OUR CITIES AND DRUG ADDICTION A HIGH POPULATION OF ADDICTS LITTLE OR NO TREATMENT FACILITIES MICHIGAN CONNECTICUT NEW HAVEN, CONNECTICUT LOS ANGELES, *SAN JUAN, PUERTO RICO to support the habits of the addicts receiving rehabilitation were reduced by $1.6 million, a saving of $600,000. As of June 30, 1969, these savings amounted to about $4 million. These savings are calculated on the finding by the President's Commission on Law Enforcement and Administration of Justice that the average addict must steal at least $60 worth of merchandise daily in order to support a $15-a-day drug habit. Between May 1968 and June 1969, the patients enrolled in the program would have had to steal an estimated $4.9 million worth of goods if they still were actively using heroin. Comprehensive narcotic addiction treatment centers A related approach to the community treatment of narcotic addicts was made possible through Title IV of the Narcotic Addict Rehabilitation Act which initiated the development of comprehensive, community-based treatment and rehabilitation centers. Six demonstration centers were established in FY 1968. Starting in fiscal 1969, the development of community treatment centers for addicts was incorporated into the Community Mental Health Centers Act, which permits the NIMH to make grants for construction and staffing of narcotic addict facilities within the communities. Funding provides two-thirds Federal contribution for construction and 51 months support for staffing on a matching basis in which the Federal share is 75 percent for the first 15 months, then 60 percent, 45 percent, and 30 percent for each successive 12-month period. For fiscal 1969, ten new comprehensive treatment and rehabilitation centers have received staffing grants amounting to a total expenditure in fiscal 1969 of $8 million for the 16 operating community narcotic addiction treatment centers. At the centers, a variety of treatment modalities are utilized and tested. Particular attention is given to the different kinds of addicts and how they respond to a specific treatment or combination of therapies. Treatment approaches range from carefully controlled experimental techniques such as methadone maintenance to behavioral modification efforts, to long-utilized therapeutic community methods as well as standardized medical-psychiatric forms of treatment. All centers plan to undertake the experimental use of the narcotic substitute, methadone. All centers include at least five essential services to addicts in their areas: 1. Inpatient services, including diagnostic as well as acute withdrawal services; 2. Outpatient services, including diagnostic services in addition to other outpatient services; 34-041-69-7 3. Intermediate services, such as half-way houses, day-nite centers, and partial hospitalization; 4. Emergency services on a 24-hour, 7-day basis; 5. Community-wide consultation and education services relating to drug addiction and treatment of drug addicts. This spectrum of services provided to the addict within his own community is intended to insure that he will receive the type of care needed at various stages of his illness and rehabilitation. Staffing patterns feature an interdisciplinary approach utilizing the professions of medicine, psychology, nursing rehabilitation and social work, but will also tap the potential of ex-addicts as a manpower resource. They are seen as particularly effective in such activities as case finding, orientation, counseling and crisis intervention. Elevating the rehabilitated addict to the highest potential of functioning takes pace through multiple training and educational programs. His participation serves as a role model for patients currently being treated as well as a motivational influence to addicts not yet involved in a therapeutic program. Strategic location in a community mental health center offers to the narcotie addition programs the advantage of professional leadership and technical competence. A community advisory board helps tie the program to local health, welfare, enforcement, employment, vocational training as well as community action and urban renewal programs. The centers attempt to gear their experience and findings toward the early intervention and prevention of drug experimentation and abuse that may lead to narcotic addiction. School age children and youth are particular targets for vigorous educational programs. Skillful involvement of ex-addicts in "partnership" with mental health professionals serves as a means to "reach" children and youth at risk of becoming addicted. All of the programs serve areas high in crime and delinquency with accompanying employment problems. Each envisions "motivation to work" as a primary rehabilitation goal. Most of the programs are located in and will serve inner-cities which have multiple socio-economic problems and are described as "ghetto" areas. One center is located in a rural poverty region. Methods have been built in as a component of each center to evaluate the effectiveness of its efforts. Uniform data collection is required. There will be an attempt to compare type and length of treatment and the economic costs of the various methods relative to their therapeutic outcome. MARIHUANA I'd like to turn now to the drug which, of all the illegal drugs currently in use in our society, has probably generated the most popular concern, marihuana. Next to alcohol, marihuana is almost certainly the most widely abused drug, and about $100 million a year is spent illegally on marihuana. While there is substantial agreement that most other drugs abused are unquestionably deleterious in their effects, there is disagreement, even among well informed scientists and medical practitioners regarding the degree of threat posed