opiates other than heroin may still be generally prescribed to addicts by any
physician.
The British have not abandoned the "British System," they have merely
modilied it to minimize the likelihood of improper medical practices. It is pos-
sible that still further restrictions on the British physicians' prerogative to pre-
scribe for addicts will be necessary, but it seems unlikely that they will abandon
careful drug maintenance as a useful technique for the management of opiate
dependence. In addition the British are exploring other avenues for the re-
habilitation of addicts.
From a pharmacological point of view there are some drawbacks to the use
of nioiphine-like opiates in a maintenance program, principally their short dura-
tion of action. The necessity to repeat dosage three or four times a day makes
practical management difficult and tends to keep the patient involved with his
drug and continuously aware of cyclic variations induced by a rapidly metabo-
lixed drug.
Dole and Nyswander, in their pioneering studies, found that methadone, a
synthetic whose chemical structure is slightly different than that of the na-
turally occurring opiates, and pharmacologic characteristics which made it
superior for maintenance :
(1) It is effective orally and can be mixed in a carrier (e.g.. orange
juice) which makes extraction of the drug difficult.
(2) Metabolism and excretion are slow enough that a single daily dose
suffices to produce the desired maintenance level.
(3) Taken orally, it has much less tendency to produce euphoria or
drowsiness than morphine-like opiates.
(4) As it is used in this program it blockades the effect of other opiates
which might be taken.
666
(5) It suppresses the desire for opiates. Patients cease talking or even
dreaming obsessively about drugs.
(6) No notable toxic effects are encountered. There is, for example, no
interference in menstrual function and women on this program have con-
ceived, and while still receiving methadone carried vo term and easily
delivered healihy babies. At birth there was nunim^il evidence of withdrawal
symptoms in the infants and no acrive thereapy was required.
The results of this approach so far have been startlingly good, and others who
have used it have had similar results. Though use of methdone is the sine qua
non of the program there is recognition that patients have other life problems
and efforts are made to assist them. Psychotherapy is not considered essential
though it is available if necessary. Freed from the need for the cycle of hustling,
scoring, fixing, nodding, and hustling again, blockaded from feeling the effects of
a shot of heroin which he may try once or twice to prove to himself that a block-
ade really exists, the patient can now proceed with the ordinary business of re-
constructing and living his life.
In Dole and Nyswander's series (<S71 as of Mar. 31, 1968) only 14 percent of
the patients had left the program, usually l)ecause of serious diflSculties with
alcohol or other nonopiate drugs, because of arrest, or because of persistent disrup-
tive behavior. All the patients are voluntary and certain selective criteria are
used : the selective criteria, however, are intended to insure that the subjects have
had intense and repeated periods of addiction.
Opposition to methadone maintenance has been waning because the results of
the programs continue to be so impressive. The argument that this is merely sub-
stituting one addiction for another seems inconsequential when one considers the
alternatives, disease, death, degradation, and prison, which await most addicts
in our society. The fact that methadone is dependency-producing is irrelevant
if we determine that long-term treatment is essential. We insist on similar long-
term use of anti-psychotic drugs in hundreds of thousands of psychiatric patients,
and anticonvulsants in equally large numbers of epileptics, which equally do not
"cure" but allow the patient to lead a life which is far more satisfactory than
it would be without the drug. And from all evidence so far, methadone appears
to be le.«s toxic than either the antipsychotic or the antiepileptic drugs.
It is of critical importance not to equate a maintenance program, whether with
methadone or other opiate drugs, with the indiscriminate distribution of opiates,
much less the "legalizing" of them.
It seems probable that a large proportion of our addicts will, in the future, be
controlled through this approach. The only tragedy will then be that we did not
earlier heed those few brave souls who have persistently advocated such an ap-
proach for the last 50 years.
OPIATE ANTAGONISTS
Some substances with morphine-related chemical structures have the effect
of negating some of the pharmacological effects of other opiates. Nalorphine (Nal-
line) and levallorphan (Lorfan) are examples of this group of drugs which are
currently in the pharmacopeia and are used primarily to treat opiate overdosage.
The phenomenon of opiate antagonism has been used in two different ways in
the management of opiate dependence. In one. the fact that small doses of nal-
orphine will counteract the miotic effect of most opiates is used as a screening test
for opiate use. Given to a person who has not recently used an opiate the nalor-
phine itself will produce miosis. The person to be screened is examined under con-
ditions of fixed light intensity and his pupil size is measured. He then receives an
injection of .> milligrnms of nalorphine and his pup''! size is reme.'sured 20 to 30
minutes later. Pupillary construction indicates a negative test while dilation is
positive. In positive or questionable tests urinalysis for opiates is requested since
it is more reliable than the screening test. For the most part this type of screen-
ing is used in parole and probation programs.
More pertinent to this discussion is the use of opiate antagonists as a therapeu-
tic toi^l, Cycl.'izocine. and more recently naloxone, luilh i)f wliich .•■tc invi\--tig-!-
tionnl drugs, have been used on a regular daily dosage schedule in several ex-
perimental treatment programs. In the hospital the patient receives the medica-
tion in gradually increasing doses till a daily maintenance level is reached. As
an outpatient he continues to receive the medication regularly. Should the patient
use an opiate, it will have either no effect or a markedly dimiTushed effect, de-
pending on dose and time relationships between the cyclazo'nne .and the opiate.
IJnlike disulfirani (Antabuse) which produces unpleasant and potentially danger-
667
ous effects when the patient treated with it talies alcohol, use of an opiate an-
tagonist results in an absence or dimunition of narcotic effect when the patient
takes an opiate.
Though clinical experience with narcotic antagonists used in this way has been
limited, results have been encouraging though not as startlingly successful as
with methadone maintenance. Besides the simple pharmacological blockading
effect, the use of these medications may serve as a nidus around which a patient
can be engaged in a program. In addition, when a patient tries opiates from time
to time, as he may, and fails to get high, or even feel any effect from the heroin,
thi.'^ may tend to induce extinction of drug-seeking behavior.
There are both parallels and differences between the maintenance treatment
using cyclazocine and that using methadone. Both tend to block the eft'eet of
opiates, and once past the stage of induction neither has significant effect on
mood or behavior. It appears that maintenance treatment on either regime may
be prolonged though ultimate discontinuation of medication may be possible.
Toxic effects have been more pronounced with the antagonists than with metha-
done. Nevertheless, fewer objections have been voiced against use of cyclazocine
for maintenance than against use of methadone. The objections appear to be based
more on moral grounds than scientific ones. Methadone is classed as an "opiate"
and is therefore considered by some to be morally objectionable, while cyclazocine
and naloxone are "opiate antagonists" and therefore morally pure. Neither has
produced '•personality deterioration" as had been fearfully predicted, and both
may continue to prove useful, each in its own way, in aiding the rehabilitation of
opiate-dependent people.
THE THIRD COMMUNITY
It has been undiplomatically stated that religiomania is a cure for narcomania.
This observation is valid, particularly if one defines religiomania broadly as the
devout acceptance of clearly defined tenets of a faith and its principles of be-
havior, and persistent participation in its prescribed rituals. The faith and its
practice will usually encompass all the life activities of the communicant and
in its practice he will have the opportunity for both penitence and ecstasy. Obedi-
ence is part of it as is the sense of heing an accepted member of the congregation,
however lowly, and thus possessing an attribute not possessed by anyone outside
the sect.
The requirements can be fulfilled not only by formal fundamentalist religious
groups such as Teen Challenge but by such an organization as Synanon and
other programs which have been modeled on it. Be'-ause Synanon does not have
a deity (though it may have a prophet) it may be improper to call it a religion.
Instead it might be called a "third community." the first being the drug-using
community and the second the "square" community.
Though some addicts can discontinue drug use and reenter the square world,
many cannot make this transition easily. If their past is known they may be
rejected ; or even if not rejected they may find it impossible to share the interests
and life styles of the squares though they may want to depart from the world
of the users. Returning to the world of users, they inevitably find leads
to readdiction. hustling, and everything else that makes up "the life."
The "third community" is made up of drug users who have decided to remain
ab.'^tinent and who join together to form what can be described as a commune,
or perhaps a synthetic, extended family, governed autocratically. They live and
work together, develop and alter rules of interaction and gather into communi-
cation groups for the purpose of learning aboiit themselves and each other and
telling what they are and how they feel. Though living apart from the larger
community they do not ignore, nor are the.v ignored by it.
Though Synanon evolved from Alcoholics Anonymous and the Therapeutic
Community, it is not a simple derivation of these approaches. It is far more
encompassing of the lives of its members than AA and unlike the usual construc-
tion of therapeutic communities there isc no staff-patient dichotomy. Though
there are ranks and privileges the hierarchy is continuous and anyone can.
theoretically, hold any position.
■ Other third community grouj^s modeled after S.vnanon differ from it in one
way or another, most prominently in the expectation in the other groups that
the person will ultimately graduate and reenter the square community, and
because of his personal growth will be able to manage his life satisfactorily and
without recourse to drugs. Though accepting the idea of the departure of gradu-
ates, the Synanon ideal is to retain members in the group indefinitely and to ex-
pand steadily, drawing in more and more members, squares as well as addicts.
668
Many people have benefited from their experiences in these programs, and
many have not. For reasons vi^liich are sufficient for tliem, Synanon does not
record the number of people who departed and returned to their fomier ways.
In most instances they are no worse oif for tlie experiences.
"Gateway" in Chicago and "Daytop Village" in New York have been modeled
after Synanon. Though governmentally supported and resiwnsible to a profes-
sional boai'd these programs are run by the addicts themselves and thus avoid
the "we-they" split which can obstruct other programs.
It is mandatory to acknowledge that Synanon is a remarkable creation, most
remarkable because it flew in the face of tlie accepted idea of the intractability
of addiction ; tliey refused to accept that notion at a time when almost everyone
else did.
CIVIL COMMITMENT FOR ADDICTS
California in 1961 and more recently New York State and the federal govern-
ment have initiated and implemented programs for the civil commitment of
narcotics addicts. The thrust of these statutes is to maximize the number of
addicts committable and minimize their opportunity to choo.se to leave.
The roots of these commitment laws can be traced to the Federal narcotics
hospital in Lexington. In recounting the initial. expectations for that institution
Isbell writes * * *
Drug addicts were to be treated within the instituiticn. freed of their
physiological dependence on drugs, their basic immaturities and i)ersonality
problems corrected by vocational and psychiatric therapy, after which they
would be returned to their communities to resume their lives. It seems to
have been tacitly assumed that this program was the answer and would
solve the problem of opiate addiction. Within a year it was apparent this
assumption was wrong * * *
* * * a more adequate treatment program (required) :
(1) Some means of holding voluntary patients until they had
reached maximum benefit from hospital treatment.
(2) Greater use of probation and parole. * * *
(3) Provision for intensive supervision and aftercare. * * *
Isbell goes on to say that the reasons why these problems were not solved
were complex.
In 1961 the California Legislature enacted laws establishing a commitment
program for addicts which was designed to accomplished those objectives recom-
mended but never carried out at Lexington.
Though the program has been useful for a small proportion of those com-
mitted, for the majority it has proven to be merely an alternative to prison.
The majority have entered a revolving system of admission-release-admission-
release, and spend a majority of their commitment incarcerated in an institution
which re.sembles a pri.son more than it does a hospital.
Commitment, strictly speaking, is not a treatment technique, it is a legal
technique to bring an unwilling patient into a treatment situation. Whether the
treatment is effective or he receives any treatment at all depends upon the pro-
gram offered.
An important consideration in evaluating civil commitment for addicits is the
fact that many people in positions of authority see commitment primarily as a
means to get the addict off the street. Their justification for this position is that
opiate dependence, particularly heroin addiction, is a life-threatening, com-
municable disease and it is therefore morally justifiable to incarcerate addicts,
to place them in quarantine, so that they win not infect others. The soundness of
this position is arguable both on constitutional and epidemiological grounds.
It is unlikely that all compulsion can be removed as one aspect of ]>nhlic policy
in the management of opiate dependence. The presence of drug control laws i-* a
primary motivating force behind the entrance of addicts into voluntary programs.
We must provide sufficient useful voluntary approaches and back them up by
involuntary programs for those unable or unwilling to receive help from the
former, but commitment programs for addicts like any other medical program
.should be flexible, imaginative, and unhindered by excessive legislative and ad-
ministrative restrictions.
COMPREHENSIVE COMMUNITY PROGRAMS
It is generally conceded that traditional psychiatric techniques have not been
useful in the management of opiate dependence. In a psychoanalytic frame of
669
reference symptoms are considered to be the behavioral or somatic representa-
tions of an underlying intrapsychic conflict. Once the conflict is resolved or
reduced to manageable proportions, the symptoms will diminish or disappear.
This conceptual model fails to account for two different issues, either or both
of which may play a role in people who abuse drugs. First, though intrapsychic
determinants may play a part in whether a person uses drugs, other circum-
stances such as drug availability, subgroup attitudes, peer pressures, and plain
chance are very often more important. In other words, in some individuals,
there may be no serious underlying conflicts, though there may be considerable
conflict with the community. Second, whatever the original determinants of
drug use may be, the symptom, dependency on drugs, can become so central an
issue that it, so to speak, assumes a life of its own, and even solving the under
lying conflicts may have no influence on the drug dependence itself. An analogy
may be drawn with a depressed person who in an attempt at suicide breaks his
neck and becomes paraplegic. Psychotherapy may relieve his depression but
will not restore function to his legs.
Because drug use has been invested with such great importance in our society
(an importance it did not always have) it is assumed that the intrapsychic
events which cause, or contribute to it, are of equal magnitude. Hence the view,
that since drug use potentially subjects the pei'sou to such serious consequences,
the psychological problem he has must be equally big. Experience with drug
users does not validate this view. Some do indeed have clearly definable psychia-
tric problems, but many do not. Where it is sought, some subtle psychiatric defect
can always be found, as has been the case with addicts. Further investigation may
clai'ify this question. In the meantime a functional approach, handling the symp-
toms, educating and giving practical assistance as well as offering psychotherapy
in selected instances seems desirable.
To this end, the Federal Government through the NIMH has been offering
support for comprehensive, community-based treatment programs for narcotic
addiction. It has become evident that programs of limited scope functioning
alone, whether a hospital, an outpatient clinic, or a social service agency, are
of limited effectiveness. At different times an addict may need different services,
and to preserve continuity of treatment it is most reasonable for all services
to be available under the auspices of a single organization. Thus, the compre-
hensive drug addiction centers are expected to provide, at a minimum, such
services as :
( 1 ) inpatient treatment, including withdrawal,
(2) outpatient services,
(3) aftercai'e services; for example, vocational and educational programs,
(4) partial hospitalization services (day hospital, night hospital),
(5) preventive services: Consultation, education, and community orga-
nization programs, and
(6) diagnostic services, including drug detection techniques.
These programs are also expected to provide ongoing evaluation both of the
program itself and the nature and extent of drug use in the community it serves.
Special techniques such as the third community approach, narcotic blockade
techniques, the use of ex-addicts as staff, or other innovations are acceptable and
are encouraged.
The Federal Government should prepare to fund treatment programs and train-
ing programs for treatment staffs as well as certain specific urgent research.
Massive application of the methadone maintenance treatment should be the
keystone of the treatment effort. In methadone programs ancillary services should
be supported as well. Particularly in areas where extensive addiction exists
comprehensive programs and abstinence programs should receive substantial
assistance.
One or several training centers are necessary to prepare staffs for these
programs.
All federally sponsored programs must be required to collect data on their
results and experiences in order that the task can be accomplished quickly and
effectively.
Development of long-acting narcotic antagonists may provide an important ad-
vance in treatment, not only of longstanding addicts, but more particularly for
those with a short history of addiction or even a nonaddicted population at seri-
ous risk.
And lastly, development of a longer acting form of methadone will help to re-
duce the risks of illicit diversion.
G70
Other researches which may discover more fundamental psychologic and phys-
iologic aspects of the addiction process deserve support but currently do not
have immediate applicability.
Chairman Pepper. We hnve now concluded wliat I consider to bo one
of the most exhpaistive examinations of the multiple aPDects of the
drug problem ever undertaken by a con2,Tessional body. The infoi-ma-
tion we have collected in this series of hearings, which began in April,
Avill trive tlie members of this committee an opportunity to revievr and
consider the testimony, ideas, and recommendations of some of the
most thoughtful men in America on this suljject. I can assure you that
we will use tins wealth of information in preparing a series of recom-
m.endations to the Congress that will outline a realistic approach to
a missive and effective drug research, treatment, and rehabilitation
program.
It has taken this Xation far, far too long to accept the severity of
the addiction crisis confronting us. It is my firm conviction that we
cannot pennit ourselves the same leisure in devising solutions to the
problem. P.ut we must guard against accepting any pat or simple
solutions that claim universal applicability. Drue addiction is a
nuilticausal phenomenon, and the solutions to it will be equally com-
plex. It is an all too human fault to fasten upon an easy solution, so
v\-e must redouble our guard against such oversimplification. Just at a
time when many people believe that methadone is the answer to heroiii
addiction, three eminent doctors told this connnittee alx>ut an en-
tirely new type of drug — the antagonists, nonaddictive drugs which
curb an addict's craving for heroin. But even these drugs when per-
fected will not be the final solution to the problem. So we nmst
continue to search, to question, to experiment. And we must do so
aware that we will not always succeed, aware that we are engaged
in a leniithy struggle. But with the necessary commitment, we can
resolve the drug addiction crisis in America: and we can — and must —
do it before we lose an entire generation of young Americans.
If there is nothing further. I declare this hearing concluded.
(The following material was received for the record:)
[Exhibit No. 28]
Statement on Behalf of S. B. Penick & Co.. Merck & Co., Inc.. and
Mallixckrodt Chemical Works
Th^ statement is siibmitted on behiilf of S. B. Ponick & Co., a di\'ision of CPC
Tnternational, Inc., Merck & Co., Inc., and Maliinckrodt Chemical Works. These
three companies are the only licensed companies in the United States wliich
imjiort opium into tliis country for the production of certain opium derivatives
in bulk chemical foruL These products are sold by the three manufacturer.* to
authorized pharmaceutical manufacturers, hospitals and pharmacies for medicinal
uses.
We understand that this committee, as a ]>art of its current invesiisration of
the heroin problem and means of combating it. is considering a recommendaifion
for an immediate ban on the importation of medicinal opium into the I'nitcd
States. This is apparently viewed as the first step in an effort to eradicate oiuum
cultivation in all parts of the world.
It is our belief that this proposed ban. however Avell-intentioned. would have
no po.sitive effect on heroin supplies in the T'nited States or elsewhere, now or
at any foreseeable time in the future. Furthermore, such a ban would adver.'^ely
affect the health and welfare of many people who require treatment with drugs
derived from opium.
G71
There is a simplistic appeal to the theory that elimination of the legitimate
importation of opium would contribute to the elimination of all opium growing
and hence to the elimination of heroin. The theory necessarily is based upon
these premises : first, that medicinal preparations containing opium derivatives
are unnecessary to medical practice (so that we would not be disadvantaged by a
ban on opium imports) ; second, that Other countries Avill be inspired by the
U.S. action and will follow this lead and ban all use of opium derivatives; third,
that in the absence of a legitimate market all opium cultivation will then be
illegal ; and fourth, that illegal opium poppies can then be readily detected
and eradicated.
The remainder of this statement will demonstrate the fallacy of this thesis.^
Initially, however, it may be useful to describe bi-iefly the existing legal channels
for the importation and processing of opium in this country.
I. Xone of the heroin used in the United States is attributable to the legitimate
importation and processing of opium.
Annually, in November, each of the three opium manufacturers provides the
Bureau of Narcotics and Dangerous Drugs with estimates of its opium require-
ments for the next year. Each company then receives an important quota from
BNDD and begins negotiations for purchases with the governments of India and
Turkey, the only countries which supply the legitimate industry in the United
States. All shipments are made through the port of New York and are accom-
panied by armed guards. Upon arrival, they are cleared through Customs, loaded
at the pier into a sealed trailer and moved under guard to the production plant
uf one of the three manufacturers. The shipments are unloaded under the guard's
supervision into an electronically-protected vault and sealed by a Customs official.
Subsequenty, sampes are removed for testing by the Government to determine
morphine content. These tests permit BNDD to ascertain the exact quantity of
derivatives which will be obtained and which must be accounted for by each
of the companies. Access to the plants is limited to security-cleared i^ersonnel.
The companies produce no heroin for sale : the importation, manufacture or
sale of heroin in the United States has long been prohibited. Those bulk opium
derivatives which the companies are permitted to make may be .sold only to
authorized purchasers who present an order form supplied by BNDD. Completed
order forms are submitted to the Bureau to enable the Government to follow all
opium derivatives through all stages of distribution in an unbroken chain of
accountability. Each firm must maintain continuous inventories and file detailed
quarterly reports with the Bureau showing the exact amount of raw opium on
hand, the amount used during the quarter, quantities in process and finished
materials on hand.
Any diversion from this tightly regulated system, which is based upon laws
initially enacted in 1909, would be immediately apparent to both the Government
and private industry. In fact, there have been no reported instances of legally
imported opium being converted into heroin for illicit used. Thus, the legitimate
supply of opium which enters this country subject to these controls is in no man-
ner related to the ever-increasing supply of illicit heroin within the United
States. The heroin that enters this country enters illegally, smuggled over the
borders and through Customs.
II. There are presently no adequate substitutes for codeine, the principal
opium derivative.
The principal substance derived from opium is codeine. Codeine alone accounts
for about 90 percent of the total production of the plants of the three U.S. opium
processors. Additional derivatives, such as morphine, papaverine, narcotine,
thelsaine, and nalorphine, are also obtained, but in relatively small quantities.
Most of these products are used in the formulation of numerous medications
having analgesic fpainkilling) or antitussive (cough-suppressive) properties.
This committee in its second report ("Heroin and Heroin Paraphernalia," H.
Kept. No. 91-1808) released in January of this year, states (p. 59) :
Since the weight of informed scientific opinion is on the side of those who
argue that there is no longer need for the opium poppy because we now have
'^ The just-released (May 27) Report of the Special Study Mission on the World Heroin
Problem, headed by Congressmen Murphy and Steele, contain 19 recommendations, none
of which contemplates a ban on legitimate United States importation and processing of
opium. To the contrary. Recommendation No. 11 (p. 3S) is that "the Congress consider
legislation which would ban the manufacture, distribution, sale or possession with intent
to use drug materials for illegal purposes" and Recommendation No. 4 (p. H7) is that "the
U.S. Government underwrite an accelerated research program to find a nonaddictive sub-
stitute for opium, which continues to have important medicinal applications."