by marihuana. Unfortunately, adequate data, particularly on the implications of low-dosage, long-term usage are generally lacking. In recent years there is clear evidence that there has been a dramatic and and continuing increase in the use of marihuana, particularly among urban and suburban middle-class youth. It is estimated that nationwide, 20 to 40 percent of high-school and college students have tried marihuana at least once. In the past year or two, use has begun to spread to junior high school and grade school students. It is believed that large numbers of middle-class adults are also involved in marihuana smoking. Of all those who have tried marihuana, about 65 percent are experimenting, trying the drug from one to ten times, and then discontinuing its use. Some 25 percent are social users, smoking marihuana on occasion when it is available, usually in a group context. Ten percent can be considered chronic users who devotes significant portions of their time to obtaining and using the drug. The effects of marihuana vary with the potency of the agent, the phychological set of the user, and the setting in which use takes place. Thus, it has been estimated that half of those who use marihuana the first time experience no effects at all. When smoked by inhaling deeply, symptons may appear after one or two puffs. Within minutes a feeling of elation and euphoria may occur. Thinking is dreamlike and there is a loosening of emotions manifested by fits of laughter without cause. Judgment may be impaired either in the direction of overestimating one's capabilities or becoming overly suspicious. There is frequently unsteadiness, drowsiness, or induction of sleep. At times an anxiety state with panic may be present rather than the expected euphoria. Physical effects include reddening of the eyes, occasionally dialition of the pupils, and in heavy marihuana smokers, a bronchial cough. Acute psychological reactions may occur. There may be a paranoid or panic state. As a disinhibiting agent marihuana like other intoxicants can cause severely impaired judgment and a lapse in the individual's usual moral values and behavior. Marihuana is not physically addicting in that no withdrawal symptoms accompany termination if its use, but it can be psychologically habituating. The chronic user of marihuana may encounter a number of psychological problems. If he is using it to escape stresses of life, his mental growth is impaired by not learning how to deal with frustration and problems. He tends to withdraw from hear-and-now reality, loses ambition and drive, and sustains a loss of motivation. He is present-oriented rather than future-oriented. He may drop out of active involvement in school or work. Despite claims by "pot" advocates, there is no evidence that creativity is enhanced. On the contrary it may be diminished because of the lack of drive and the reduced goal directed activity pattern. In countries where the long-term use of strong marihuana preparations is traditional, marihuana psychoses are described, indeed dementia in lifelong hashish eaters is mentioned. These findings require repetition with more rigorous scientific methodology before we can be certain of the relationships. We do not know today. Further research is needed to elucidate more clearly both the short and longterm effects of marihuana use. The absence of good scientific data should not lead to the assumption that long-term use is harmless. As in the case of tobacco, it is possible that there are serious consequences of chronic use which will only become apparent through careful longitudinal studies. One needs to be particularly concerned about the potential effect of a reality distorting agent on the future psychological development of the adolescent user. We know that normal adolscence is a time of great psychological turmoil. Patterns of coping with reality developed during the teenage period are significant in determining adult behavior. Persistent use of an agent which serves to ward off reality during this critical developmental period is likely to compromise seriously the future ability of the individual to make an adequate adjustment to a complex society. The observed increase in marihuana use in the presence of stringent laws prohibiting it is a major challenge to both the enforcement and health systems. Based on our previous experience with LSD we are convinced that a reduction in marihuana abuse can only be accomplished by a combination of enforcement techniques aimed primarily at the distributor, and public education focused on wide dissemination of scientific information about its dangers. Despite our acknowledgedly scanty information on adverse effects there is reason to believe that the marihuana user is taking a significantly increased risk of either acute or chronic psychologic damage each time he lights a marihuana cigarette. Though the incidence of serious adverse reaction appears to be low, by definition as the number of users increase, the total number of those experiencing adverse reactions will also rise. The effects of the drug on judgment and perception might very well be a factor in automobile accidents. Those users who already have significant psychiatric problems might readily be led to avoid obtaining necessary psychiatric treatment by this form of self-medication, only to wind up as one of the 10 percent of users whose entire life becomes absorbed in the drug culture. While marihuana use is not a casual factor in heroin addiction, we do know that involvement in illicit drug use does provide increased accessibility to agents such as amphetamines and heroin. The recent appearance of heroin as a drug used by middle-class urban and suburban youth can probably be traced to this phenomenon. |