672
synthetic painkillers, our committee has recommended that Congress oiitlaw
the importation into the United States of all cultivated opium and its byproducts.
We think it possible that when it wrote those words, the committee was think-
ing of morphine. Indeed, a fair reading of the report as a whole suggests that the
committee may have been unaware of the medicinal importance of codeine." As
will be seen, the two substances differ markedly in their properties, the medical
usages to which they are put, and the availability of synthetic substitutes for
those uses.
A. Morphine
Morphine, classified as a strong analgesic, has for years been the standard
drug employed in the treatment of patients suffering extreme pain — as in the
cases of terminal cancer ; biliary, renal, or ureteral colic ; or coronary occlu-
sion. It is used frequently as a last resort when other medication is no longer
effective.
Although this committee seems to have written off morphine as a needed pain-
killer because, it says, the search for synthetic substitutes has been successful
(second report, p. 36), respected medical and scientific authorities still acclaim
morphine as best suited for certain applications.' Furthermore, this committee
has recognized that all the high-potency synthetic drugs appear to share
with morijhine the characteristics of producing dependency and addiction in
some recipients (second report, p. 36).
Whether morphine is for all purposes replaceable today by the newer syn-
thetics remains a question as to which experts differ. Certainly it is a fact
that mon)hine production and sales have fallen sharply in this country. At least,
as several witnesses have already suggested to this committee, prescribing
physicians should not be deprived of morphine until the various substitutes have
been fully evaluated and the medical profession has been made fully aware of
their availability, potential, and possible limitations.
B. Codeine
Codeine is classified as both a mild analgesic and as an antitussive. It is one
of the oldest medications in use today and, alone or in combination, is one of
the most widely prescribed of all drugs. In contrast to morphine, U.S. consump-
tion of codeine has steadily increased — from approximately 5,000 kilo.grams per
year in the early 1930's to approximately 30,000 kilograms in the past few years.
Codeine consumption in other countries has grown at an even faster rate.*
Codeine relieves pain of varying intensity up to and including that requiring
moriihine. It is generally considered the most effective of the mild analgesics.
The fact that it is effec'tive in a wide dosage range renders it a imiquely flexible
and versatile drug for the treatment of pain in a great variety of conditions
such as neuralgia, colic, dysmenorrhea, postpartum and postoperative pain,
arthritis, and phlebitis. Because of its relative safety, codiene is the best known
narcotic tjipe of analgesic. It is generally the first analgesic thought of for
moderate to severe pain, as it can be administered for relatively long periods
without undue fear of addiction.
In addition to its painkilling properties, codeine is a potent antitussive. In
this respect, its properties are unique, affording not only antitussive but also
analgesic and mild sedative action.
Whatever the merits of morphine, we know of no authority that suggests syn-
thetics are yet fully capable of replacing codeine. Dr. Seevers, te.stifying before
this committee in April in answer to conmiittee counsel's question whether we
now have a single drug which will substitute for codeine, replied that while the
search for a codeine substitute has been one of the primai'y aims of industry
in the last decade, an effective substitute has not yet been achieved. Similarly,
Dr. Brill testified that there is yet no synthetic which will suKstitute completely
for codeine. It is, he said, a drug that has a combination of qualities that are
not easily mimicked. In response to a question from Congressanan Steiger. Dr.
2 For pxamplo. tho report has a soparate siibchapt(>r (pp. .".5-.''>f)) on "S.vDthptic Anal-
prosifs for Morphine." There is no eomparnble disenssion of synthetic suhstitntes for codeine.
Similarly, its recommendation No. 2 (p. 47) is that "Conjrress should outlaw the licit
imtiortation of opium and morphine." To tho best of our knowledge, no morpliine lias
ever been imported into the Tlnited States.
'Recent statements on morpliine by such authorities, Incliidina: Dr. .Jerome .Taffe who
testified before this committee on problems of addiction on Apr. 2S, 1071, are collected
in an ajipendix to this statement.
' See p. 10, infra.
673
Brill stated that on a scale of 1 to 10, with codeine at 10, lie would rate the
known cough-suppressant substitutes lor codeine at 2 or 3. Although not ques-
tioned on the subject. Dr. Eddy, who also appeared before this committee in
April, has written that "codeine serves a need which is not presently met by
other substances." ^
Rather than burden the text of this statement with additional expressions by
experts in this field, we have noted several in the appendix. These views indicate
that codeine is generally recognized by medical authorities as superior for both
analgesic and antitussive uses to the variety of synthetics presently available.
To ban its use, therefore, would result in a rergrettable lowering of the quality
of medical care throughout the United States.
The American people should not be deprived of these valuable medicines unless
it can be clearly demonstrated that, by doing so, they are making a positive
contribution to the heroin addiction problem. Such, as we will now show, is not
the case.
III. A ban on the importation of opium into the United States will not lead to
a universal ban on opium cultivation and will impede current control efforts. —
The second premise underlying the proposal to ban opium imports focuses on the
issue of control, rather than the question of medical utility. The hypothesis is
that the United States can act as a world leader by prohibiting the importation
of opium, with the result that other nations will act accordingly. Ultimately,
it is theorized, the legal cultivation of the poppy will be eliminated, and thereby
facilitate the eradication of illicit production qs well.
The chain of logic breaks at the first link, however, for there is no likelihood
that this initial step will culminate in multilateral action. It must be remembered
that the United States first sought and failed to obtain international support for
the elimination of legitimate poppy production and purchases 10 years ago. Once
again, in October of 1970, this proposal failed at the Geneva meeting of the In-
ternational Commission on Narcotic Drugs.
We are unlikely to witness a change of heart by other countries importing
opium and its derivatives. Quite the contrary, in the 20 years between 1950
and 1969, world consumption of medicinal codeine has increased from 51,823
kilograms to 142,903 kilograms.* It is thus apparent that there is no intent abroad
to stem the legitimate flow of narcotic drugs or to impose restraints upon the
accessibility of these valuable substances for medical treatment. The growing
concern about problems of the illicit narcotic traflic in other countries has focused
international efforts on positive programs, including training of law enforcement
officers, education, crop substitution and the rehabilitation and social reintegra-
tion of drug addicts.'' No suggestion has ever been endorsed by the International
Commission to eliminate legitimate sales or usages of narcotic drags as part
of this program
Moreover, the maintenance of a legitimate channel for opium production has
proved to be a highly useful mechanism for controlling opium cultivation. For
example, the techniques employed by the Indian Government, based upon a li-
censing and quota system with incentives for compliance, are premised upon the
existence of a legitimate channel for official sales. Indian officials purchase the en-
tire opium crop of licensed farmers annually, at a fixed rate, adjusted according
to the farmer's yield, and sell the supplies for medicinal and scientific uses. By
providing an outlet at reasonably high prices, without criminal risks, the Govern-
ment of India has thus successfully ended diversion from licensed fields.* Were
this outlet jeopardized, the essence of the Indian control system would be
threatened.
Today, U.S. purchases of legitimate opium supplies amount to about 20 percent
of the total legal world production. Such a proportion is not large enough to alter
materially the planting schedules on either Indian or Turkish farms. This excess
opium would inevitably become available to the illegal traffickers, swelling the
black markets with as much as 20,000 kilograms of heroin annually. The proposed
unilateral ban by the United States may thus simply divert opium derivatives
from our hospitals to our streets.
^Eddy, Nathan B., M.D., "Codeine and Its Alternates for Pain and Cough Relief" 40
Bulletin of the World Health Organization 723 (1969).
"TJ.N. International Control Board. "Statistics on Narcotic Drugs."
" U.N. Commission on Narcotic Drugs. "Suggestions for Short-Term and Long-Term
Measures Against Drug Abuse and Illicit Trafficking," E/cn. 7/530, at S-11 (1970).
* Id. at 4. See also Murphy and Steele, note 1 supra, at 32.
074
IV. A universal ban on legitimate oi)ium derivatiA'es vvil! not affect illicit opium
cultivation or traffic in heroin.
Suppo.se, however, that a ban on U.S. imports of opium were to stimulate other
countries to talie similar action, with the result tliat all poT)i».v cultivation were
declared illegal. Would this enable law enforcement officials to eradicate illicit
poppy fields or to curb heroin traffic?
Consider, first, the economic dimension of the question. There is presently u sub-
stantial financial inducement to poppy growers to sell in the illicit market. In
Turkey, for example, according to the Bureau of Narcotics and Dangeron-; I)rua:s.
the price paid to a farmer for raw opium in 19fi0 was .'?11 per kilogram for legal
((uantities: th^^ illicit market, in that year, paid Turkish farmers ai)proxinia:e'y
$25 per kilogram," Thus, there is a simple profit motive to grov and sell opium
illegally, especially in regions which will not supiwrt other crops or provide labor
alternatives.
A ban on legitimate pop]>y cultivation will in no manner affect this economic
inc(>ntive. for the ban is not addressed to tho.^e who produce for the illicit market
or to those who respond to the lucrative prices paid by bhick marketeers. A bar to
legal production does not offer even an opportuniiv — much less an incentive — to
abandon the illegal production of ooium.
Apart from economic concerns, however, it has been suggested that the elim-
ination of legal poppy fields would facilitate the detection and eradication of
illicit production. If both legal and illegal supplies originate in substantially
the same fields, then a ban on licit cultivation, if enforceable, might reduce illegal
production as well. On the other hand, if illegal opium, or most of it, is grown
in illegal fields away from tho^e which produce ft.r the legitimate purchaser, then
the continued production of legal r-rops has nothing to do with our heroin
problem. It is essential, therefore, to deternnne where illicit opium poppies are
grown. ::, . .
Last month, the Bureau of Narcotics and Dangeroiis Drugs, in its submission
to the House Subcommittee on Appropriations for the Department of Defense,
noted that "illicit production is now concentrated in Southeast Asia (the h'U
country of Burma. Laos, and Thailand) and in Afghanistan and Pakistan, al-
though it continues to some extent in India and Turkey." lo BNDD further
believes that Burma, Laos, and Thailand alone account for more than ."^O per
cent of all illegal cultivation worldwide, despite the fact that none of the.se
countries produces or sells any legal opium whatever.
There are presently two countries engaged in major legitimate cultivation and
exportation of the opium poppy: India f)nd Turkey. ^^ Illicit supplies, hov;ever,
are not concentrated in those countries. In fact, BNDD estimates that in 1968,
scarcely more than 20 percent of worldwide illicit opium cultivation occurred
there.i- In other v,'ords, a.ssuming that both legal and illegal poppies grow in the
same fields in India and Turkey, the elimination of legitimate production in
tho.se two countries would effectively stem no more than one-fifth of the world's
illicit supply. At maximum efficiency, then, the ban on legitimate cultivation
would leave at least 80 percent of illicit opium production totally unaffecteil.
The truth is that governments which do not have political and physical control
over their countries cannot enforce restrictions on the cultivation of opium. The
Bureau of Narcotics and Dangerous Drugs concurs in this .iudgment. asserting
thnt. "Most of the world's illicit opium is now produced by tribal peoples over
which their respective national governments impose little political control." '^^^
Consequently, while Turkey was once viewed as the single greatest source of
the heroin problem in the United States, Congressmen Murphy and Steele have
recently reported to the House Committee on Foreign Affairs, that today, "From
the American viewpoint, Thailand is as important to the control of the illegal
international traffic in narcotics as Turkey." i*
Tb'^ oresence of U.S. servicemen in Southeast Asia has encouraged tlie traffic
to shift further east, illustrating that the picture of the heroin trade will alter
according to risks and in response to demand and the opportunity for gain. It
'' P.r.i-oan of Narcotics .Tnd Dan.ireroiis Dnics. "Thp World Opiiiin Sitnatinn," submitted
to tlip TToMSP Subcommittee on Appropriations for the Department of Defense, at 7
(April 5, 1971).
w Id. at 45.
11/^. at 10.
^ Tri.
IT Td. at 3S.
" Murphy and Steele, note 1, supra, at 20.
675
api-eurs, in fact, that an increasing arnotinr of the heroin used by American
troops in ^outli Vietnam and entering the United States, is produced from pop-
pies grown not only in Burma, Laos, and Thailand, but also in parts of Com-
munist China. ^" Thus, even as Turkey demonstrates increasing interest in control,
the problem is developing a new focus. The proposal to ban legitimate crops is,
therefore, based on a theoretical, static, and unrealistic concept of the source.
In .short, enforcement policies in each of the countries producing iUegitimate
supplies are determined indei)eudently of the existence of legitimate supplies
elsewhere. Indeed, as indicated, no legitimate opium is grown in the countries
providing major supplies of illicit poppies. The U.S. import policy would thus
have no effect upon these countries and tlieir appreciation of the signihcauce
of the narcotics crisis. Congressmen Murphy and Steele, therefoi-e. logically con-
clude that, "The problem * * * is not the control of legal production, btit to
find ways to stop leakage of opium to the illegal market." "
V. Crop substitution and .subsidies, police traiaiug, education and rehabilita-
tion are viable means to ctirb heroin supply and demand.
If a universal ban on licit opium cultivation is inappropriate and ineffective,
then what is to be doue? There must, as many Congressmen and others have
urged, be incentives, and, indeetl. coercion where necessary to impress uiuni fitr-
eign governments the necessity for controlling illicit opium productiim.
There have been bills ^'' proposed to eliminate foreign aid to countries which
refuse to exert controls over opium production. Senator Mondale has recent! v
pointed out that such a measure would have cost Turkey $100 million in Ameri-
can aid during the last 3 years, unless proper steps had been taken to eliminate
illicit poppies from that country." In contrast, a ban on U.S. opium imports
would liave negligible impact upon Turkey for no more than G percent ot our
opium requirements presently come from this country.
A second, more positive program aimed at supply, and favored by this com-
mittee, would focus on crop substitution to provide the opium farmer witii a
realistic, marketable alternative. Such an approach is already underway on a
small scale in Yugoslavia for example, and has proven successfu.. But money,
even in the form of crop subsidies, must supplement any stich plan. And wiiile
we aiay decry the failure of other nations to contribute to such efforts, our own
funds must not be withheld.
Enforcement techniques abroad have been meager, and largely the product of
inclilTerent governments. Nevertheless, even at our own borders, U.S. offlciais
fail to detect over 95 percent of the heroin smuggled into this country. We, there-
fore, endorse this committee's recommendation to encourage the development of
improved surveillance and detection techniques and devices, in the hope that
we will police ourselves with the same effectiveness that we expect of other
countries.
Supply S'hoiild not be the only focus of control. The United Nations Commis-
sion on Narcotic Drugs has concluded that there is little chance of success in
the fight against drugs, unless illicit demand is controlled as well as supply.
Iran is cited as an example. In 1955, Iran siiccessfully banned poppy growing,
but adopted no measures to curb demand for opium by large numbers of tradi-
tional opitim smokers. Unable to obtain opium, many of thse smokers then turned
to heroin supplied by outside sources. As a result, "the country now has several
hundreds of thousands of addicts, with a large proportion of heroin users," the
Commission reports.^
It is a drug demand crisis which we face. It is fed by depressants, stimulants
and hallucinogens, and poor social and economic conditions, as well as nar-
cotics. To control Turkish opium is not to control heroin ; and. to control heroin
is not to control drug addiction. Indeed, many synthetic compounds having high
addiction characteristics have been identified at the U.S. Public Health Service
Addiction Research Center in Lexington, Ky. Two of these substances, keto-
bemidone and dextromoramide, are illegal in the United States, but are manufac-
tured and available in Europe. Doubtless, addicts deprived of heroin will turn
to other addictive substances which can be manufactured in clandestine labora-
tories here or abroad.
" Murphy and Steele, note 1, supra, at 19.
M Id. at 32.
"See, e.g., H.R. 7821, introduced on April 29. 1971, and sponsored by Congressmen
Range!, Hamilton, and Dellums.
« Senator Walter F. Mondale, "Some of Our Friends Are Killing Us With Drugs" in
the Washington Post, Parade Magazine, at 1.3 (May 23, 1971 j.
■ " "U.N. Suggestions," note S, supra, at 3-4.
676
iTlius we must look to education, treatment, rehabilitation, and social reintegra-
tion of addicts — and potential addicts — to meet this crisis. These are long-range
programs, as is crop substitution, but pilot projects must first be undertaken. Suc-
cessful experiments have been attempted. Tliey liave also demonstrated that there
is no single solution. We must not deceive ourselves into believing that there is.
VI. Conclusion.
We must look for sensible means to meet the multifaceted problem — means
whicli are reasonably related to tlie ends we seek to achieve — rather than a simple
panacea. The proposed ban on the importation and cultivation of all opium does
not provide even a partial answer. Rather, it would eliminate a significant med-
ical tool without adding to our prospects of controlling illegitimate narcotics.
We urge this committee to call experts from various international organiza-
tions such as the United Nations, Interpol, and the International Narcotics Con-
trol Board, and doctors from a wide range of practice who deal with these drugs
on a day-to-day basis. We believe that their experience and expertise will lead to
the conclusion that the prohibition of the production, importation, and manu-
facture of legitimate opium will not contribute to the objective which we, along
with this committee, earnesly hope for — an end to the present drug epidemic.
Appendix
a. statements with respect to the advantages of morphine
1. Jaffe, Jerome H., M.D., "Opiate Dependence and the Use of Narcotics for
Relief of Pain," 5 Modern Treatment 1121 (Nov. 1968) : "Narcotic analgesics
relieve pain more selectively than any others now available."
2. Jaffe, Jerome H., M.D., "Narcotic Analgesics." in The Pharmacological Basic
of Therapeutics (Goodman and Oilman, eds.) (1970) : "Today, morphine, the al-
kaloid that gives opium its analgesic actions, remains the standard against which
new analgesics are measured. Many of the newer agents may be considered its
equal, but it is doubtful that any of them is clinically superior." (p. 237). " * * *
for the present, however, morphine and its narcotic surrogates retain their very
special place in the never-ending combat against pain" (p. 253) .
Dr. Jaffe also describes the relief afforded by morphine, properly administered
in the case of terminal cancer, as a "blessing to the patient and his family" (7f7.
at 254) and as "valuable for the preoperative sedation of patients in pain" (Id.
at 255) .
3. Chatton, Milton J., M.D., in Handbook of Medical Treatment (M. J. Chatton,
S. Morgan and H. Brainerd, eds.) (1970), describes morphine as "the most valu-
able of the potent narcotics for general clinical use" (p. 21 ) .
4. Pearson. J. W.. IM.D., in "Analgesia for Obstetric and Gynecologic Pa-
tients." 5 Modern Treatment 1136 (Nov. 1968), concludes that "postoperative
pain in gynecologic pntients is best treated by morphine."
5. Wang, R. I. H., M.D., "Potent Analgesics," 5 Modern Treatment 1136 (Nov.
1968) ; "Since 1929, under the auspices of the National Research Council a per-
sistent search for a substitute has failed to replace morphine by any synthetic
analgesic."
6. AMA Drug Evaluations (1971), ch. 21, "Strong Analgesics." p. 169: " * * *
very severe pain (e.g., that associated with biliary, renal, or ureteral colic, or
with coronary occlusion) can be relieved best by morphine or its potent con-
geners."
B. STATEMENTS WITH RESPECT TO THE INDISPENSABILITY OF CODEINE
1. AMA Drug Evaluations, 1971. Ch. 22, "Mild Analgesics," divides mild anal-
gesics into two main subgroups: (1) those agents chemically related to the
strong analgesics (codeine, ethoheptazine, and propoxyphene) and (2) the anal-
gecic — antipyretics, of which aspirin is the prototype. The review goes on to say
(p. 177) "of the drugs in the first subgroup, codeine is the most effective and,
although it has a potential for producing physical dependence, this risk from
usual oral doses is small. By varying the dosage, codeine can be used to relieve
a considerable range of pain intensity: with lower doses (32 to 65 mg.) its
effectiveness is comparable to aspirin (650 mg.) : more severe pain may be re-
lieved with larger doses, but the incidents of untoward effects is increased . . .
Propoxyphene is used alone and in mixtures, and is the most widely used drug
of this suI)group. However, it is less effective than codeine and is no more effec-
tive due to the fact that it does not require a narcotic prescription rather than to
its effectiveness as an analgesic. Tlie usefulness of ethioheptazine, the other drug
677
of this subgroup is questionable." See also p. 179 : "Codeine is probably the
most useful mild analgesic because it has a wide effective dosage range."
2. AMA Drug Evaluations, 1971, Ch. 43, Antitussive Agents," pp. 359-360:
"Codeine is generally accepted as the most useful antitussive. . . . The disadvan-
tages of the narcotic antitussives have led to intensive inve.stigation to find
agents that are effective but relatively free of undesirable effects. As a result,
a number of chemically unrelated nonnarcotic antitussive agents have been syn-
thesized and used clinically. Although the mechanism of action of most of these
compounds has not been adequately studied, they appear to act primarily by a se-
lective depression of the central cough mechanism. IVIany of these newer drugs
possess typical anesthetic elfects, but this property does not contribute signifi-
cantly to their antitussive action. None of these antitussives has expectorant
action or produces bronchodilation when used in the usual dosage, and none of
them is sufficiently potent for use in the preparation of patients for endotracheal
procedures. All of the newer agents are capable of reducing experimentally in-
duced cough, but few of them have been adequately studied in patients with cough
of pathologic origin. Even though patients I'eport subjective impressions of im-
provement, objective measurements oftem fail to reveal a significant reduction in
the frequency of cough."
3. Beaver, W. T. M.D., "Mild Analgesics in the Treatment of Pain," .") Mod-
ern Treatment 1094 (Nov. 1968). "Codeine is therefore, a very flexible drug in
that the physician may adjust the dose within wide limits to cope with a con-
siderable range of pain intensity." (p. 1110) "In summary, oral codeine is an
effective mild analgesic of proven merit with substantial versatility in terms of
useful dosage range ... In view of a time-tested record of efiicacy and safety,
a physician would do well to consider the use of codeine before prescribing newer
drugs which ultimately prove deficient in one or the other of these virtues."
4. Jaffe, Jerome H., M.D., "Narcotic Analgesics," in The Pharmacological
Basis of Therapeutics (Goodman and Gilman, eds.) 2.53,271, asserts that among
antitussives, nonnarcotic agents do not yet suffice as substitutes for opiates, and
points out that present clinical studies are inadequate in this regard. There-
fore, he concludes that "for the present, the older narcotic cough suppressants
such as codeine, hydrocodone, and dyhydrocodeine remain the standards against
which nonnarcotic agents will be measured." To the same effect is Goth, A., M.D.,
Medical Pharmacology 274 (1970).
5. Eddy, Nathan B., M.D. (with Drs. Hans Friebel, Klaus-Jurgen Hahn and
Hans Halback), "Codeine and Its Alternates for Pain and Cough Relief," 40
Bulletin of the World Health Organization 723 (1989) : "For most indications
codeine is still that antitussive which is pre.scribed most frequently. A major fac-
tor supporting its popularity is the rarity of serious side-effects and of misuse.
Another may be the combination of antitussive, pain-relie\ing and calming ef-
fects, perhaps appreciated by more physicians and patients than is generally
realized . . . On theoretical grounds several of the codeine alternates have these
proi>erties desired in a perfect cough depressant :
(1) they possess significant cough-depres.sing potency ;
(2) they depress coughs of different pathological origins ;
(3) their frequency of side-effects is no greatei-, i^erhaps less, than for
codeine ; and
(4) they are devoid, or practically devoid, of abuse liability.
"For none of them, however, is our quantitative and practical knowledge com-
plete enough to establish therapeutic priority." (p. 728)
Citing Dr. Seevers, Dr. Eddy also states ". . . codeine can be replaced in cer-
tain siiecified and limited situations, but : Judging from the continued popularity
of codeine among physicians and laymen alike throughout the world in spite
of the easy availability of the so-called 'non-toxic' preparations, it seems illogi-
cal to abandon a drug like codeine which possesses, in one agent, not only anti-
tussive properties but also pain relief and sedative properties which are helpful
in relieving the discomfort often associated with a cough . . . Codeine serves a
need which is not presently met by other substances ; . . . [the evidence] hardly
justifies discontinuing its availability."
[Exhibit No. 29]
Statement of Arnold Becker, Public Defender, Rockland County, N.Y.
This is a recommendation to Chairman Claude Pepper, for his Select Com-
mittee on Crime in the House of Representatives for the Congress of the United
60-296 — 71 — pt. 2 2.3
678
states, from Arnold Becker, public defender of Rockland county, and clinical
instructor of psychiatry (Law), and head of the section on law, psychiatry and
the behavioral sciences within the Department of Psychiatry at ihe Cornell
Medical College.
The malignancy of drug addiction is no less acute in 1971 than it was in 1961
and 1951. The stricter controls, the more punitive measures, have not even
effected a temporary turn-back in narcotic cases. Indeed, the law.s that have been
enacted, which are brought to play against those who are afflicted with narcotic
addiction or who abuse drugs to any extent, do nothing to strike at (the cause but
merely hits at the affect. Drug abusers in general, and drug addicts in particular,
are no less prone to become what tliey are, because of the penal nature of the
laws that are enacted by the legislatures.
It is diflScult to say why people, young and old, become drug abusers or drug
addicts. However, it has become quite obvious that the mere fact that drug
l)ossession is prohibited by law, does not prevent those who wish to use drugs
from purchasing and possessing any drug they de.sire.
Whatever the drug users drives may be, peer pressure, psychological or socio-
logical need or the host of reasons that are now being explored by those in drug
research, the fact is, people who want drugs, get drags, regardle.ss of how harsh
the Penalties and punishments set by law.
We are all aware of the debilitating affect of drugs on the mental and
physical health of drug abusers. We have also seen families destroyed, our citizens
imrglarized, robbed, and in some cases, murdered by the insatiable hunger di'Ug
addiction produces. No one is more aware of the deadly affect of drug use than
the drug user himself. I have personally spoken to hundreds of drug users and
they all realize they are traveling on a short road to death. But somehow, the
threat of prison, of young, sudden death means little to those v\-ho exi.st in the
twilight world of drugs. r
For him or her, the period of euphoria: the perio<l of warmth and security;
the period of not having to fight with the world surrounding them overcomes
al' the rational arguments against the use of drugs.
Tnrlperl, all the lows and arguments against drug- have ar^-ompMslied litt'".
America's drug problem has reached epidemic proportions. It is time to admit
that our courts, law enforcement agencies and our feehle attempts at drug
rehabilitation have reached the point of utter failure. I have reached the con-
r-liivinn that new methods must be tried, new avenues mu.st be explored in orcjer
to den' effectively with the problem.
I siiggest that the entire problem of drug abuse and addiction be taken out
of the hands of the courts and law enforcement agencies and placed in the hands
of those, whom I feel have the knowledge, and background to deal with drug
abuse smd addiction : the medical profession.
It is the medical practitioner, the doctor, the psychiatrist, the behavioral
scientist, who may be in the best position to come up x^-ith an answer to the'
problem. Throwing drug abusers and drug addicts into jail or State prison with-
out meaningful treatment is a useles'-- effort. For upo-i di.'^charge, whatever
caused them to seek drugs in the first in tance, will, in nil probal>ility. still
be present. It has been my experience that the untreated drug abuser or dmc
addict, within a short time, upon release from any period of incarceration, is
drawn to the very drugs that put him in prison, as a bee is drawn to iK'ileii
The s<-resses of society or war in Vietnam seems to have had a drug cultivat-
ing effect on our military personnel so that drug abuse ard drus adrlirtion i-
now flourishing among a great number of veterans who have returned from the
Far Eastern theater. How many of these veterans are in State prisons because
thev were involved in crimes brought about b.v their drutr abuse or drug addiction?
I use the word "treatment" and not "punishment". Punishment, I submit and
the threat of punishment, can never be used to cure what is either a medical
disorder or a social disorder.
Is drug abu.se and drug addiction a social dilemma or is it a medical dilemma?
One thing seems very clear, the penal law, the courts and the law enforce-
ment officials have had more than 30 years to effectively deal with the problem.
They have been unable to do so. I suggest that at this junctun'. they abdit-ate
their major roll and turn the task over to tho.se to whom it rightfully belongs"
namely : the medical profession.
The courts and law enforcement officials have had their chance. Let the
doctors, psychiatrists and behavioral scientists now have theirs.
679
[Exhibit No. 30]
Statement of Rev. Stanley M. Andrews, for Liberty Lobby
Mr. Chairman and members of the committee :
I am Rev. Stanley M. Andrews, former national coordinator of the Save our
scliools program, a special project of Liberty Lobby. I am also chairman of the
Maryland Citizens Committee for Decency and Morality, and pastor of the First
Bible Baptist Church, Rockville, Md. My interest in and study of this subject
dates back to my years both on the staff of the Governor of Ohio, and later as a
member of Senator Frank J. Lausche's staff here on Capitol Hill.
I would appreciate an opportunity to appear in person before your committee
to present the following testimony, on behalf of the 20,000-member board of policy
of Liberty Lobby, and the 200,000 sub.scribes to our monthly legislative report.
Liberty Letter :
During the past few years, I have been engaged in activities relating to the
pul)lic school system and its problems. Presently in Montgomery County, Md.,
where I live, not only pot but so-called hard drugs are a problem both in the senior
and junior high schools. Regrettably, even the elementary schools are now in-
filtrated by pushers of drugs.
So far, no adequate program of education relating to drug use has been devised.
We would sui)port any reasonable research to devise such educational aids that
could be developed, but we believe that education and rehabilitation are not cures
for this most serious problem.
I am sure you will all agree that as you look back on your own youth, teenagers
especially respond to the challenge of the unknown. There is a natural desire to
try that which is forbidden, and to demonstrate that the Establishment ( whether
school, church, government, or family) is "out of date or out of touch with ihe
new scene." This is a part of "growing up" and so far no educational methods
have been developed to cope with this natural rebellion against authority which
is inherent in adolescents.
Along with this age-long conflict between the older generation and youth today,
we face an era in which the various communications media — the press, magazines,
radio, and TV — have given unusual emphasis and publicity to the exponents of
drug use. Dr. Timothy Leary was made the "hero of the drug age" because the
press exploited his views. The u.se of grass and LSD by youth in our public schools
and in our universities spread like wildfire in the wake of Leary's public ex-
posure as the high priest of drugs. The media must accept great responsibility for
their part in creating the American drug scene as it relates to youth. Perhaps your
committee could consider the drafting of legislative guidelines to insure" the
proper presentation of the dangers of drug use by our national media agencies.
Much is being written and has been already discussed by witnesses before
your committee relating to the serious growth of drug u.se in the armed forces. Dr.
Charles Winnick, of the American Social Health Association, said, "A young
man who may face the possibility of having his head blown off in Vietnam is
hardly dissuaded from drug use by being told 'he will go out of his head' by taking
drugs." A program of education, no matter how much crash priority the Govern-
ment gives it, will not meet the "now" generation, which does not want to delay
its personal gratification. It wants its kicks and thrills now, especially since it
has little faith in the Establishment and its ability to make a better world for
the new generation. Education, then, is only a stop-gap, not a solution.
Presently, many romantic and self-satisfying theories relate to the dangers of
drug use. Some believe that this is "just a passing phase" in American society.
Yet, the history of China, of Indo-China, and of Turkey indicates clearly that
drug use is never abated by education or soft-sell approaches to the problem.
Much is said for setting up on a national basis of rehabilitation centers, especially
for our veterans. Looking back on the results of our present Federal drug rehabii-
itation centers, such as Lexington, Ky., and other drug farms and clinics, we see
the prospect of full rehabilitation is extremely problematical. It is a truism that
ultimately most drug addicts go back into the same environmental in which drn?s
are part of the scene, and are lost to productive society. It is true that with the
use of new drugs that are being developed, the future will see a larger percentage,
of drug users truly rehabilitated.
680
However, we must look at rehabilitation pragmatically, and accept the fact th;!t
such national x-ehabilitation programs as proposed will cast on the Federal budget
and the American taxpiiiyer an additional heavy burden.
I recognize that local and State governments have not accepted their respon-
sibility toward the drug user in the local community. Again, in my home county
(Montgomery) there is only one hoispital that will accept even youngsters who
are on bad trips. One night I was called to a home where a 16-year-old girl cele-
brated her birthday l»y taking drugs and was climbing the wa.Us literally when
I arrived. We rushed her to the largest hospital in the area, only to be told they
had no facilities to handle such cases. The Federal Government should devise
means of cooperation with local and State governments to provide some type of
responsible emergency treatment.
Since I have indicated a lack of faith in education or rehalulitation a.s the
means of coping with the problems, the question can be naturally asked, "What
then do you suggest?"
Looking at the dangerous problem, which if not met will destroy the moral fiber
of our Nation, one cannot escaiie the logical conclusion — ^the u.se of drugs is an
economic problem. Like most crime, there is a profit motive. It is most significant
that law enforcement history indicates that the real pushers of drugs, the big
wholesalers and most local pushers, are not addicts. They are in the drug traflic
for one rea-^on only : to make money. They have no noble ideals nor emotional
arguments, such as are used by the disciples of Dr. Leary and his ilk. They sim-
ply are in the business to put money in their pockets. The economic loss to
American society is tremendous. Beyond the lives made useless and wasted is
the hidden loss to our productive society. Both manpower and money are going
down the drain into the pockets of these criminals. This must be stopped.
Today, as I have indicated, there is too much soft-.selling of solutions to this
problem. I believe that only by the adoption of the most severe and harshest of
Ijenalties can this traffic in drugs be stopped. I therefore urge this committee to
recommend the drafting and enacting of Federal legislation which would make
the unlicensed sale of addictive drugs a capital crime. If there is a .lack of respect
for the authority of the law today, it is largely due to the fallacious arguments
of those who would treat all criminals as "sick people needing rehabilitation."
It is time that the courts treat the criminal as a criminal. No one gets into the
drug traffic because he is sick. He gets into the traffic for money and money
alone. He is no different from the Mafia member who takes a contract to kill a
complete stranger. The drug seller morally is no different from the murderer for
profit. Often his victims are literally murdered by the drugs the pusher has sold.
During recent months, efforts have been made to cut off the supply of drugs
coming into the United States. IMuch publicity has been given to the efforts by
our Government to persuade Turkey to reduce its opium crops and enforce drug
controls. However, as your committee has already pointed out, "the Turkish
Government has merely weeded out the inefficient opium-producing areas." All
effoi-ts to secure enforceable stiff controls through the United Nations have failed,
and the Communist and neutral nations merely say "it is an American problem."
While we do not accept that conclusion and be,lieve these unsatisfying re.sults
only show the futility of attempting to use the U.N. channels, these efforts do
point up my argument that di-ug traffic is purely an economic problem.
I recall the time when it was the munition-makers who were pilloried as
"merchants of death" and there was a great outcry in the public press. I believe
that in the 1970's the drug wholesalers and pushers are the real "merchants of
death." I urge your coniimittee, therefore, to give most serious consideration to
our recommendation that the Federal Government enact legislation which would
impose death as tlie penalty for unlicensed trafficking in drugs. If we enforce
such a Federal law, then methods for suitable education and rehabilitation will
not become another burden on our Federal budget.
Finally, it occurs to me that recently we were threatened with a rash of air-
line hijackings. We met that crisis by quickly enlisting and training air mar-
shals. So far, I have not .seen suggested that with drug traffic becoming our No. 1
flomestic problem, we consider the crash enlargement of the work of the Bureau
of Narcotics, which fights on like King Canute tiTiJiS to stem the unceasing tide.
Let's give them the monev, the men, and the law which will meet the issue head
on!
Thank you for this opportunity to present our views on this most vital subject.
681
[Exhibit No. 31]
Harvard Medical School — Department of Medicine,
Boston City Hospital,
Boston, Mass. August 4, l^^l.
Hon. Claude D. Pepper,
Chairman, Select Committee on Crime,
U.S. House of Representatives, Washington, D.C.
Dear Congressman Pepper : Our recently completed study entitled "Decreased
drug abuse with transcendental meditation : A study of 1,862 Subjects," indi-
cated that individuals who regularly practiced transcendental meditation (a)
decreased or stopped abusing drugs, (6) decreased or stopped engaging in drug-
selling activity, and (c) changed their attitudes in the direction of discouraging
others from abusing drugs. No data were collected concerning hard-core addiction,
but 16.9 percent claimed use of narcotics such as heroin, opium, morphine, and
cocaine before starting the practice of transcendental meditation. After 22-33
months of meditation, only 1.2 pei'cent claimed continued use of these drugs. No
data were gained concerning the socioeconomic background of these subjects.
So few alternatives to hard-core drug addiction now exist that I believe
further investigation of the effects of transcendental meditation no such addic-
tion is warranted. The above-noted study, while encouraging as preliminary
findings, should be viewed in the context of an idea which requires additional
data for verification. Extensive control groups, more information relating to
degree of usage and addiction with urine verification, more data concerning the
socioeconomic background of the subjects, and adequate followup studies to
learn what the possible long-term effects of transcendental meditation are on
hard-core addiction are required.
Enclosed please find a preliminary research proposal for your consideration,
and a copy of the study entitled "Decreased Drug Abuse With Transcendental
Meditation."
I remain.
Sincerely yours,
Herbert Benson, M.D.,
Assistant Professor of Medicine.
Enclosures : (2).
Enclosure 1
Preliminary Research Proposal
In order to study whether meditation may indeed be a uonchemical alternative
to narcotic addiction, and to ascertain M-hich, if any, subsets of this addiction
population would find such an alternative applicable, the following study is
proposed :
Two populations will be studied :
(a) One group from half-way houses from lower-, middle-, and upper-class
environments ;
(&) A second group from civil committment type facilities. Each population
group should be composed of approximately 600 persons.
Each of the groups will be divided into three different sections which will be
geographically isolated, but otherwise as closely matched as possible with i-egard
to age. sex, socioeconomic background, drug abuse habits, and degree of addic-
tion. Each person within each group will complete a questionnaire with built-in
internal checks for consistency concerning his use of narcotic-class drugs. The
accuracy will be verified by urine testing.
Within each group, one section will be left alone with the routine rehabilitation
measures. The second will have transcendental meditation offex'ed as it is rou-
tinely taught — namely as a volitional choice. The third will be required to attend
sessions v.'here transcendental meditation instruction is being given.
At the end of 1, 3, 6, 9, 12, 24. and 36 months, use of narcotic drugs will be
reassessed as above and meditational habits ascertained. It is assumed that
after 6 months the subjects will have returned to their home environments.
Data will thus be obtained which will yield the following from both halfway
houses and civil-committment-type facilities :
682
(a) The natural history of narcotic usage as influenced by routine rehabilita-
tion measures will be assessed. These results will be obtained from those not
offered transcendental meditation.
(&) The effect of transcendental meditation as normally taught and offered
on such usage Avill be assessed.
(c) The effect of required transcendental meditation on such usage will be
i^ssessecl.
(d) The effects of tran.scendental meditation as well as the routine measures
will be asses.sed as per socioeconomic grouping and degree of addiction.
(c) The long-term noninstitutional effects of both types of programs will be
assessed. Attempts will be made to determine environmental influences on parti-
cipants in the study after they return to their home communities by readminis-
tering the questionnaire and verifying with urine samples.
Enclosure 2
Decreased Drig Abuse With Transcendental ^Meditation— A Study
OF 1,862 Subjects
(By Herbert Benson, M.D., and R. Keith Wallace, Ph. U., with the technical
assistance of Eric C. Dahl, B.A., and Donald F. Cooke, B.S.)
From the Thorndike Memorial Laboratory, Channing Laboratory, Harvard
Medical Unit, Boston City Hospital, Boston, Mass., and the Department of Medi-
cine. Harvard Medical School, Boston, Mass.
Supported in part by grants from the National Heart and Lung Institute (HE
10539-05). the National Institutes of Health (SF 57-111), and from Hoffmann-
LaRoche, Inc., Nutley, N..J.
The altuse of drugs of all kinds is widespread in the United States and the
extent of abuse, particularly of marijuana and hallucinogenic drugs, is growing
( 1-3). It is estimated that in the United States 35-50 percent of high school and
college students have tried marijuana at least once, and of these about 35 per-
cent have tried marijuana more than 10 times (2). A conservative estimate of
persons in the United States, both juvenile and adult, who have used marijuana
is al»out 5 million and may be as high as 20 million (2). In surveys of d-lysergic
acid diethylamide (LSD) use in college populations, 5 percent of the students
polled admitted to using LSD. with about 30 percent of the sample being classi-
fied as "serious'" u.sers and the remaining 70 percent as "experimentors'' (2).
Law enforcement agencies report there are approximately 65.000 active "hard"
narcotic addicts in the United States. Other estimates indicate that there are
100.000 active narcotic abusers (2). The abuse of amphetamines and barbiturates
is widespread, but difficidt to estimate. College surveys have indicated that over
20 percent of the students have abused these drugs (3). Stanley F. Yolles, M.D.,
Director of the National Institute of Mental Health, summed up the situation as
follows :
'•The spreading of the abuse pattern into unusual and exotic drugs and the
involvement of increased numbers of people have serious implications. It seems
that today if a chemical can be abused, it will be. Further, it appears tliat
stronger and more dangerous drugs tend to displace weaker drugs dtiring this
period of excessive preoccupation with mind altering chemicals. One further
identifiable ominous trend is the indulgence in drugs of abuse by younger and
younger age groups.
"It is to be expected that the use of all sorts of drugs in the next 10 years will
increase ;i hnndicdfold. It is necessary, therefore, to develop effective proces.ses
to control their abuse today." (3)
Few programs or treatments have been reported which alleviate drug abuse.
One at^parently successful program for the rehabilitation of persons abusing
narcotics involves the substitution of methadone (.'/.."). Existing programs for
thp allevintion of other drug nbuse usujilly involve education r.s to the dinigers
of tlie effects of drugs and sometimes provide jtersonal counselling or psychiatric
care (6'-.''') . The efficncy of these programs has yet to be established.
A preliminary observation suggested that the practice of transcendentnl medi-
tation. ;is taught by Maharishi Mabesh Yogi, may be effective in allevi.ntion of
(irug abuse ilO). The i)resent report contirnis and expands the earlier observa-
tion.
683
METHODS
Tiie tecliDique of transcendental meditation is reported to be an easily learned
mental technique vrhich originated in ancient Vedie tradition of India ilJ,!^).
Practitioners are personally instructed by a teacher qualitied by Mabarishi
Mahesh Yogi. The technique" is claimed to be a spontaneous natural process, and
unlike many techniques of meditation or self-impi'ovement, does not employ men-
tal control,' physical control, belief, suggestion, or any change in life style. It is
also claimed that anyone can learn the technique in four or five instructional
sessions. Practitioners are asked to abstain from drug abuse for a 15-day period
prior to starting meditation. Following the start of transcendental meditation,
the program involves practicing the technique twice a day for periods of 15 to
20 minutes. The program does not involve any type of personal counseling or
giving advice about personal problems. Individuals practice the technique on
their own. The only additional contact between the individual and the instruc-
tors or organization is concerned with ensuring correct practice of the technique
and providing intellectual knowledge about it.
Questionnaires w^ere given to appi'oximately 1,950 sub.iects who had been
practicing transcendental meditation for 3 months or more and who were attend-
ing one of two meditation training courses offered by the Students' International
Meditation Society ^ in the summer of 1970. Of these, 1,862 completed the ques-
lionnaire. Age, sex, educational status, and length of time that transcendental
meditation had been practiced were obtained. Further, frequency of drug use,
drug selling activity, and attitudes toward drug abuse were asses.sed for each
of five separate time periods: {a) 6 months before starting Meditation; {h)
0-3 months after starting; (c) 4-9 months after starting: id) 10-21 months
after starting; and (e) 22 months or more after .starting. The separate drugs
and categories of drugs included in the questionnaire were {a) marijuana; ih)
LSD; (c) other hallucinogens (2,5-dimethyloxy-4-methyl amphetamine (STP),
N,N-dimethyltryptamine (DMT), peyote, and mescaline) ; (d) narcotics (heroin,
opium, morphine, and cocaine) ; (e) amphetamines; and (/) barbiturates.
Additional information was requested concerning the frequency of use of "hard
liquor" and the number of packs of cigarettes. Hard liquor was defined as '"alco-
holic beverages stronger than wine or beer."
The information on the questionnaires was analyzed on an IBM 360-65 com-
puter. The CROSSTABS " multivariant data analysis program was utilized and
all processing was done by Urban Data Processing, Inc.* The subjects were class-
ified into four categories depending on the frequency of drug use ; (a) nonusers :
{h) light users; (c) medium users; and ul) heavy users. For the subjects using
marijuana, narcotics, amphetamines, barbiturates, hard liquor, and cigarettes, a
"light user" indicated a frequency of three times a month or less : "medium user,"
once a week to six times a week ; and "heavy user," once a day or more. For LSD
and other hallucinogens, "light user" indicated a frequency of less than once a
month ; "medium user," from one to three times a month ; and "heavy user," once
a week or more.
RESULTS
A total of 1,862 subjects responded to the questionnaire. There were l.OSl male
subjects and 781 female subjects (table 1). The age of the subjects ranged from
14 to 78 years and approximately half of the subjects were between the ages of
19 and 23. Most had attended college and many had college degrees (table 2).
The average length of time they had been practicing transcendental medita-
tion was approximately 20 months.
Following the start of the practice of transcendental meditation, there was a
marked decrease in the number of drug abusers for all drug categories (tables 3-
8). As the practice of meditation continued, the subjects progressively decreased
their drug abuse until after practicing 21 months of meditation most subjects had
completely stopped abusing drugs. For example, in the 6-month period before
starting the practice of meditation, about 80 percent of the sulijects used mari-
juana and of those about 28 percent were heavy users. After practicing trans-
cendental meditation 6 months, 37 percent used marijuana and of those only 6.5
percent were heavy users. After 21 months of the practice, only 12 percent con-
tinued to use marijuana and of those most were light users ; only one individual
^ Xatinnnl Hpadqnarters, tOl.5 Oaylpv Avemip. Los AtispIps. Cal^f
2 Oamhridce Compntpr Associates, 22 Alewife Brook Parkwav. Cambridirp. ^lass.
3 Urban Data Processing, 552 Massachusetts Avenue, Cambridge. IMass.
684
was a heavy user. The decrease in abuse of LSD was even more marked. Before
.starting the practice of transcendental meditation, 48 percent of the subjects had
used LSD, and of these subjects about 14 percent were heavy users. In the 3
months following the start of the practice of meditation, 11 percent of the subjects
took LSD, while after 21 months of the practice only 3 percent took LSD. The
increase in tlie number of nonusers after starting the practice of meditation was
similar for the other drugs : nonusers of the other hallucinogens after 21 months
of the practice rose from 61 to 96 percent : for the narcotics from S3 to 99 percent
for the amphetamines from 70 to 99 percent ; and for the barbiturates from 83 to
99 percent.
In the 6-month period before starting the practice of meditation, 60 percent of
the subjects took hard liquor, and, of these, about 4 percent were heavy users
(table 9). After 21 months of the practice of meditation, approximately 25 per-
cent took hard liquor and only 0.1 percent were heavy users. Approximately 48
percent smoked cigarettes before starting meditation and 27 percent were heavy
users (table 10). After 21 months of practicing meditation, 16 percent smoked
cigarettes and only 5.8 percent were heavy users.
jNIost subjects felt that transcendental meditation was instrumental in their
decreasing or stopping abuse of drugs : 61.1 percent stated that it was extremely
important ; 22.8 percent that it was very important ; 12 percent somewhat im-
portant and 3.6 percent not important. Of those individuals who continued drugs
following storting transcendental meditation, 55.9 percent had been irregular in
meditation and 24.8 percent had stoiiped for a week or more.
Three hundred seventy-four subjects (20.1 percent) sold drugs before start-
ing meditation. Of these, 71.9 percent stopped and 12.5 percent decreased drug
selling during the period 0-3 months after instruction. Among the subjects who
practiced meditation 21 months or longer and who at one time were actively in-
volved in selling drugs, 95.9 percent stopped selling drugs. In addition. 997 (65.5
percent) had either encouraged or condoned drug abuse before starting medita-
tion. Over 95 percent of these subjects discouraged drug abuse in others after
beginning the practice of meditation.
DISCUSSION
Individuals who regularly practiced transcendental meditation (a) decreased
or stopped abiising drug.s, (&) decreased or stopped engaging in drug selling ac-
tivity, and (c) changed their attitudes in the direction of discouraging others
from abusing drugs. The magnitude of these changes increased with the length of
time that the individual practiced the technique. Similar decreases were noted
in the use of "hard" alcoholic beverages and cigarette smoking. A high percen-
tage of the individuals who did change their habits felt that transcendental medi-
tation was very or extremely important in influencing them to change.
During transcendental meditation oxygen consumption and heart rate signif-
icantly decrease, skin resistance significantly increases and the electroencephalo-
gram shows predominantly slow alpha wave activity with occasional theta wave
activity (13). Thus, the practice of transcendental meditation is physiologically
distinguished from sitting quietly with eyes open or closed, from sleeping or
dreaming and from suggesting relaxation or rest through hypnosis. During tran-
scendental mediation subjects rejiort that their awareness is spontaneously
drawn to "finer" or "more abstract" levels of the thinking process.
There are no simple explanations of the factors which lead to drug abuse. The
types of motives which initiate and prolong drug abuse range from .'^uch things
as social pressure, curiosity, desire for "kicks," rebellion against authority,
escape from social and emotional problems to more philosophical motives such as
self-knowledge, creativeness. spiritual enlightenment or expansion of conscious-
ness iJJf). Student drug u.sers are, as a grouj), knowledgable about the undesir-
able effects of drug almse. In genei-al. it is not diflficult for most student drug
abusers to stop. The issue is to get them to want to stoji. For a drug abu.^e pro-
i;ram to be effective it must provide a nonchemical alternative which can at least
fulfill some of the basic motivations behind student drug abuse.
Transcendental meditation is acceptable among youthful drug abusers. It is
offered as a iirogram for perj^onal development anrl is not specifically intended
to be a treatment for druir abuse: the allevintioji of the nroblems of drug al)use
is mei-ely a side effect of the practice. Thus, it may not threaten those beliefs of
the connnitted al)user who condones the use of druirs. Since the introductiou of
685
transcendental meciitation into the student community 5 years ago, over 40,000
individuals have allegedly begun the practice (15). Further, the movement con-
tinues to grow. It is presently being presented through campus organizations at
some 300 colleges and universities and at several universities it is offered in the
context of an accredited course.
Involvement in other kinds of self-improvement activities may also lead to
decreased drug abuse. The motivation to start meditation may have influenced
the subjects to stop drug abuse. The subjects in the present study may have
spontaneously stopped, continued, or increased taking drugs independently of
transcendental meditation.
However, since there are few effective programs which alleviate drug abuse,
transcendental meditation should be investigated as an alternative to drugs by a
controlled, prospective study.
SUMMARY
Drug abuse is widespread and increasing in the United States, especially in
student populations. However, few effective programs exist for the alleviation
of drug nliuse. Transcendental meditation, a popular and easily learned mental
technique which allegedly originated from the ancient Vedic tradition of India,
was investigated as a possible means of decreasing drug abuse. Eighteen hundred
sixty-two subjects who had practiced transcendental meditation at least .3 months
formed the basis of this study. These subjects sigiiifioantly decreased or stopped
abusing drugs; decreased or stopped engaging in drug selling activity; and
changed their attitudes in the direction of discouraging others from abusing drugs
after starting transcendental meditation. Further, the subjects decreased their
use of "hard" alcoholic beverages and cigarette smoking. The magnitude of these
changes increased with the length of time that the suliject practiced transcen-
dental meditation. Involvement in other types of self-improving activities may
also lead to decreased drug abuse. However, since there are few effective pro-
grams which alleviate drug abuse, transcendental meditation should be investi-
gated as an alternative to drugs by a controlled, prospective study.
REFERENCES
(1) Resource Book for Drug Abuse Education. National Clearinghouse for
Mental Health Information, United States Department of Health, Educa-
tion, and Welfare, Public Health Service, Health Service and Mental Health
Administration, National Institute of Mental Health : 1969. Washington.
D.C., Government Printing Office, 1969 (PHS Publication No. 1964), p. 25.
(2) Recent Research on Narcotics, LSD, Marijuana and Other Dangerous Drugs.
National Clearinghouse for Mental Health Information, U.S. Department
of Health, Education, and Welfare, Public Health Service. Health Service
and Mental Health Administration, National Institute of Mental Health,
1969. Washington, D.C.. Government Printing Office, 1969 (PHS Publica-
tion No. 1961), pp. 1, 2, 7, 11, 18.
(3) Yolles, S. F. : Statement for Stanley F. Yolles, M.D.. Director. National
Institute of Mental Health, Before the Subcommittee on Public Health and
Welfare of the Interstate and Foreign Commerce Committee on H.R. 11701
and H.R. 13743. 1969, Loose leaf, pp. 13-16.
(4) Byrd, O. E. ; Medical Readings on Drug Abuse, Reading, Mass., Addison-
Wesley Publishing Co., 1970, pp. 255-257.
(5) Eddy, N. B. : Methadone maintenance for the management of persons with
drug dependence of the morphine type. Drug Dependence. 3 : 17-26, 1970.
(6) Wiesen. R. L., I. H. Wang, and T. J. Stensper : The drug abuse program at
Milwaukee County Institutions, Wisconsin IMed. J.. 69 ; 41-150, 1970.
(7) Murphy, B. W., A. M. Leventhal, and M. B. Baiter : Drug use on the campus :
A survey of universitv health services and counseling centers. .J. Amer.
Coll. Health Ass.. 17 : 389-402, 1969.
(S) Pollock, M. B. ; The drug abuse problem: Some implications for health
education, J. Amer. Coll. Health Ass., 17 ; 403-411, 1969.
(9) Hickox, .7. R. : Drug abuse education. Texas Med.. 65 : 31-33. 1969.
(10) Benson. H. : Yoga for drug abuse. New Eng. J. Med., 281 : 11.33, 1969.
(11) Maharishi Mahesh Yogi: The Science of Being and Art of Living. London,
International S.R.M., rev. ed., 1966, pp. 50-59.
(12) Maharishi Mahesh Yogi: Maharishi Mahesh Yogi on the Bhagavad Gita :
A new translation and commentary. Baltimore, Penguin, 1969. Originally
published by International S.R.M., London, 1967, pp. 10-17.
686
(13) Wallace. R. K. : Physiological effects of transcendental meditation. Science,
167 : 1751-17.54. 1970.
(14) Cohen, A. Y. : Inside what's happening: Sociological, psychological, and
spiritual perspectives on the contemporary drug scene. Am. J. publ. Hlth.,
59 : 2092-2097, 1969.
(15) Jarvis, J. : Personal communication from the Students' International Medi-
tation Society, 1015 Gayley Avenue, Los Angeles, California. 90024.
TABLE 1.— AGE AND SEX OF THE RESPONDENTS TO THE QUESTIONNAIRE
Age
Sex
14 to 18
19 to 23
24 to 28
29 to 38
39 and over
Total
Male:
Number
61
574
322
82
42
1.081
Percent
3.3
30.8
17.3
4.4
2.3
58.1
Female:
Number
71
363
167
81
99
781
Percent
3.8
19.5
8.9
4.4
5.3
41.9
Total:
Number
132
937
J89
163
141
1,862
Percent
7.1
50.3
26.2
8.8
7.6
100.0
TABLE 2.-EDUCATI0N OF THE RESPONDENTS TO
THE QUESTIONNAIRE
Less than
High school
College
Advanced
Educational experience
high school
graduate
Some college
graduate
college degree
Total
Number
100
183
971
460
148
1,862
Percent
5.4
9.8
52.2
24.7
7.9
100.0
TABLE 3.— USE OF MARIHUANA AND HASHISH BEFORE AND AFTER STARTING THE PRACTICE OF TRANSCENDENTAL
MEDiTATION
Before (months) After (months)
-6to0 0to3 4 to 9 10 to 21 22 to 33
Usage' Number Percent Number Percent Number Percent Number Percent Number Percent
Heavy _._ 417 22.4 47 2.5 39 2.1 13 1.3 1 0.1
Medium 618 33.2 190 1C.2 137 7.5 65 4.6 18 2.1
Light 422 22.7 613 32.9 500 27.3 264 18.6 85 10.0
Nonuser 405 21.7 1,012 54.4 1,154 63.1 1,070 75.5 748 87.8
Total 1,862 100.0 1,862 100.0 1,830 100.0 1,417 100.0 852 100.0
I See text for definitions.
TABLE 4.~-USE OF LSD BEFORE AND AFTER STARTING THE PRACTICE OF TRASCENDENTAL MEDITATION
Usa.?e '
Heavy
Medium
Light
Nonuser..
Total....
' See text for definitions.
Before (months)
After (months)
-6 too
0to3
4 to 9 IC to 21
22 to 33
Number Percent
Number Percent
Number Percent Number Percent
['lumber Percent
132 7.1
301 16. 1
467 25. 1
962 51.7
14 0.7
60 3. 3
159 8.5
1,629 87.5
13 0.7 6 0.4
36 1.9 23 1.7
151 8.3 72 5.1
1,630 89.1 1,316 92.8
0 0
3 .3
23 2.7
826 97. 0
. 1,852 100.0
1,862 100.0
1,830 100.0 1,417 100.0
852 100.0
687
TABLE 5— USE OF OTHER HALLUCINOGENS BEFORE AND AFTER STARTING THE PRACTICE OF TRANSCENDENTAL
MEDITATION
Before (months) After (months)
-6 too Oto3 4 to 9 10 to 21 22 to 33
5
0.3
4
0 2
5
0.3
3
0.2
0
0
56
3.0
32
1.7
30
1.7
19
1.4
0
0
665
35.7
143
7.7
130
7.0
%
6.4
34
4.0
136
61.0
1,683
90.4
1,665
91.0
1,305
92.0
818
96.0
Usage' Number Percent Number Percent Number Percent Number Percent Number Percent
Heavy..,
Medium
Light
Nonuser 1,136
Total 1,862 100.0 1,862 100.0 1,830 100.0 1,417 100.0 852 100.0
' See text for definitions.
TABLE 6.— USE OF NARCOTICS BEFORE AND AFTER STARTING THE PRACTICE OF TRANSCENDENTAL
MEDITATION
Before (months) After (months)
-6to0 0to3 4 to 9 10 to 21 22 to 33
Usage I Number Percent Number Percent Number Percent Number Percent Number Percent
Heavy.. ....:;........ 12 0.6 1 0. 1 1 0. 1 1 0. 1 0 0
Medium 17 .9 2 .2 2 .2 2 .2 0 0
Light 286 15.4 47 2.5 39 2.1 30 2.1 10 1.2
Nonuser 1,547 83.1 1,812 97.2 1,788 97.6 1,384 97.6 842 98.8
Total 1,862 100.0 1,862 100.0 1,830 100.0 1,417 100.0 852 100.0
' See text for definitions.
TABLE 7.— USE OF AMPHETAMINES BEFORE AND AFTER STARTING THE PRACTICE OF TRANSCENDENTAL
MEDITATION
Before (months) After (months)
-6 too 0to3 4 to 9 10 to 21 22 to 33
Usage' Number Percent Number Percent Number Percent Number Percent Number Percent
Heavy 30 1.6 7 0.4 3 0.2 2 0. 1 0 0
Medium 96 5.2 11 .6 9 .5 2 .2 0 0
Light 470 25.2 104 5.6 79 4.3 49 3.4 10 1.2
Nonuser 1,266 68.U 1,740 93.4 1,739 95. U 1,364 93.3 842 98.8
Total 1,862 100.0 1,852 100.0 1,830 100.0 1,417 100.0 852 100.0
' See text for definitions.
TABLE 8.— USE OF BARBITURATES BEFORE AND AFTER STARTING THE PRACTICE OF TRANSCENDENTAL
MEDITATION
Before (months) After (months)
-6 to 0 0 to 3 4 to 9 10 to 21 22 to 33
Usage ' Number Percent Number Percent Number Percent Number Percent Number Percent
Heavy 19 1.0 1 0.1 3 0.2 1 0. 1 0 0
Medium 43 2.3 7 .4 3 .2 2 .1 1 .1
Light 258 13.9 56 2.9 37 2.0 27 1.9 8 1.0
Nonuser. 1,542 82.8 1,798 96.6 1,787 97.6 1,387 97.9 843 98.9
Total 1,862 100.0 1,862 100.0 1,830 100.0 1,417 100.0 852 100.0
' See text for definitions.
688
TABLE 9.-USE OF "HARD LIQUOR" BEFORE AND AFTER STARTING THE PRACTICE OF TRANSCENDENTAL
MEDITATION
Before (months) After (months)
-6 to 0 0 to 3 4 to 9 10 to 21 22 to 33
Usage 1 Number Percent Number Percent Number Percent Number Percent Number Percent
Heavy 50
Medium 295
Light... 770
Nonuser 747
2.7
21
1.2
16
0.9
8
0.6
3
0.4
15.8
149
8.0
100
5.5
52
3.7
22
2.6
41 4
646
34.7
551
20.1
365
25.8
187
21.9
40.1
1,046
56.1
1,161
63.5
992
69.9
640
75.1
Total... 1,862 100.0 1,862 100.0 1,830 100.0 1,417 100.0 852 100.0
1 See text for definitions.
TABLE 10.--USE OF THE NUMBER OF PACKS OF CIGARETTES BEFORE AND AFTER STARTING THE PRACTICE OF
TRANSCENDENTAL MEDITATION
Before (months)
-6 too
After (months)
0to3
4 to 9 10 to 21
22 to 33
Usage'
Number
Percent
Number
Percent
Number
Percent Number
Percent
Number
Percent
Heavy
Medium
503
. . .. 180
27.0
9.7
10.9
52.4
314
165
186
1,197
16.9
8.9
10.0
64.2
222
136
163
1,309
12.2 118
7.4 86
8. 9 105
71.5 1,108
8.4
6.0
7.4
78.2
49
34
55
714
5.7
4.0
Light. _
Nonuser
203
976
6.4
83.9
Total
1,862
100.0
1,862
100.0
1,830
100.0 1,417
100.0
852
100.0
' See text for definitions.
ACKNOWLEDGEMENT
We thank Miss Barbara R. Marzetta and Miss Lyne Heppner for their help
in the preparation of the manuscript.
689
0.
100
80
60
40
20
0
100
80
60
40
20
LSD
(18621
[18621 (13301 (KITl (852)
2;
^ '■m^/.
OTHER HALLUCItJOGENS Q
(1862) (1862) (1830) (KIT) (852)
i
^^ ^^ ^^
Months -5-0 T 0-3 4-9 10-21 22-33
Start
Meditation
NARCOTICS
(16621
(1862) (13301 ( 4!71 (8521
AMPHETAMINES
(16821
(1862) (1630) (UI71 (8521
g^^ v?7777?\ r---
BARBITURATES
(18621 (1330) JH17) (852)
-5-0
0-3 4-9 iO-21 22-33
Start
Meditation
n = ( )
[_] Heovy Users [_J Medium 'Users ^Light Users [ ;N!on-Users
(The following letter was sent to 79 drug companies concerning
ongoing research in narcotic blockage and antagonistic drugs and
related areas. A summation of their responses will appear in the com-
mittee's report to Congress to be printed in the fall.)
[Exhibit No. 32]
Select Committee ox Crime.
House of Eepresentati\t:s,
Congress of the United States.
Washinffton, B.C., June I4, 1971.
Dear Sir : You may know that the Select Committee on Crime has, over the past
two years, devoted a considerable portion of its time and energy to the multiple
problems of drug abuse and drug dependence in the United States. Testimony
which has been recently received by my Committee lends credence to the thought
690
that, with accelerated narcotic res*earch, a possible solution to the crisis in
America lies, to a considerable extent, in the development of longer lasting and
more effective narcotic blockage and/or antagonistic drugs.
At present, the drug most relied upon to treat and rehabilitate narcotic addicts
is methadone. As you are no doubt aware, the development of naloxone and
cyclazocine provide hope that we are on the right road toward discovering a
safe and non-addictive alternative, however, testimony before this Committee
indicates that oidy a very minimal amount of research in this direction is on-
going currently. Accoi-dingly, we hope to reconmieiid to the Congress ways in
which research in this area can be stimulatetl, including possible encouragement
of the private drug industry to work cooperatively with the Federal Government.
To assist and guide our Committee to better understanding the ongoing research
in this field, as well as the capabilities for research, we would be most apprec-iative
if you would respond to the following (piestions :
1. Describe the research facilities you have at your disposal, including physical
plant and equipment and number of medical, scientific, and other personnel (by
category) who are qualified, in your opinion, to work in the area with which we
are concerned.
2. What, if any, research has ycnir company conducted or sponsored during
the past ten years toward the development of narcotic blockage and/or antag-
onistic drugs?
3. What research is presently being conducted by your company, or at the
request of your company, toward developing narcotic blockage and/or antag-
onistic drugs?
4. What, if any, research does your company plan to sponsor, conduct or par-
ticipate in, directly or indirectly, towai'd the deveioi>jng narcotic blockage and/or
antagonistic drugs?
5. What amount of money has been spent, from 1960 to date, by your company
for actual research toward the development of narcotic bloc-kage and/or antag-
onistic drugs?
6. Briefly describe, in general terms, the status and residts of research re-
ferred to in questions 2 througli .5, supra.
7. To the extent that your budget has been planned for the future, what amount
of money has been allotted for the development of narcotic blockage and/or
antagonistic drugs?
8. If funds were to be provided to your company to develop a narcotic blockage
and/or antagonistic drug, what are the minimum and maximum dollar amounts
your company would require to develop same as rapidly as possible?
Several schemes have been suggested to our Committee toward stimulating
research by the private sector. I have personally suggested that it might be
possible to develop an arrangement whereby the Federal Govermnent would fund
a portion or all of the original research costs with a private firm under a licensing
agreement, whereby that firm would retain a license or patent to distribute the
drug with the ancillary provision that once approval and distribution occurs, the
company would, from initial profit, reimburse the Government for all monies
originally advanced. This, or similar schemes for the stimulation of narcotics
research by the private sector, obviously suggest many possible variations. We
would like to benefit from your advice and counsel in this regard ; and conse-
quently, would greatly appreciate your considered judgment as to the types of
programs which would be attractive to your firm in the development of drugs
which might be helpful in the treatment and i-ehabilitation of narcotic addicts.
The Committee is convinced that all facets of the drug problem in America
should receive the highest priorities. However, we are mindful that action is
not necessarily progress, and the only way that we can take the most prudent
steps is with your full cooperation. We would very much appreciate a response
by July 1. 1!J71. The Chief Counsel to the Committee, Paul I.. Perito (202-22ri-
7955), or the Administrative Assistant Counsel, Jordan P. Rose (202-225-7954),
will be glad to clarify or expand upon this request if you should so desire.
Kindest regards, and
Believe me,
Very sincerely yours,
Claude Pepper. CJiainncni.
(Wliereii])on, at 4 p.m., the hearings in tlie above-entitled matter
Vv-ere concluded.)
o
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